ADA Moves to Improve Referrals for Diabetes Self-Management

Miriam E Tucker

June 06, 2015

BOSTON — A group of US societies has issued new guidance to doctors on when they should refer patients for diabetes self-management education.

"There is confusion as to why diabetes education is needed, when diabetes education should occur, what is needed in diabetes education, and how it should be provided.…This confusion leads to patients not receiving the needed services of diabetes education and support," said lead author of the joint position statement Margaret Powers, PhD, research scientist at the International Diabetes Center at Park Nicollett, Minneapolis, Minnesota, and American Diabetes Association (ADA) healthcare and education president-elect.

"Our goal with this paper was to reduce this confusion and provide clear guidelines and expectations for clinicians and for patients," said Dr Powers.

The joint position statement has been released by the ADA, the American Association of Diabetes Educators (AADE), and the Academy of Nutrition and Dietetics, in collaboration with the National Diabetes Education Program (NDEP).

It was published online June 5 in Diabetes Care and presented in a press briefing here at the American Diabetes Association (ADA) 2015 Scientific Sessions.

The statement calls for referral to accredited diabetes education programs at four key points: at diagnosis of diabetes, on an annual basis, when new complicating factors (diabetes-related or other) influence self-management, and at the time of transitions in care, such as pediatric to adult or for an adult to a nursing home. The document provides detailed guidance for issues that should be addressed at each of those points, such as an emphasis on urgent safety concerns at diagnosis and ongoing management of trouble spots at annual visits.

While the statement focuses primarily on type 2 diabetes, the general principles apply to everyone with diabetes. The aim is to fill a gap that is not covered by other guidelines addressing medication use and HbA1c targets — the aspects of care that interweave with human elements affecting diabetes control, such as patient preferences, cultural differences, and individual barriers to medication and lifestyle adherence.

"We thought really the daily decisions that people with diabetes have to make were not being addressed appropriately, so we wanted to provide an algorithm that would guide clinicians and patients as to the diabetes education that was needed," Dr Powers said.

Education Improves Outcomes

"There is actually a substantial body of research on the value of education," explained coauthor Martha M Funnell, RN, research scientist and adjunct nursing lecturer at the University of Michigan, Ann Arbor, "including lowering hemoglobin A1c levels, reducing the onset or advancement of diabetes complications, improving lifestyle behaviors, reducing diabetes-related distress, and improving quality of life."

And, Ms Funnell said, the literature also shows that diabetes education is cost-effective, particularly in reducing hospital admissions and readmissions. Studies have also shown that patients who receive diabetes education are more likely to receive kidney and eye screenings.

Medication costs typically go up with diabetes education, "but that's because people are actually taking their medications and getting their prescriptions refilled. So, diabetes education works," she noted.

But despite the benefits, one recent study showed that among adults aged 18 to 64 years with diabetes, less than 7% had received formal diabetes education. "While less than 7% is a great A1c number, it's a really lousy number for the number of people who get education," she quipped.

Barriers to referral include providers not knowing how to refer, not thinking about it, not having diabetes education nearby, or not believing that it's helpful, Ms Funnell said.

"Our hope for this position statement is that it will begin to change some of that perception, so that patients do get the referrals that they need so they can effectively manage as they go through their lives with diabetes."

"An Underutilized Benefit"

The statement also addresses reimbursement. Currently in the United States, Medicare and many private insurers cover 10 hours of initial diabetes education and 2 hours in each subsequent year, delivered by programs that have been accredited by either the ADA or AADE. Providers can be certified diabetes educators or other specially trained individuals such as community health workers under supervision.

Covered services include an initial one-on-one assessment and subsequent group education and support sessions, unless the prescribing provider supplies a specific reason that the individual patient needs more one-on-one attention, another of the statement coauthors Joan Bardsley, RN, from the MedStar Health Research Institute and MedStar Nursing, Hyattsville, Maryland, and immediate past-president of the AADE, told Medscape Medical News.

She said that this reimbursement model is somewhat outdated and needs to be revised, an issue that the AADE has been working on.

"It shouldn't be locked into how many hours Medicare says. Some patients need much more over a certain period of time. And the way Medicare goes, so does everybody else.…Insurance is dictating what a patient may or may not need without knowing what the patient needs," Ms Bardsley said.

However, she pointed out that while not ideal, the current reimbursement is still better than nothing and should be used more often. "Even though it's reimbursed, people aren't using the benefit that's there.…It's an underutilized benefit."

Dr Powers added, "The accountable-care organizations [ACOs] are looking at pay for performance. We know that we can improve diabetes outcomes.…So the more educators are utilized for the services we've described, we contribute to the ACOs' bottom line because they will meet their quality measures and get lots of money back."

The authors have no relevant financial relationships.

Diabetes Care. Published online June 5, 2015. Article

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