For years now, we’ve complaining about the state of diabetes education in this country: overworked educators, near-impossible hoops that prospective CDEs have to jump through, and difficulties in getting reimbursed by insurance companies (so what else is new?). Who read my big exposé article on this issue waaay back in 2007?
We DOC advocates met with representatives from the American Association of Diabetes Educators (AADE) at the second Roche Diabetes Social Media Summit in 2010, 
but that meeting of the minds didn’t exactly go as planned. Diana Pihos, the organization’s Director of Communications, wasn’t prepared for our onslaught of criticism. Afterwards, however, she shared her positive feedback about what the AADE planned to do to improve the quality and availability of diabetes education.
It’s now been FOUR YEARS since the initial article, and a year since Diana’s post, so we were wondering… Are things getting any better? What has the AADE done to address the most salient problems?
We were fortunate to meet Donna Tomky, the new President of the AADE at this year’s conference in Las Vegas, and we invited her to address these concerns:
A Guest Post by Donna Tomky
It’s no secret that the American healthcare system is not adequately meeting the needs of patients—and those with diabetes in particular. While there is movement toward patient-centered, preventative, and chronic care models and services, too many healthcare providers and payers continue to adhere to an outdated, ineffective, and expensive way of doing business. This situation is particularly concerning when viewed in the context of the diabetes epidemic. In the coming years, the number of individuals with diabetes will increase exponentially…taxing an already over-burdened healthcare system.
Amy Tenderich’s article in the 2007 issue of Diabetes Health Professional, “The Crisis in Diabetes Education: Essential Care That’s Riddled with Problems and What We Can Do to Fix It,” identified several of the key factors that have prevented diabetes education from growing as a profession and becoming a more widely-used benefit, including the lack of a viable career path for diabetes educators, limited patient access, and variations in the quality and nature of diabetes education services support and reimbursement.
I’d like to thank Amy for asking us to provide an update on the developments that have been made since her article was published. AADE recognized the same challenges she mentions in her article and we have been systematically addressing them for the past several years. I’m pleased to report that much has been accomplished and a solid foundation has been laid for the future growth of the diabetes education.
def·i·ni·tion
DSMT = Diabetes Self-Management Training (official term for working with a CDE)
Defining the Diabetes Educator Career Path and Diminishing Barriers
One of the most significant ways that the discipline has been strengthened since 2007 is by the development of documents that support and clarify the roles and scope of practice for diabetes educators. In 2009, AADE released The Guidelines for the Practice of Diabetes Education and the Competencies for Diabetes Educators. This groundbreaking document outlines the various levels of practitioners (see below), their level of responsibility and the specific knowledge, content and abilities that are needed to practice at that level.
The Guidelines are inclusive and specifically include a place for community health workers and other non-healthcare professionals who can reinforce the messages of diabetes education in the community and provide vital support to individuals with diabetes:
- Level 1 – the non-health care professional that is typically a community health worker or healthcare technician
- Level 2 – the health care professional that occasionally educates a person with diabetes as they provide medical support
- Level 3 – the health care professional that may specialize in diabetes education but who is not yet a certified diabetes educator
- Level 4 – the Certified Diabetes Educator (CDE)
- Level 5 – the diabetes educator that has advanced skills and experience to develop and manage diabetes education programs or provide comprehensive clinical management. The CDE credential or Board Certification in Advanced Diabetes Management (BC-ADM) is a necessary prerequisite for this level.
The Guidelines were accepted by the National Guidelines Clearinghouse in June of 2009 and were incorporated into the clearinghouse later that summer (NCG is made available by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services). This means that the guidelines are widely available for review by health care professionals and the public, although the details of how individuals will be officially certified and recognized at these various levels are still being worked out.
To this end, the guidelines are being used by several programs seeking accreditation through AADE’s Diabetes Education Accreditation Program and are being examined in an AADE pilot study that integrates multi-level DSMT teams into patient-centered medical homes. AADE also uses the guidelines and levels to help us classify our professional development opportunities with an eye towards meeting the needs of all levels.
Another barrier that Amy identified in growing the diabetes educator workforce is the process for earning a credential.
The National Certification Board for Diabetes Educators has lowered the required number of hours to 1,000 in order to sit for the exam. This development should remove some of the barriers to becoming a diabetes educator.
Establishing State Licensure for Diabetes Educators
Another way to potentially alleviate this catch-22 is by establishing State Licensure for Diabetes Educators.
At this time, there is no way of recognizing qualified professionals who are practicing diabetes educators with or without a voluntary CDE or BC-ADM credential. Licensure for Diabetes Educators would set the minimum quality standards and the scope of practice for the diabetes educator. It will ensure that all healthcare providers who deliver diabetes education will have sufficient knowledge to provide safe, effective care to persons with diabetes. And by doing so, will provide a clear entry point for diabetes educators who can then pursue credentials, if they wish.
Establishing state licensure for diabetes educators is a long-term endeavor. For it to have a significant impact at the national level, quite a few states will need to establish licensure. AADE only recently embarked on this initiative on a state-by-state basis, and Kentucky was the first. Several other states have stepped forward to be next. Each state sets their own requirements for licensure, so the Kentucky regulatory bodies are now determining the specific qualifications for KY licensure for diabetes educators.
AADE does have recommended requirements for state licensure, and while we provide these to the state leaders, the actual specifics of the legislation are up to the state’s regulatory body. While advocating is really up to the educators and individuals within those states, AADE provides support and resources to help them get organized and start the legislative process.
New Delivery Models Expand Access to Services
Improving access to diabetes education has been a major strategic priority for AADE for several years. To that end, we have been proactive in exploring the potential of new delivery models as they emerge.
We are particularly pleased to begin work on a new demonstration project focusing on mobile health. With the Office of Minority Health, Baylor Diabetes Health and Wellness Institute and AT&T, we are facilitating a project that will connect diabetes educators with patients via mobile technology and video platforms. We believe these mobile technologies have huge potential to revolutionize the way educators can interact with their patients and increase access to diabetes education services, particularly in rural and underserved areas.
Improving Reimbursement for Diabetes Education Services
If we hope to grow the profession and increase both the number of diabetes educators at all levels and the number of individuals taking advantage of our services, we must focus on the “bottom line.” Diabetes education must become profitable, and to do this, reimbursement levels must be increased. Although our work is not done, AADE has made some positive progress in this area over the last year.
Together with other diabetes organizations, AADE petitioned CMS (Centers for Medicare & Medicaid Services - the organization that determines coverage) to increase reimbursement for DSMT services. Our efforts succeeded and a significant increase was effective January 1 of this year (for example, coverage for 30 minutes of one-on-one training went up to $54.70 from $23.45). Also, DSMT has been added to the list of reimbursable telehealth services, meaning that programs are getting paid more for these services — which has the potential to increase clinics’ profits, helping them to remain financially viable now and in the future.
Another way that we are approaching this issue is by continuing our efforts to get CMS to recognize credentialed diabetes educators as providers of DSMT at the national level via House Bill 2787 and Senate Bill 1468.
Much Progress Has Been Made, But Work Continues
AADE recently commissioned a study to help us understand the current landscape of diabetes education and to determine the future demand for and supply of diabetes educators. The study showed that as the diabetes epidemic worsens, the demand for diabetes educators is projected to increase by at least 60 percent between now and 2025. This number will increase exponentially if more individuals – such as those with pre-diabetes – become eligible for diabetes education.
The progress we’ve made over the last few years has significantly strengthened the profession and has positioned us for growth. But work still needs to be done. We will continue to work toward refining the profession, increasing access to and awareness of diabetes education, exploring new technologies and delivery models, and improving reimbursement for services.
We at the ‘Mine are 110% behind increasing quality of and access to diabetes education — so we’re crossing our fingers (and toes) that the work of the AADE here makes an impact. Any prospective CDEs in the audience?
Glad to see the introduction of a Level 1 category. Has AADE opened up access to more of their publications? As the number of people with diabetes continues to increase and the ratio of diabetics to endos gets worse, CDEs are going to be crucial in the next decade or so. Especially CDEs associated with groups of internists. Any progress on better reimbursement for CDE appointments? That seems to be a remaining roadblock in many places.
I would like more information on the Level 1 category. How and where does one get the training? What are the prerequisites?
Call me a skeptic when it comes to the AADE: this is a group that works to promote its own interests, which means keeping as many out of the profession as possible. Patients would be served best if there was an alternative to the current certification process, meaning a rival “certification” board existed, just don’t expect the AADE to promote such a thing.
Call me a skeptic when it comes to the AADE: this is a group that works to promote its own interests, which means keeping as many out of the profession as possible. Patients would be served best if there was an alternative to the current certification process, meaning a rival “certification” board existed, just don’t expect the AADE to promote such a thing.
This is mostly a rant, but I’ll preface by saying it’s encouraging to see that they’re trying to expand the profession, thus expanding patient access. I understand those kinds of changes take time to structure and implement.
However, I still have a bee in my bonnet that social workers and psychologists can get certified, but other masters level mental health professionals can’t. I chatted with a couple of psychologists who are CDE’s over the summer, and if I recall correctly, one of them told me how many psychologists actually hold the CDE credential, and I was appalled at how low the number was, I think well below 20… 20! (I don’t know where to verify that number, and I’m drawing from memory of a conversation, so that might not be accurate.) That despite the fact that successful medical outcomes are not only contingent on patients having a solid knowledge base, but also following through on management-related behaviors. Diabetes is obviously a medical condition, but the nature of management may as well make it a behavioral health condition. I’ve ranted about this all over the interwebz on many occasions (as you DM ladies know!), but it burns me up every time the issue comes up. Furthermore, CDE’s are in the early process of establishing state licensure which will allow for reimbursement, but many mental health providers already have state licensure that means patients can get reimbursed for the services they receive. If the CDE standards were expanded to better integrate mental health care, many patients could get the behavioral health support they need, the diabetes education they need, and they could get reimbursed. It’s so frustrating to me, it makes my head spin.
All of that being said, thanks for the update. I hope AADE and NCBDE continue their efforts to expand access of much needed services to patients, even beyond the successful implementation of the initiatives outlined here. I’m a big fan of creative thinking, and that’s going to be instrumental in alleviating the disconnect between who needs diabetes education and who’s getting it.
It’s very interesting what Lee Ann said because it turns diabetes around. Most look at diabetes as a medical condition and then bemoan that patients don’t change their behavior. But if we look at it as Lee Ann said, as “a behavioral health condition” then we have a whole different starting point for qualified professionals to enter the field and a different concentration in training.
Currently, very few GPs, endos, nurses and even CDEs have behavioral change skills and so after they tell patients what meds to take, they think they’re done. Patients go home, have trouble doing what they’ve been told and get complications. But if we started from the point of view that diabetes is a behavioral condition, professionals would get trained to help patients make the necessary changes to support their self-management and their health.
But it will take a whole different model for the AADE to see it that way let alone turn the ship around.
I was in the same conversation as Lee Ann (I think), and I believe the number given was 12. Twelve psychologists in the whole country who are certified CDEs.
And unless I missed it, the career path doesn’t seem to be laid out here, does it?
I love my CDE, and wish hundreds more just like her were available to all in D-land. Can the AADE invent a cloning machine?
Thank you for the questions. I?ll try to answer them here:
Bernard: While some of our publications are for members only, there are also many that are available to everyone. We agree that diabetes educators need to be in many different practice settings and we?re noticing that more are partnering with PCPs and providing care in the physician office, community centers, and non-traditional settings. Reimbursement for diabetes education went up 44% ($12.99 to $18.69) for group classes in 2011, which is a positive step in the right direction!
Mary: At this time there is no formal training for Level 1 educators but you may want to check out our online Fundamentals of Diabetes Care course (https://www.diabeteseducator.org/ProfessionalResources/products/fundamentals.html), which is free and meant for healthcare technicians and others interested in the practice of diabetes education. We?re also in the process of developing resources to help facilitate a career path for the beginning levels so stay tuned.
Lee Ann and Riva: Please review AADE’s position statement on AADE7 Self-Care Behaviors (http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/AADE7_Position_Statement_version_2011_update.pdf) to learn more about the changing paradigm of DSME/T. We recognize that behavior change is the key outcome of DSME/T and encourage all diabetes educators to use interventions for facilitating healthy self-care behaviors in their practice. We have learned and continue to learn from behavioral health specialists and would encourage more to join AADE to enrich our multi-discipline organization.
Thank you all for your comments and questions. l will try to answer them here:
Bernard: While some of our publications are for members only, there are also many that are available to everyone. We agree that diabetes educators need to be in many different practice settings and we’re pleased to see that they are increasingly partnering with PCPs and providing care in the physician office, community centers, and non-traditional settings. Reimbursement for diabetes education went up 44% ($12.99 to $18.69) for group classes in 2011, which is a positive step in the right direction!
Mary: At this time there is no formal training for Level 1 educators but you may want to check out our online Fundamentals of Diabetes Care course (https://www.diabeteseducator.org/ProfessionalResources/products/fundamentals.html), which is free and meant for healthcare technicians and others interested in the practice of diabetes education. We’re also in the process of developing resources to help facilitate a career path for the beginning levels so stay tuned.
Lee Ann and Riva: Thank you so much for speaking up for mental health professionals. AADE recognizes that behavior change is the key outcome of diabetes education and believes that the emotional impact of diabetes needs to be cared for in addition to the physical. That’s why we include Healthy Coping and Problem Solving as two of our AADE7 Self Care Behaviors. We have a updated position statement on the AADE7 if you are interested: (http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/AADE7_Position_Statement_version_2011_update.pdf). Over the past several years, we’ve developed curricula around behavior change, created tools for measuring it and incorporate it as an outcome in all our demonstration projects. I don’t know exactly what NCBDE’s requirements are for mental health professionals wanting to become a CDE, but I do know that we have learned and continue to learn from behavioral health specialists and would encourage more to join AADE to enrich our multi-discipline organization.
Again, thank you for the feedback.
@LeeAnn: Just a quick note on the issue of clinical psychologists and why there are so few — and virtually none at the MA/MS level.
If you read the eligibility requirements for initial certification 2011 as found on the National Certification Board for Diabetes Educators page(http://www.ncbde.org/eligibility.cfm), qualification 1a reads:
1.Discipline
A.Clinical psychologist, registered nurse, occupational therapist, optometrist, pharmacist, physical therapist, physician (M.D. or D.O.), or podiatrist holding a current, active, unrestricted license from the United States or its territories.
Most people understand “clinical psychologist” to mean someone who works with people who have moderate to severe behavioral, emotional and mental issues (exceedingly basic, I know, but please bear with me). For decades, there have been a number of MA/MS-level programs in clinical psychology that led to students becoming licensed clinical psychologists without having to obtain a doctoral degree. By the late 1980s, though, that changed. Prozac was new on the market and both psychiatrists (MDs with specialized training in psychiatric disorders) and psychologists recognized that a new era in the treatment of many mental disorders had arrived — the era of prescription meds. At that time, licensed psychologists, counselors, social workers, etc, did not have prescription privileges. Members of the American Psychological Association thought it was wrong and began to wage a long war to allow prescription privileges. I was an undergrad psychology major at the time and I remember my department chairman telling me and my classmates that if we intended to work in the mental health field, we needed to be willing to obtain a PhD, since by 1990, no one with a master’s degree in a mental health field would be allowed to sit for the psychologist-licensing exam in Pennsylvania. These same changes have been enacted throughout the country, and it was due at least in part to the push to obtain prescription privileges. The APA could tell states and the federal government that the only people who could call themselves “psychologists” or “clinical psychologists” were people with a doctoral degree, thousands of hours of internships, (and now) post-doc work — giving clinical psychologists comparable training to psychiatrists. I’ve done some research on the current state of affairs and there is only one state in the union that allows people to be licensed as psychologists with only a master’s degree: Vermont. Other states that do allow people to practice psychology do not grant MA/MS holders a full license. These licenses are “Associate” or “Assistant” psychologist licenses and requre the holder to be supervised under a licensed, doctoral-level psychologist. They are NOT clinical psychologists and are not allowed to call themselves by such a title.
Are there still some MA level clinical psychologists out there? Yes, there are, though many of them were “grandfathered” into the current licensing rules. For the most part, though, clinical psychology MA programs have had to change. People coming out of those programs are often encouraged to sit for the LMSW tests — if their states allow them to do so. They are also allowed to work under terms such as “behavioral therapist”, “mobile therapist”, occassionally couselor, but almost never are they allowed to work under the term “clinical psychologist” or even simply “psychologist”.
Therefore, under the rules for the CDE exam, virtually no one with a Master’s degree in psychology would be allowed to sit for it. Even certain doctoral degree holders might not be allowed to sit for the exam, such as those receiving their PhDs in Health Psychology, if it does not have the backing clinical internships, APA or CPA certification, post-doc positions, and a host of other hoops through which the candidate for psychology licensing must jump. To me, that is simply a waste of potential talent. In reality, when it comes to the mental health arena, there are only two groups who are allowed to play: PhD/PsyD/EdD clinical psychologists and MSWs. The rest of us with backgrounds in, oh, say, LEARNING SCIENCES (c’est MOI, and isn’t that what diabetes EDUCATION is supposed to be about — LEARNING??) or Art Therapy (c’est toi!!) aren’t welcome at the table.
IMO, the diabetes education industry is not taking advantage of the intellectual and clinical resources that are out there, despite the growing shortage of trained professionals and the exploding patient population. By only accepting only those with very specific backgrounds, the AADE and the NCBDE are ensuring that more people with diabetes will not know how to manage their diabetes. I do agree with you, Lee Ann. Things need to change!! (Ok, so it wasn’t quick, but this was my rant!)
Enjoyed the article, I am a diabetes educator in utah
Sitting here listening to Amy at conference. Awesome stuff!