Why You Should Prescribe Diabetes Education

New guidelines provide physicians with information to help steer patients toward educators

With Martha Mitchell Funnell MS, RN, CDCES, FAAN

Diabetes educator

According to the Centers for Disease Control and Prevention, only 6.8% of people with health insurance receive any diabetes self-management education and support services (DSMES) within a year of diagnosis, while the Centers for Medicare and Medicaid Services says that for its patients, the number is less than 5%. The American Association of Diabetes Educators says that the majority of people who do access the services, which are usually covered, only do so more than a year after diagnosis. 

Why is diabetes education underused?

Barriers to receiving diabetes education most commonly involve poor referral systems and issues with reimbursement. As a result, a new set of guidelines for DSMES has been released with the hope that it will reduce those obstacles to diabetes education, which has been shown to improve outcomes and reduce medical costs. 

The new guidelines were created by a consortium of diabetes organizations, including the American Diabetes Association, the AADE, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of Physician Assistants, the American Association of Nurse Practitioners, the American Pharmacists Association, as well as patient advocates who were included in the drafting process.

Does every diabetic patient need diabetes education?

Reasons why every diabetic patient needs rapid access to DSMES include:  

  • Improved A1c, with reductions in blood sugar of 0.45% to 0.57% 
  • Reduced onset following prediabetes diagnosis
  • Reduced complications related to diabetes
  • Reduced all-cause mortality
  • Improved quality of life
  • Increased beneficial behaviors such as healthy eating and exercising
  • Reduced diabetes distress
  • Reduced healthcare costs

Four times when providers should bring up DSMES

  1. At diagnosis, which can be overwhelming and distressing to patients
  2. When the patient isn’t meeting their health goals, or at their annual medical appointment
  3. When there are complications, such as diabetes distress, which may affect as many as 36% of patients with diabetes 
  4. When there are transitions in life and/or care (such as moving to assisted living)

 

The guidelines also compare what resources are available to diabetic patients at these four moments, both from a medical provider and from an educator. For example, while a physician may answer questions and provide some emotional support to the patient upon diagnosis, the diabetes educator’s to-do list includes assessing “cultural influence, social determinants of health, health beliefs, current knowledge, physical limitations, family support, financial and work status, medical history, learning preferences and barriers, literacy, and numeracy to determine which content to provide and how.”

"Physicians, in a 10 or 15 minute appointment, don’t have time to do that," says Martha Mitchell Funnell MS, RN, CDCES, FAAN, one of the authors of the guidelines and a research scientist at the University of Michigan Medical School. Even if a patient is seeing a nurse practitioner or a physician assistant, 30 or 45 minutes won’t be enough to find out all the information that can lead to improved patient outcomes.

7 recommendations for HCPs to help encourage patients toward diabetes education

  • Talk about the benefits of DSMES
  • Refer patients to a program at each of the four critical moments mentioned above
  • Ensure coordination between nutritional therapy, medication management, DSMES, and overall health management
  • Identify any barriers for patients to participating in diabetes education and help remove them
  • Expand awareness, access, and utilization of DSMES
  • Identify and remove barriers that providers have in referring patients for these services
  • Facilitate referrals, reimbursement, and other financial supports of DSMES

Funnell says that there are some patients who feel a real stigma from diabetes, and they may think that education will be boring lectures from people who will scold them and tell them what they're doing wrong. “We don’t necessarily do a good job of letting diabetic patients know that we're there to make their lives easier – and the physician’s life easier, not harder. We need to talk more about that and make it more clear.”

She likens diabetes to a puzzle with many pieces: medications, how the patient feels, their emotional response to disease, and the food and lifestyle choices they make. “My job is to help patients put all those pieces together. Maybe they have gone on the internet and found a little about diabetes, and about medications from their doctor or pharmacist. But there is more to it than that. It can be confusing, overwhelming, and a lot of work.”

While patients sometimes don’t follow through on a referral, another big issue is providers failing to refer patients, and then not following up to see if they have taken advantage of the education, she says.

"HCPs, too, may have an obsolete and incorrect view of what DSMES can do," Funnell says. They may have heard from patients that the content was boring, or that it took too long. “We hear from patients that no one told them about it and from providers that their patients don’t like it. There's a big disconnect happening that we're trying to remedy this time around.”

Taking a patient-centered approach to diabetes education

For patients who think they'll be bored, Funnell explains she doesn’t start with a lecture on the pancreas. “I ask them why they're here and what's important to them. I hear a lot of questions about how to get off the medications they're currently on.”

"Physicians can tell patients that with diabetes education, it might be possible to maximize the effectiveness of their medications, potentially reduce dosages, and reduce the number of medications, or even eliminate prescription management of their disease as an incentive to motivate them to try it," she says.

“We talk a lot about what patients are struggling with, and how to deal with the emotional side of this disease,” Funnell notes. “Diabetes distress is more known now, and we discuss that. When patients hear that it's a common reaction to diabetes, they feel relief that they're not alone. Then we help them manage it.”

"Five years ago, when the original guidelines were published, we thought we would see an increase in referrals, but that didn’t happen. So, we worked to figure out how to make them more useable to our audience,” Funnell says. One problem with the first set was that it was circulated mostly in the diabetes education world and publications that diabetes educators read. Unfortunately, physicians who could make referrals were not part of the built-in audience.

The new guidelines are updated, especially regarding new medications and technologies that can be leveraged to help patients better manage their diabetes. There is also an effort to help providers better understand patient-centered care, and the guidelines now include suggested patient-centered questions that HCPs can ask at every appointment. “We don’t want patient-focused care just to be buzzwords, we want to help physicians implement it in their offices,” says Funnell. Lastly, the new guidelines include more information on how to appropriately code for this service so that it can be more easily covered by insurance and reimbursed.

What can HPCs do once they review the new guidelines?

“They need to convey that diabetes educators can provide answers to questions they don't have time to address during a brief medical appointment, and that we can help patients manage their new diagnoses. We can provide more personal help that will make physicians more efficient. It's time to treat diabetes education as necessary, just like the medications they prescribe.”

It’s never too late for a patient to get this information. “We see patients after eight or 10 years, when they are starting with insulin, and we help them use it to the best advantage, working with their schedule and their food choices. We help them fit diabetes into their lives.”

Ideally, every patient with diabetes would be referred for education. “Not everyone will come, but I’d like to see physicians know more about the value, give that information to patients so they can make a decision, and think about more than the prescriptions they can write. This is cheaper than many medications, and no one’s head will explode from too much information. Please keep it at the top of your list of things to tell your patients, not at the bottom.”

Continue Reading:
Expanding the Role of Clinical Diabetes Educators Intensifies Diabetes Management
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