COMMENTARY

New Algorithm Guides Referrals for Diabetes Education

Linda Siminerio, RN, PhD, CDE

Disclosures

August 27, 2015

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Hello. I'm Linda Siminerio. I work at the University of Pittsburgh Medical Center. I am a diabetes educator and I do research in healthcare delivery systems. I am very excited to be at this meeting, where I was fortunate enough to be a part of developing a position statement on diabetes self-management education for people with type 2 diabetes. This position statement was jointly published by the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.[1] We are very excited about this position statement because it presents all of the evidence that we have of the benefits of diabetes self-management education for people with type 2 diabetes.

We know from the literature that diabetes education has a significant impact on improving clinical outcomes, behavioral outcomes, and psychosocial outcomes in people with diabetes. We know that it works. The challenge is that the number of people we reach with diabetes self-management education is abysmally low. Recent reports say that only 4% of Medicare participants have received diabetes self-management education services, whereas 6.8% of commercially insured people in the United States have received this service during the first year after being diagnosed with diabetes.

This is critically important. Diabetes education builds the foundation for self-management. We like to think that we manage diabetes from a doctor's office, but the truth is that more than 90% of the daily decisions about a lifestyle disease like diabetes are made by the person who lives with the disease.

What should they eat? How much should they exercise? What do their monitoring results mean? We can prescribe all of the medications that we want, but the person must know when and how to take them, particularly medications that are injectable. How can we expect our patients to have quality outcomes unless they understand the foundation for which they are doing all of these complex tasks in order to prevent the complications of diabetes?

 
How can we expect our patients to have quality outcomes unless they understand the foundation for all of these complex tasks?
 

One of the challenges that we have is that referral rates are particularly poor. In order for patients in the United States to receive self-management education from a trained professional, they have to have a referral from a physician. And for many reasons, referral rates are low. In a busy practice, one of the reasons is that there are so many things that the physician is expected to do with the patient, that referral for education may not be at the top of the agenda.

The way that we deliver education has not changed with the times. Traditionally, education has been delivered in outpatient hospital facilities. For a typical patient who is expected to start self–blood glucose monitoring or is expected to start insulin—complex tasks that take time to teach—the time isn't available during a quick visit.

The physician is expected to refer, and he may say something like this: "You need to start on insulin and I want you to start testing your blood glucose. It would be a great idea for you to go to an education program at the local hospital. I think they do it on Wednesday nights."

This is the communication to the patient, but there is no connection to those systems. The patient is expected to go. The physician thinks, "I recommended this for the patient. I am expecting that he goes." Then we find that there is a disconnect and the patient hasn't received the education.

Given the dynamic and complex nature of the self-management tasks that patients are expected to take home with them, they may not be done appropriately, and the patient may have difficulty adhering to that strategy. There are a lot of challenges with our healthcare delivery systems in making sure that patients have access to and receive this service.

What I am so excited about is this wonderful position statement that summarizes all of the evidence. It also includes an algorithm for physicians who have told us that they don't know when to refer patients. It clearly outlines in the algorithm for physicians that newly diagnosed patients with diabetes should receive a referral for diabetes education.

Patients who have a change in their condition or are developing a new complication should receive a referral for education. Or it could be a patient who is taking on a new complex task or who hasn't been able to handle their care, or patients who have had frequent visits to the emergency room or frequent hospitalizations, or those who are transitioning in life from living at home to living in a care facility. All of those critical points are outlined and are all based on the science of when those tasks and referrals should be made. They are available in this position statement.

The position statement was organized to be a user-friendly tool for primary care physicians to understand the importance of diabetes education and to easily access a means to understand the referral process. We have directed this position statement and developed it particularly for those who work in primary care, because the reality is that most people in the United States—more than 90% of people with type 2 diabetes—have their diabetes managed in primary care. We understand the many challenges that are going on in primary care, where physicians aren't just seeing a patient for diabetes but also for many, many other complex conditions that go along with diabetes.

I am happy to be here when we are launching this exciting tool, and I am very excited and enthused about the opportunity to reach more people with this very evidence-based service that we have to offer. Thank you very much for this opportunity to speak to you today.

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