With new name, diabetes educators positioned to meet growing health challenges
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The roles of diabetes educators — and the settings where they work — are evolving to address the increasing prevalence of diabetes and meet new demands for population-level diabetes performance measures. To signal this evolution, the American Association of Diabetes Educators is promoting a new name for these professionals: diabetes care and education specialists.
Far from the idea of an educator teaching carb counting in a classroom, diabetes care and education specialists today are working with people with diabetes in new ways, and the need for more of these professionals is expected to grow. In a workforce analysis recently commissioned by the AADE, researchers projected a substantial increase in the demand for diabetes care and educators specialists through 2025.
That demand cannot be met today, however. According to an April report from the National Certification Board for Diabetes Educators (NCBDE), 19,783 health professionals in the U.S. currently hold the certified diabetes educator (CDE) credential. Another estimated 15,000 diabetes educators who do not hold the CDE credential are also in practice, according to AADE. At the same time, the prevalence of diabetes is doubling roughly every 15 years. For every CDE, there are an estimated 1,600 people with diabetes in need of services.
Photo by Amy Lullo. Printed with permission.
“With the number of people with diabetes vs. educators that are actually certified, the numbers do not match,” Susan Cornell, PharmD, CDE, associate director of experiential education and associate professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, told Endocrine Today. “We need more diabetes care and education specialists to manage the growth of people with diabetes.”
As the diabetes educator workforce changes, it is also aging. According to the 2017 AADE National Practice Survey, 44% of respondents reported potentially retiring in the next 10 years, although it is unclear whether the data indicate a decrease in the educator workforce or providers becoming educators later in their careers. Efforts to replace those retiring will need to be addressed by encouraging health care providers to specialize in diabetes education, according to William H. Polonsky, PhD, CDE, president of the Behavioral Diabetes Institute and an associate clinical professor at the University of California, San Diego.
“My story is unusual,” Polonsky told Endocrine Today. “As a psychologist working in the field of diabetes, which still is rare, it was important to me working with diabetes care professionals that I wanted to be seen as someone who knew what I was talking about. Getting the CDE was one way to simply make myself legitimate in the eyes of health care providers.”
Guillermo Umpierrez, MD, FACP, FACE, professor of medicine and director of the Clinical Research and Metabolism Center at Emory University School of Medicine and an Endocrine Today Editorial Board Member, said support systems that create avenues to increasing the number of CDEs are “critical.”
“Having a CDE in a busy practice of endocrinologists, or even in primary care, is extremely valuable for setting up the best treatment for the person with diabetes,” Umpierrez, who directs a program that prepares health professionals to take the CDE board exam, told Endocrine Today. “The CDE is the one who will outline the treatment plan. The CDE will educate the patient, educate the family members, set up the technology, offer nutrition therapy, exercise therapy and, more importantly, answer questions in the day-to-day from people with diabetes. I guarantee to you that the midlevel provider is so busy that there is not sufficient time to invest the diabetes education that is needed.”
Changing landscape
Diabetes care and education specialists are a distinct group of interdisciplinary health care professionals. According to 2019 NCBDE statistics, 47.8% of CDEs are nurses, including registered nurses, nurse practitioners and clinical nurse specialists; 41.8% are dietitians, including registered dietitians and registered dietitian nutritionists; and 7.5% are pharmacists, with the balance made up of other disciplines, such as exercise physiologists, podiatrists, ophthalmologists and behavioral health specialists. AADE also offers a credential for board certification in advanced diabetes management, or BC-ADM.
“If you look across the landscape — all the disciplines — their scope of practice is so different,” said Cornell, who is also an Endocrine Today Editorial Board Member. “If you have a physician or a nurse practitioner CDE, they have prescribing rights. Pharmacists, we can do medication management. We do more than provide education. It’s about the care and the management of the person with diabetes. That’s where the landscape is changing.”
Diabetes education today means educators must be prepared to address all related comorbidities and complications, Karen Kemmis, PT, DPT, RN, MS, GCS, CDE, CEEAA, FAADE, immediate past president of AADE, told Endocrine Today. This includes serving as a go-to expert for diabetes technology for patients and incorporating a focus on behavioral health. Still, provider referral rates for diabetes self-management education and support (DSMES) remain low.
“We are currently underutilized,” Kemmis said. “We need to make sure people have utilization of our services, so that those who can benefit know about what we do and come to see us.”
Specialists must also become more adept at identifying gaps in care and developing creative solutions to fill them, according to Diana Isaacs, PharmD, BCPS, BC-ADM, CDE, clinical pharmacy specialist and continuous glucose monitoring program coordinator in the department of endocrinology, diabetes and metabolism at the Cleveland Clinic Diabetes Center.
“A lot of PharmDs have a collaborative practice, where we can make adjustments in diabetes medications and start and stop diabetes medications, depending on state laws,” Isaacs told Endocrine Today. “That is what I was originally hired for, to see patients in between their usual endocrinology appointments and do that, but when I came to Cleveland Clinic, I found we were really underutilizing CGM, especially professional CGM, which most insurance will cover. That really helped to transform my role into not just a clinical pharmacy specialist, but to a CGM program coordinator.”
Redefinition of roles
Health care systems in the United States are in the midst of a shift from the traditional fee-for-service payment model, in which providers are reimbursed based on the number of individual services provided, to a pay-for-performance model, which offers financial incentives to physicians, hospitals, medical groups and other providers for meeting certain performance measures. The pay-for-performance model, often referred to as value-based care, is designed to link reimbursement with quality health outcomes, Kellie Rodriguez, RN, MSN, MBA, CDE, director of the Global Diabetes Program at Parkland Health & Hospital System in Dallas and 2020 president-elect for AADE, told Endocrine Today. That outcomes-driven approach will drive more opportunities for diabetes care and education specialists, she said.
“Health care is moving from a pay-for-service model — being paid because you did something — to a value-based payment model — being paid because what you did positively impacted outcomes,” Rodriguez said. “This creates enormous opportunities for diabetes care and education specialists to demonstrate broader roles and value as it directly relates to achieving patient and organizational outcomes.”
The change means diabetes care and education specialists must move from the mindset of a traditional diabetes education program to one that embraces an “integrated diabetes service-line,” she said.
“If we look at, for example, health assessments, we can assist organizations with developing and implementing a robust health assessment structure that goes beyond the clinical assessment, which is often what we are focused on, and includes more of the social determinants of health factors, which really are about 80% of health outcomes,” Rodriguez said. “As a multidisciplinary group, we have the ability to impact not only the assessment, but the intervention and evaluation of those social determinants.”
Diabetes care and education specialists can also embrace technology to provide “care at scale” beyond individual patient visits.
“A lab order is a great example. Instead of ordering a lab order for a single patient, if I need HbA1c data for 300 patients due for an HbA1c, I’d rather use my electronic medical records framework to order lab work for all of those patients with only a few clicks of a button, leveraging the efficiency of our system,” Rodriguez said.
“We are the required integrator for care delivery,” she said. “The opportunity — or not — lies in our hands.”
Promotion backed by evidence
Diabetes self-management training is a benefit covered by Medicare and most health plans when provided by a diabetes educator within an accredited or recognized program. Yet fewer than 5% of Medicare beneficiaries with diabetes and 6.8% of privately insured people with diabetes in the United States participate in DSMES services within the first year of diagnosis, according to the CDC.
The issue is a two-pronged problem, Cornell said: There are not enough diabetes care and education specialists, and available specialists are not being employed effectively.
“I spoke with a doctor recently who asked how he should convey the reason to send his patients to a diabetes educator,” Cornell said. “That is the missing link, that referral. ... Educators may be getting referrals and the patients are not showing, or the patients are not getting them because the doctor thinks, why can’t I do it myself?”
Polonsky said specialists must also self-promote. That starts with more empirical evidence showing outcomes data, he said.
“I don’t want to sound too academic, but where is the evidence?” Polonsky said. “We have seen impressive strides with respect to the value of including pharmacists and even pharmacist/CDEs, and this is partly due to good published research that has documented their value. We now need to see similarly higher-quality published evidence of added value for diabetes care and education specialists. It is not unreasonable for endocrinologists to be skeptical in the face of inadequate evidence. ... I am not saying CDEs are not valuable; I am quite certain they are. I’m saying that value has not been well documented.”
Isaacs agreed that diabetes care and education specialists must do a better job of monitoring diabetes outcomes and publishing outcomes research.
“Our physicians want to see the literature,” Isaacs said. “We are not just lecturing people. We are doing such powerful things for our patients.”
Creating a partnership
Isaacs said ongoing communication across the health care team can determine how the diabetes care and education specialist will best complement the endocrinologist or general practitioner.
“The team has saved me on many occasions,” Isaacs said. “As a CDE, I try to find out where I can help the provider the most. For one provider, I see her patients the same day she sees them, and I help with the insulin pump adjustments. For another provider, I’ll see patients the same day and provide education. We work very collaboratively together.”
Cornell said specialists can work with physicians to determine how to best implement a care plan for the person with diabetes, ideally in the same building to make referrals easier.
“If we do this as a team, little chunks are done by each person on the team, and it takes the burden off the one,” Cornell said. “You focus on what your talent is, your scope of practice, and then you pass the baton to the next runner who will pick up where you left off and continue managing that same patient. If we can do this all under one roof, where we’re not having to have the patient go from one building to another building on a different day, we improve the office visit adherence.”
Endocrinologists have limited time to spend with each patient, Kemmis said. There is an opportunity for diabetes care and education specialists to work hand-in-hand with the endocrinologist to help people with diabetes get the full care they need.
“It is about allowing the person to demonstrate how to put a CGM on correctly, or change pump settings,” Kemmis said. “Diabetes takes a lot of time to help a person manage well. We are part of the team, and we can aid in that. Endocrinologists and primary care providers in general are so happy to work with us because we do have a lot to accomplish. We all want the best for the individual, and it takes a team.”
Changing names, competencies
At its annual conference in August, AADE announced what would be the first of several major changes for the organization and its members to better position educators to meet the need for services. The first, Kemmis said, would be a new name for its members: diabetes care and education specialists. The new designation is designed to better reflect the role of educators as the cornerstone of the diabetes care team — performing comprehensive assessments, setting goals, designing interventions and assessing diabetes outcomes.
In 2020, the CDE designation will transition to certified diabetes care and education specialist, or CDCES, according to NCBDE.
“Current CDEs will not have to retake the examination to use the new CDCES credential and may continue using the CDE designation,” NCBDE stated in a December press release. “However, as renewals take place beginning in 2020, certification documents will use the CDCES title, and newly certified individuals will use the CDCES credential.”
Additionally, the NCBDE organization will become the Certification Board for Diabetes Care and Education, or CBDCE.
Kemmis said she hopes the changes will serve to better get the word out about the utilization of diabetes education services.
“By working with people with diabetes, with referring providers, with governmental agencies, AADE wants to increase utilization of services of the diabetes care and education specialist,” she said. “When people do go through the process, they have better health and quality of life outcomes.” – by Regina Schaffer
- References:
- CDC. National Diabetes Statistics Report 2017. Available at: https://dev.diabetes.org/sites/default/files/2019-06/cdc-statistics-report-2017.pdf.
- CDC. Overcoming Barriers to Referral and Treatment. Available at: www.cdc.gov/diabetes/dsmes-toolkit/referrals-participation/overcoming-barriers.html.
- NCBDE. 2019 Count of CDEs by State and Other Statistics. Available at: www.ncbde.org/2019-count-of-cdes-by-state-and-other-statistics/.
- Pierson TL, et al. Diabetes Educ. 2019;doi:10.1177/0145721719857728.
- Rinker J, et al. Diabetes Educ. 2017;doi:10.1177/014521718765446.
- For more information:
- Susan Cornell, PharmD, CDE, can be reached at 555 W. 31st St., Alumni Hall 355, Downers Grove, IL 60515; email: scorne@midwestern.edu.
- Diana Isaacs, PharmD, BCPS, BC-ADM, CDE, can be reached at the Cleveland Clinic Diabetes Center, 10685 Carnegie Ave., Cleveland, OH 44195; email: isaacsd@ccf.org.
- Karen Kemmis, PT, DPT, RN, MS, GCS, CDE, CEEAA, FAADE, can be reached at State University of New York, Upstate Medical University, 750 E. Adams St., Syracuse, NY 13210; email: kemmisk@upstate.edu.
- William Polonsky, PhD, CDE, can be reached at the Behavioral Diabetes Institute, 5404 Oberlin Drive, #100, San Diego, CA 92121; email: whp@behavioraldiabetes.org.
- Kellie Rodriguez, RN, MSN, MBA, CDE, can be reached at Parkland Health & Hospital System, Global Diabetes Program, 5201 Harry Hines Blvd., Dallas, TX 75235; email: kellie.rodriguez@phhs.org.
- Guillermo Umpierrez, MD, FACP, FACE, CDE, can be reached at Emory University School of Medicine, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303; email: eumpie@emory.edu.
Disclosures: Cornell, Isaacs, Kemmis, Polonsky, Rodriguez and Umpierrez report no relevant financial disclosures.
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