Diabetes is a complex, costly and unrelenting disease.1 The rapid increase in pharmacologic and monitoring options, combined with an ever-changing health care environment, have created additional challenges not only for the person living with diabetes and their families or support persons but also for health care teams and health care organizations. Diabetes educators are uniquely positioned to help bridge the complex clinical environment with the self-care needs of the person with diabetes, optimizing outcomes. Transitioning clinical recommendations to effective real-world implementation seems unattainable, with only 14% of people with diabetes reported as achieving combined blood glucose, blood pressure and cholesterol targets.2 Transition requires thorough assessment, education and resource connection, in an overwhelmed health care environment and beyond into the community, where people with diabetes live with their disease. These are the unique skills that diabetes educators have developed and apply daily, which have led to the development of expanded roles beyond direct diabetes self-management education and support (DSMES). Our specialty practice is indeed one of the most valuable items in the “Diabetes Tool Kit.” Unfortunately, our skills are grossly underutilized, and our true value is largely unknown beyond our specialty.3 For professional survival, we must demonstrate, articulate and be recognized for our inherent value, not only to people with diabetes who seek our services but, just as importantly, to other health care professionals and our organizations that need our services for outcome-based results and payment. Our language must support the value of current and expanding roles in driving more effective and efficient care delivery models. Value-based health care provides the framework and language for greater recognition of our diverse and expanding contributions to diabetes care and education.
As diabetes educators, we have embraced the importance and value of language as it relates to people with diabetes. In 2017, the American Association of Diabetes Educators (AADE) and American Diabetes Association (ADA) created a joint paper providing important and clear communication recommendations about and to people with diabetes.4 Diabetes educators need to embrace language with the same degree of commitment for the specialty, with verbiage that expresses the same respect and value for who we are, what we do and our impact on the disease. Figure 1 outlines the opening statement to AADE’s language guidance document for people with diabetes5 if, for illustration only, we were to simply change out the words “people with diabetes” with “diabetes educators.”
We must harness the strength that can come from unified and targeted language for the specialty and address the losses that can occur without it.
There is national discussion regarding the title of “diabetes educator” and the applicability to our evolving roles. There is no question that people with diabetes and their families or support persons are at the heart of who we are and what we do.6 It is, however, professionally limiting and risky if it is all-encompassing and defines our total professional value. This is especially important to consider when our foundational reimbursement model of diabetes self-management training (DSMT) is one of fee-for-service, reflecting the opposite direction of where reimbursement is going in our health care environment. Alternate reimbursement models must be explored.
Value-based health care, founded on the Quadruple Aim principles, provides the role and language framework we need (Figure 2.)7,8 Educators should harness the Quadruple Aim framework to demonstrate their contributions toward population health, cost reduction, patient experience and clinician experience. There is a critical need to move from a mindset of diabetes program to one that is a broader system-based service. Educators should conceptualize, define and articulate their care team beyond their diabetes program, in an approach I term “Octopus and Bridge,” representing expanded reach and connection across their organization and beyond into the community. In our organization of more than 10,000 employees, every employee is considered a member of the diabetes care team, from clinical to business and administrative staff. Training initiatives have been developed within our hospital, specialty clinics, primary care centers and into the community to streamline the provision of quality diabetes care and education. Diabetes-related committees and workgroups have been established with multidisciplinary, multispecialty and administrative representation, ensuring system-wide involvement and communication. We are in the midst of developing a diabetes, behavioral health and oncology programs strategic plan to identify and address common clinical needs and processes, which also results in streamlined efforts and resource utilization.
As a multidisciplinary specialty group, diabetes educators can harness their broad knowledge, reach and resources to assist their organization to achieve Quadruple Aim objectives. In every patient interaction, we engage, assess, prioritize care, develop targeted strategies, communicate our messages and evaluate effectiveness—the same skills that can be applied to a broader population health model and other organizational initiatives (Table 1). Effective diabetes management requires prioritized and coordinated health care delivery approaches, in an environment that often suffers from inefficiencies, lack of collaborative practice and workforce fatigue. Diabetes educators have an ability to build and train effective care teams, streamline complex care processes and support a workforce and patient population under stress. Our role in workforce training and optimization provides a clear opportunity to drive our value for the person with diabetes, care teams and our organization.
System-based initiatives can also result in exposure to alternate payment models, such as state funding, grants, etc., raising our recognition for system contributions and value. In our organization, we have embraced the opportunity to participate in the Texas Waiver program, providing outcomes-based reimbursement for Medicaid and low-income uninsured patients.9 Outcome measures relating to hemoglobin A1c (A1C) testing and results (A1C<9%), foot exams, blood pressure control and reduced emergency department and hospital utilization have clear links to expanded roles for diabetes educators. Alternate payment opportunities can far exceed those payments received from direct DSMES service provision.
In a health care environment focused on outcomes, we must talk from a perspective not of what we do, but what we achieve in all these key areas. We need to demonstrate and articulate our contributions to clinical and process measures. We must review our respective reimbursement models in our work environments and reduce dependency on fee-for-service payments. For those working in smaller clinical environments, there is a need to optimize external “Octopus and Bridge” opportunities that result in partnerships that bring bi-directional value. Strength and value are gained from collaboration, strategic partnership, system exposure and impact.
The AADE has outlined its new vision for the specialty, called Project Vision. The six key vision pillars outlined in Table 2 highlight the important opportunities identified for expanded roles, organizational reach and recognition.10 While diabetes educators may have roles in some or all elements of the vision, it is important that our contributions are optimized, recognized and connected to people with diabetes, care team experiences and system outcomes.
Other strategies to consider in raising our professional value:
1. Embrace our inherent ability to lead. The “Seven C’s” of leadership—character, commitment, connectedness, compassion, confidence, courage and capacity11—are what our multidisciplinary richness as diabetes educators demonstrates and instills in people with diabetes every day. These are the exact leadership skills we should demonstrate with our broader colleagues and organizations. A leadership title is not a requirement to lead.
2. Align with the strategic priorities of our organization or identified partners. Diabetes educators should have intimate knowledge of their organization’s strategic priorities. It is highly recommended to print out a copy of our respective organization’s strategic plan and highlight the key activities and words outlined. What language is used or repeated? Is the language identified the same verbiage used when meeting with organizational colleagues, leadership and strategic partners? It should be! What are the key pillars of activity in the strategic plan? How can we each authentically align with those and advance them? Our diabetes service line should target or develop areas of contribution toward system goals and then “Octopus and Bridge.” Diabetes is everywhere, and so there are significant departmental or organization opportunities for bi-directional contributions and recognition. Having broader reach, impact and connectedness is important when administrators are making tough budget decisions. It is a much harder decision to close down a service line that is infused throughout an organization than it is to close down a department. It does not matter in which dark and remote location our department may be housed in our health system if our service is infused through all other layers of the organization, where it authentically belongs. We should not wait to be asked to contribute to initiatives; rather, we should identify authentic opportunities and proactively engage with them.
3. Spread the word. Internal marketing is as important as our external marketing. Actively identify and utilize organizational resources for role and service exposure: online platforms (e.g., webpage development), face-to-face, print, committee and corporate communications/media opportunities. Do not wait to be asked. The message we want to deliver effectively is not about what we do but how our work contributes to desired outcomes of the audience listening. We should utilize the Quadruple Aim framework as if it were designed specifically for our needs. We must outline how we can contribute to improved workflow and efficiencies by supporting practices. We must demonstrate the impact of improved training and efficiencies on provider, care team and patient experience. We must describe how, as a multidisciplinary rich specialty, we can connect people with diabetes to resources that support self-care and reduce cost or burden of disease. We can demonstrate our ability to assess and prioritize our population with diabetes and, through the use of care pathways and technology, provide care when, where and how it is needed.
As challenging as many people perceive the health care environment to be, one apparent certainty is that value-based, outcomes-driven care and reimbursement remain in our foreseeable future. The multidisciplinary richness of our specialty makes us uniquely qualified to contribute to the Quadruple Aim elements of population health, cost reduction, patient experience and clinician experience. To achieve our deserved value recognition, we must believe it is possible and proactively attain it. Value will not come to us. We must demonstrate through our actions and language the broader roles and outcomes we can achieve in diabetes care and education delivery, beyond DSMES. The time to demonstrate our specialty’s true valYOU is now!
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