DSME Coordinator Role

Diabetes educators often find themselves faced with the challenge of starting a diabetes education program/service or they are hired to manage one. For many educators with varying levels of clinical competence, starting, coordinating or managing a diabetes self-management program poses many challenges, and the development of additional skills for diabetes educators has become as important as clinical skills. These skills include:

■ Program development

■ Strategic and business planning

■ Financial management

■ Human resource management

■ Continuous quality improvement (CQI)

■ Outcomes management

The development of a strategic marketing analysis plan, when starting a DSME program, will increase the potential for long-term success. Along with a thorough market analysis, the educator needs to conduct a financial analysis of the proposed service, and be prepared to present this to the sponsoring organization or community supporter. Budgeting is an important aspect of program development and will continue to be an important component of ongoing program management.

Familiarity with the National Standards for Diabetes Self-Management Education or other applicable standards (Table 4) is essential for coordinators in the early stage of starting a program. The National Standards define quality DSME that can be implemented in diverse settings and which will facilitate improvement in healthcare outcomes for people with diabetes. They comprise ten evidence-based standards, which address structure, process and outcomes. The first national standard states that DSME must have documentation which describes its organizational structure, mission statement, and overall goals. It also states that quality must be an integral component of the program. There is strong scientific evidence in the business and healthcare literature which suggests that establishing a commitment to a strong organizational infrastructure which supports all of the above elements results in efficient and effective provision of services (25-28).

After the standards have been reviewed and 'homework' done, which includes community assessment, competitive analysis, target population and resource identification, a simple business plan is developed. It does not need to be complex, but serves as a guide for the leader and the team. According to the Joint Commission on Accreditation of Health Care Organizations (JCAHO), this type of documentation is important to both small and large organizations (29). Once the target population, their needs, and the resources needed have been identified, a team will need to be formed. This 'core' clinical team usually consists of three or four healthcare professionals with complementary skills who are committed to a common goal and approach (30). The diabetes educator may be the person who champions the case for diabetes education, but the organization's decision makers must demonstrate their commitment to a multidisciplinary team, along with the resources and infrastructure that enables the team to function (13).

The diabetes education team will be the most important resource of the DSME. Without knowledgeable and competent diabetes educators, there will not be a program. The studies on diabetes education and diabetes care have rarely studied the characteristics of who actually

TABLE 4 Clinician Educator Role

Self-care and family-care assessment, patient education skills

Communication, contact (acute/ongoing)

Review of clinical progress, problem-solving

Care trends, research, equipment, insurance team coordination

Care/case management provides the diabetes education, and what the outcome measures are of provider efficacy (31). The studies have been clear that the provision of diabetes care and education always require a team. The national standards state that DSME must be provided by a multifaceted educational instructional team, which may include a behaviorist, exercise physiologist, ophthalmologist, optometrist, pharmacist, physician, podiatrist, registered dietician, registered nurse, other professional, and paraprofessionals in the community.

They must be collectively qualified to teach all content areas, and must include, at a minimum, a registered dietitian and registered nurse (16,32). All instructors must be either a CDE or have recent didactic and experiential preparation in education and diabetes management. The research to date has shown that DSME is most effective when delivered by a multidisciplinary team with a comprehension plan of care (30-34). If the program aims to become an ADA Education Recognized Program (ERP), the minimum team, as described in the national standards and adopted by the ADA ERP, must be in place (39).

Following the market survey, a mission statement and goals should be developed before beginning to develop the team and program's services. There are several ways of approaching this. One common approach is to go back to the national standards and develop a curriculum based on Standard 7, which states that a written curriculum with criteria for successful learning outcomes is required, and the assessed needs of the individual will determine which content areas are delivered (Table 5). There are also a number of curricula already developed that meet the national standards criteria (Table 6).

For predicting success, program services must be based on the selected curriculum, as well as on the needs of the target population (Table 7). Demographics are analyzed for age, type of diabetes, payer mix (Medicare and some other insurers will mandate the delivery modality), and ethnic background. Clear descriptions of program services are important in order to market your program. There is still a widespread belief that 1:1 DSME is the best delivery modality, and that group teaching is a compromise made in response to economic pressure. However, there is data to support that group DSME is just as effective as individual education when utilized appropriately. The dilemma becomes not whether to provide quality DSME programs in a group format, but whether diabetes educators have acquired the skills and strategies to provide effective educational, behavioral, and clinical interventions in a group format. The diabetes educator who has assumed a role as program coordinator will need to be comfortable with applying change strategy not only for the patients but also for the staff. Quality management is also necessary to support the service.

Quality is a management philosophy that supports a continuous striving for service excellence and an unrelenting commitment to customer satisfaction. As individuals and organizations in healthcare began to attempt to define quality, hundreds of definitions came into existence. The definitions include terms such as quality assurance, quality assessment, total quality management and continuous quality improvement. The two models of quality activities most frequently cited have been the traditional structure, process, and outcome model of quality assurance, as described by Donebedian, and the industrial model of quality described by Deming, and Juran (40-42). Quality is fundamentally a philosophy, and there is no one prescription for application. It is the concepts that need to be applied to the goal of striving for service excellence. There are a number of quality methodologies, with continuous quality improvement (CQI) being one of the most utilized. Two other frequently used methodologies are quality planning and quality measurement (43). Understanding CQI is an important aspect for all diabetes educators, but especially for those who have assumed the coordinator role for program services. The steps in the CQI process are:

TABLE 5 National Education Standards Resources

Canadian Diabetes Association, Diabetes Educator Section, Standards for Diabetes Education in Canada U.S. Department of Health and Human Services, Medicare Program; Expanded Coverage of Outpatient Diabetes Self-management Training Services

International Diabetes Federation Consultive Section on Education, International Consensus Standards of Practice for Diabetes Education

U.S. National Standards for Diabetes Self-Management Education

TABLE 6 Curriculum References

American Association of Diabetes Educators (AADE). The Art and Science of Diabetes Education-A Desk Reference for Health Professionals

American Diabetes Association (ADA): Life With Diabetes: A Series of Teaching Outlines by the Michigan Diabetes Research and Training Center. International Diabetes Center, Type 2 Diabetes Curriculum Guide.

■ Identify problem/opportunity

■ Data collection

■ Data analysis

■ Identify alternative solutions

■ Generate recommendations

■ Implement recommendations

■ Evaluate actions improvement

Implementing a CQI program for DSME has now become one of the national standards for DSME, and has been adopted by the ADA ERP (2,20). Outcome measures form part of CQI; these are reviewed below.

Coordinator of professional, community education/consultant/advocate. Educators are often sought to provide professional and community intervention, together with prevention education, for a variety of groups ranging from other diabetes specialists to staff nurses, case managers, office nurses, pharmacists, primary care providers, and the general public. Educators develops their skill sets based on their current practice environment and their personal areas of interest (Table 2). Topics that they may be called on to present are diverse, and range from the core content areas in the National Standards to clinical management, and less traditional areas, such as program development, quality management, and behavior change strategies. They may include support group and screening activities, school and camp programs, or work-site or faith-based presentations. The topic areas are as diverse and multidimensional as the role of the diabetes educator itself. Use of talking circles, promoters, parish nurses and other community based programs offer a number of resources and opportunities for educators to help their patients access comfortable information and support resources.

Coordinator of disease/case management is a new term. In recent years there has been an effort to identify new models of care for chronic diseases such as diabetes. The traditional model of acute care has been shown to inadequately address the needs of people with diabetes. A recent survey of patients who received their diabetes care from primary care providers showed that they were receiving 64 to 74% of the ADA Provider Recognition Program recommended services (47). The new models apply some recurring themes, such as systems approach, population based; preventive services, evidenced-based medicine; and outcomes management through IS solutions. These new models of care are often called disease and case management (51). The diabetes educator has often been identified as a health professional with the requisite skill-set to coordinate such a model of care.

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