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Part 1 of 6 Parts
When I first started reading this, mythought was to bypass it and maybe consider this later, if at all. Something made me come back and read some parts, and ouch! I mustsay my wife was surprised and asked me what was making me roar withlaughter. In reality, this is not funny, but the content and some ofthe ways they approach different parts do make me wonder.
It starts with the first paragraph. Isee these numbers in most sources and can believe that they arerealistic as estimates. The algorithms used probably make thesenumbers more accurate than we realize. Now is where the amusementstarts. The American Association of DiabetesEducators website formerly had listed memberships of about 13,000members. They have now removed this number for whatever reason and asearch of the site does not reveal the membership numbers.
With 18,800,000people with diabetes and 13,000 CDEs (certified diabetes educators),this means that allotting one hour per patient would mean seeing1,446 different patients per year and having 594 patients they couldsee twice a year. This is figured on a 2,040 hour work year andallowing 80 hours for vacation or two weeks. Now we know thesenumbers are not realistic as many patients are seen four times peryear, or more. We don't know how many CDEs only work part-time, howmany are not doing actual educator work, how many are retired, howmany are in administration, and other numbers writing books and goingon speaking tours. We know that most people with type 2 diabetesnever even see a CDE, therefore we have to question if the CDEmembership numbers are realistic. This says nothing about manyrural areas of the USA where no CDEs live.
I did not include the seven millionpeople that are estimated with undiagnosed diabetes because the CDEswould not be seeing them. Nor will I include any of the estimated 79million people said to have elevated risk of type 2 diabetes. Thenfor the people on the “Task Force” for developing the standardsto make this statement, “Diabetesself-management education (DSME) is a critical element of care forall peoplewith diabetes and those atrisk for developing thedisease,” (bold is my emphasis) really makes me laugh asmany CDEs do not even teach DSME. They seem to prefer mandates andmantras to doing an actual assessment and developing an educationplan based on any assessment.
Until the AADE starts a division forpeer-to-peer workers and peer mentors and gives them some of theskills needed, there will not be sufficient people to use DSME orgive DSMS (diabetes self-management support) to the people with type2 diabetes, much less those at risk for developing the disease. Thestandards have high ideals, but not the personnel to make them work. This is why I needed to laugh to avoid becoming angry.
When I read statements like this blog,and I have to agree with the sentiments expressed, and then alongcomes a comment like the first comment, it really points out theproblems existing in our healthcare system. It also points out theproblems in the CDE profession and their attitude about people withtype 2 diabetes. I am not denying that people with type 1 diabetesmay need more education and support than many people with type 2diabetes. For people to say that endocrinologists should beexclusively for people with type 1 diabetes is not realistic. Morepeople with type 2 diabetes are finding out that insulin works forthem and has less side effects than many of the oral medications. They also need the education and support.
If you are concerned about peer-to-peerworkers, peer mentors, and think I am pushing my own agenda, readthis by the Standards Task Force.
“In thecourse of its work on the Standards, the Task Force identified areasin which there is currently an insufficient amount of research. Inparticular, there are three areas in which the Task Force recommendsadditional research: 1. What is the influence of organizationalstructure on the effectiveness of the provision of DSME and DSMS?2. What is the impact of using a structuredcurriculum in DSME?3. What training should be required forthose community, lay, or peer workers without training in health ordiabetes who are to participate in the provision of DSME and toprovide DSMS?”
Yes, this is one of my aims and I amhappy to see the Task Force suggesting that it be researched. Whileit is being researched, it needs to be acted on now as the number ofpeople developing diabetes will continue to grow and the numbers ofCDEs is not growing at a pace to keep up.
As for research on the influence oforganizational structure on the effectiveness of the provision ofDSME and DSMS, all we need to do is look at what has happened withDSME in the past. The organizational structure may be there at theupper levels, but at the practicing levels, there is no support forit except from rare individuals. There is also little research andsupport for DSME for the elderly as many CDEs will not work with themand consider this a waste of time since these people are no longercontributors to society. I have written about this here and here. It will remain to be seen if they will consider the value many ofthese elderly people could contribute as peer workers. Just don'thold your breath waiting for this to happen.
I would urge everyone to take the timeto read the National Standards to be able to understand what may bepossible. I would also encourage this so that if allowed, we areready for an intelligent dialog and if denied this, as a way to holdthe feet of the CDEs (including the AADE) to the fire. This may beonly one of the ways we can break the exclusionary lock theypresently have and are still very much trying to hold onto by keepinglay people out.
25 Şubat 2013 Pazartesi
National Standards for DSME and DSMS – Part 2
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Part 2 of 6 Parts
In this blog, I will start with thestandard number one and cover several of them. However, thedefinitions should be stated first and I will quote them.DSME (Diabetes Self-ManagementEducation). “The ongoingprocess of facilitating the knowledge, skill, and ability necessaryfor prediabetes and diabetes self-care. This process incorporates theneeds, goals, and life experiences of the person with diabetes orprediabetes and is guided by evidence-based standards. The overallobjectives of DSME are to support informed decision making, self-carebehaviors, problem solving, and active collaboration with the healthcare team and to improve clinical outcomes, health status, andquality of life.”
It is important to note thatprediabetes is mentioned here and no distinction is made to preferone type of diabetes over another. Yet, this distinction isprevalent in the activities of certified diabetes educators (CDEs) inpractice today. This is the reason for calling attention to this.
DSMS (Diabetes Self-ManagementSupport).“Activitiesthat assist the person with prediabetes or diabetes in implementingand sustaining the behaviors needed to manage his or her condition onan ongoing basis beyond or outside of formal self-managementtraining. The type of support provided can be behavioral,educational, psychosocial, or clinical.”
These are the two key definitions thatapply to this and several following blogs. Keep them in mind whenreading the materials.
The first standard states, ”Theprovider(s) of DSME will document an organizational structure,mission statement, and goals. For those providers working within alarger organization, that organization will recognize and supportquality DSME as an integral component of diabetes care.”
This is a powerful standard in anyprofession, but from practical knowledge, this is the first standardviolated by most providers (CDEs). There are a few that do have thisin place and do make use of it for the intended purpose. I am awareof one diabetes clinic in a Midwest city that has something like this on file andall new personnel are required to read this and agree with it beforean interview even takes place. In addition, some of the literaturehanded out by the clinic includes parts of this document. CDEs thatfall short of this or violate it are dismissed rather quickly. Thisis not my clinic, but one in a city about three hours distantdepending on the traffic.
Another clinic also has a similardocumentation, but this one was written by the doctors that own thediabetes clinic and it works very well. As to how it conforms to theabove standard, I can only guess, but a relative of mine does saythat she receives excellent education in all areas except nutrition. Since she is a retired nutritionist, she has learned not to includedietitians on her team.
The second standard states, “Theprovider(s) of DSME will seek ongoing input from externalstakeholders and experts in order to promote program quality.”
This is a standard that depends on theoffice, clinic, or hospital. Some doctors prefer their input only,while others want their CDEs out in the community and participatingin community meetings and after work activities. One primary carephysician does have his CDEs involved with the school system andchecking that pupils with diabetes are receiving proper care. Whenit was discovered that the school system had made a budget cut toeliminate the nurses, he went before the school board and warned themthat they had better reinstate the cut or have the ADA investigatingas well as the state board of education. It was reinstated at thenext meeting and the two nurses rehired.
Some diabetes clinics do work to haveinput from the community and have proper channels for other input. Iam not aware of any formal advisory boards, but they may exist and Idon't know about them.
The third standard states, “Theprovider(s) of DSME will determine who to serve, how best to deliverdiabetes education to that population, and what resources can provideongoing support for that population.”
Ouch! It is no wonder there iswidespread discrimination in the service provided. In many areas,this has to be the reason people with type 2 diabetes don't have CDEsavailable to them and receive no education about diabetes. Yes, eventhe standards authors recognize this and state, “Currently,the majority of people with diabetes and prediabetes do not receiveany structured diabetes education.”
It is interesting the follow upstatement the standards people make. Without the qualified people tobe available, this just points out the fact that lay people needtraining to fill in gaps where CDEs are not available.
This information is from the National Standards for DSME and DSMS.
Part 2 of 6 Parts
In this blog, I will start with thestandard number one and cover several of them. However, thedefinitions should be stated first and I will quote them.DSME (Diabetes Self-ManagementEducation). “The ongoingprocess of facilitating the knowledge, skill, and ability necessaryfor prediabetes and diabetes self-care. This process incorporates theneeds, goals, and life experiences of the person with diabetes orprediabetes and is guided by evidence-based standards. The overallobjectives of DSME are to support informed decision making, self-carebehaviors, problem solving, and active collaboration with the healthcare team and to improve clinical outcomes, health status, andquality of life.”
It is important to note thatprediabetes is mentioned here and no distinction is made to preferone type of diabetes over another. Yet, this distinction isprevalent in the activities of certified diabetes educators (CDEs) inpractice today. This is the reason for calling attention to this.
DSMS (Diabetes Self-ManagementSupport).“Activitiesthat assist the person with prediabetes or diabetes in implementingand sustaining the behaviors needed to manage his or her condition onan ongoing basis beyond or outside of formal self-managementtraining. The type of support provided can be behavioral,educational, psychosocial, or clinical.”
These are the two key definitions thatapply to this and several following blogs. Keep them in mind whenreading the materials.
The first standard states, ”Theprovider(s) of DSME will document an organizational structure,mission statement, and goals. For those providers working within alarger organization, that organization will recognize and supportquality DSME as an integral component of diabetes care.”
This is a powerful standard in anyprofession, but from practical knowledge, this is the first standardviolated by most providers (CDEs). There are a few that do have thisin place and do make use of it for the intended purpose. I am awareof one diabetes clinic in a Midwest city that has something like this on file andall new personnel are required to read this and agree with it beforean interview even takes place. In addition, some of the literaturehanded out by the clinic includes parts of this document. CDEs thatfall short of this or violate it are dismissed rather quickly. Thisis not my clinic, but one in a city about three hours distantdepending on the traffic.
Another clinic also has a similardocumentation, but this one was written by the doctors that own thediabetes clinic and it works very well. As to how it conforms to theabove standard, I can only guess, but a relative of mine does saythat she receives excellent education in all areas except nutrition. Since she is a retired nutritionist, she has learned not to includedietitians on her team.
The second standard states, “Theprovider(s) of DSME will seek ongoing input from externalstakeholders and experts in order to promote program quality.”
This is a standard that depends on theoffice, clinic, or hospital. Some doctors prefer their input only,while others want their CDEs out in the community and participatingin community meetings and after work activities. One primary carephysician does have his CDEs involved with the school system andchecking that pupils with diabetes are receiving proper care. Whenit was discovered that the school system had made a budget cut toeliminate the nurses, he went before the school board and warned themthat they had better reinstate the cut or have the ADA investigatingas well as the state board of education. It was reinstated at thenext meeting and the two nurses rehired.
Some diabetes clinics do work to haveinput from the community and have proper channels for other input. Iam not aware of any formal advisory boards, but they may exist and Idon't know about them.
The third standard states, “Theprovider(s) of DSME will determine who to serve, how best to deliverdiabetes education to that population, and what resources can provideongoing support for that population.”
Ouch! It is no wonder there iswidespread discrimination in the service provided. In many areas,this has to be the reason people with type 2 diabetes don't have CDEsavailable to them and receive no education about diabetes. Yes, eventhe standards authors recognize this and state, “Currently,the majority of people with diabetes and prediabetes do not receiveany structured diabetes education.”
It is interesting the follow upstatement the standards people make. Without the qualified people tobe available, this just points out the fact that lay people needtraining to fill in gaps where CDEs are not available.
This information is from the National Standards for DSME and DSMS.
National Standards for DSME and DSMS – Part 3
To contact us Click HERE
The fourth standard states, “Acoordinator will be designated to oversee the DSME program. Thecoordinator will have oversight responsibility for the planning,implementation, and evaluation of education services.”
This works well in larger cities wheretwo or more certified diabetes educators (CDEs) work for the sameoffice, however, I do have to wonder about CDEs working alone in someof the smaller offices, clinics, and hospitals. As the DSMEcontinues to evolve, the coordinator should play a pivotal role inensuring accountability and continuity in the education program. Will coordinators need to travel from large offices to smalleroffices and rural areas as an area coordinator? This is something tobe considered. The standard does state, in some cases, particularlyin small practices, the coordinator may also provide DSME and/orDSMS.
The fifth standard states, “Oneor more instructors will provide DSME and, when applicable, DSMS. Atleast one of the instructors responsible for designing and planningDSME and DSMS will be a registered nurse, registered dietitian, orpharmacist with training and experience pertinent to DSME, or anotherprofessional with certification in diabetes care and education, suchas a CDE or BC-ADM. Other health workers can contribute to DSME andprovide DSMS with appropriate training in diabetes and withsupervision and support.”
Maybe historically, nurses anddietitians were the main providers of diabetes education, but inrecent years, this has been expanded to mainly pharmacists. It istherefore natural to see this in the hierarchy of people in theliterature and whom they assign the functions of the differentstandards to for completion. At least the obligatory continuingeducation is included as a way of segregation to keep lay people onthe sidelines.
The next area seems an attempt to makeeveryone welcome, but remember it is only the CDEs that can superviseand monitor the education and support. This means fewer CDEs doingactual DSME and DSMS. A number of studies have shown that amultidisciplinary team approach to diabetes care, education, andsupport works well for the patient. Yet in too many cases, thepatient is often not the center of the efforts and central to theteam approach.
“Thedisciplines that may be involved include, but are not limited to,physicians, psychologists and other mental health specialists,physical activity specialists (including physical therapists,occupational therapists, and exercise physiologists), optometrists,and podiatrists. More recently, health educators (e.g., CertifiedHealth Education Specialists and Certified Medical Assistants), casemanagers, lay health and community workers, and peer counselors oreducators have been shown to contribute effectively as part of theDSME team and in providing DSMS.”
Yes, they do include lay health andcommunity workers plus peer counselors or educators when it is totheir advantage. But, notice that a system must be in place thatensures supervision of these lay people. I agree that for questionsthe lay people do not have answers for need to have professionalsavailable to answer when the questions are beyond their training. This is wise even for the CDEs to have doctors or other professionalsavailable to back them up, but this seems to be an insult to theircredentials.
This information is from the National Standards for DSME and DSMS.
The fourth standard states, “Acoordinator will be designated to oversee the DSME program. Thecoordinator will have oversight responsibility for the planning,implementation, and evaluation of education services.”
This works well in larger cities wheretwo or more certified diabetes educators (CDEs) work for the sameoffice, however, I do have to wonder about CDEs working alone in someof the smaller offices, clinics, and hospitals. As the DSMEcontinues to evolve, the coordinator should play a pivotal role inensuring accountability and continuity in the education program. Will coordinators need to travel from large offices to smalleroffices and rural areas as an area coordinator? This is something tobe considered. The standard does state, in some cases, particularlyin small practices, the coordinator may also provide DSME and/orDSMS.
The fifth standard states, “Oneor more instructors will provide DSME and, when applicable, DSMS. Atleast one of the instructors responsible for designing and planningDSME and DSMS will be a registered nurse, registered dietitian, orpharmacist with training and experience pertinent to DSME, or anotherprofessional with certification in diabetes care and education, suchas a CDE or BC-ADM. Other health workers can contribute to DSME andprovide DSMS with appropriate training in diabetes and withsupervision and support.”
Maybe historically, nurses anddietitians were the main providers of diabetes education, but inrecent years, this has been expanded to mainly pharmacists. It istherefore natural to see this in the hierarchy of people in theliterature and whom they assign the functions of the differentstandards to for completion. At least the obligatory continuingeducation is included as a way of segregation to keep lay people onthe sidelines.
The next area seems an attempt to makeeveryone welcome, but remember it is only the CDEs that can superviseand monitor the education and support. This means fewer CDEs doingactual DSME and DSMS. A number of studies have shown that amultidisciplinary team approach to diabetes care, education, andsupport works well for the patient. Yet in too many cases, thepatient is often not the center of the efforts and central to theteam approach.
“Thedisciplines that may be involved include, but are not limited to,physicians, psychologists and other mental health specialists,physical activity specialists (including physical therapists,occupational therapists, and exercise physiologists), optometrists,and podiatrists. More recently, health educators (e.g., CertifiedHealth Education Specialists and Certified Medical Assistants), casemanagers, lay health and community workers, and peer counselors oreducators have been shown to contribute effectively as part of theDSME team and in providing DSMS.”
Yes, they do include lay health andcommunity workers plus peer counselors or educators when it is totheir advantage. But, notice that a system must be in place thatensures supervision of these lay people. I agree that for questionsthe lay people do not have answers for need to have professionalsavailable to answer when the questions are beyond their training. This is wise even for the CDEs to have doctors or other professionalsavailable to back them up, but this seems to be an insult to theircredentials.
This information is from the National Standards for DSME and DSMS.
ACA Will Help Spark Boom in RPM
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RPM means remote patient monitoring andwill be here to stay under the Affordable Care Act (ACA). Initiallythis started with heart patients, but it will expand. And yes,diabetes is on the list of types of patients that will be remotelyfollowed. Now why would they do this, considering that few type 2diabetes patients receive education on managing their diabetes? Notonly that, but without the personnel available to educate people withdiabetes, how can they expect patients with type 2 diabetes to feelanything but contempt for remote patient monitoring.
I expect to see something appear in theAmerican Diabetes Association (ADA) website as early as this summerhinting at the possible monitoring to be done and when it will start. Then, I am guessing that the ADA 2014 guidelines will have much moreto say about this. If not this summer, then announcements willhappen by the summer of 2014 and will be part of the ADA 2015guidelines. It is coming and of this, I have no doubt.
This press release says a lot about RPMfor five major chronic illnesses that will grow by 6-fold by 2017. This is because the ACA will be pushing hospitals and physicians tostop the revolving door treatments by hospitals. In 2012, cliniciansreviewed remote patient monitoring data for about 227,000 patientswith congestive heart failure (CHF), chronic obstructive pulmonarydisease, diabetes, hypertension, and mental illness. Thefigures include a number of other patients with asthma, coronaryartery disease, and hemophilia.
CHF patients were almost half of PRM in2012. In 2017, diabetes will overtake CHF and the monitoring willgrow by 67.5 percent from 2012 to 2017. The next fastest group ofRPM will be patients with mental illness. Demand for this monitoringcomes from patients and private insurers, which seek to reduce costlyhospitalizations. All of these trends build on an even larger one, anaging population beset with chronic conditions.
The ACA will bring financial incentiveinto play to promote RPM and this will mean rewards for physiciansand hospitals that comply. In addition to sharing payment for anepisode of care, they will earn a bonus, or take a pay cut, dependingwhether they come under or exceed a cost target. With the financialincentives and penalties that the ACA can and will enforce, hospitalsand physicians will have money reasons to physically monitorpatients. Then there are those providers that want to remotelypatient monitor at home for improved care whether there are monetaryrewards or not.
The one factor not included in thisarticle if the role of the Food and Drug Administration and how fastthey will be approving these remote monitoring devices. Thiscould be the flaw in the current thinking, but this should not delayprogress for long as CMS and most insurance payers are on board andlooking to the benefits this will provide.
Currently, the task of reviewing RPMdata falls to nurses at third party triage and call centers services. They then alert the relevant physician to flagged changes. Currently, under the existing fee-for-service reimbursement, there isno incentive to take remote medical data that will not result in abillable office visit. Under the ACA, there will be many financialincentives for physicians to change their way of doing businessincluding penalties.
Presently, remote-monitoring systemsare relegated to call centers, but this will change as pressure isput in place for the electronic health records (EHR) to be capable oftracking this data. Yes, the manufacturers of EHR systems arebalking; however, congressional pressure is being applied quiteliberally to force them to make their systems more responsive toreceiving RPM data and working together (interoperability) tocorrespond with competing EHR systems. This can only be positive asthe Health and Human Services and Centers for Medicare and Medicaidare applying pressure saying their systems will not meet usefulstandards, as they exist. The pressure is to make all systems“telehealth-ready.”
RPM means remote patient monitoring andwill be here to stay under the Affordable Care Act (ACA). Initiallythis started with heart patients, but it will expand. And yes,diabetes is on the list of types of patients that will be remotelyfollowed. Now why would they do this, considering that few type 2diabetes patients receive education on managing their diabetes? Notonly that, but without the personnel available to educate people withdiabetes, how can they expect patients with type 2 diabetes to feelanything but contempt for remote patient monitoring.
I expect to see something appear in theAmerican Diabetes Association (ADA) website as early as this summerhinting at the possible monitoring to be done and when it will start. Then, I am guessing that the ADA 2014 guidelines will have much moreto say about this. If not this summer, then announcements willhappen by the summer of 2014 and will be part of the ADA 2015guidelines. It is coming and of this, I have no doubt.
This press release says a lot about RPMfor five major chronic illnesses that will grow by 6-fold by 2017. This is because the ACA will be pushing hospitals and physicians tostop the revolving door treatments by hospitals. In 2012, cliniciansreviewed remote patient monitoring data for about 227,000 patientswith congestive heart failure (CHF), chronic obstructive pulmonarydisease, diabetes, hypertension, and mental illness. Thefigures include a number of other patients with asthma, coronaryartery disease, and hemophilia.
CHF patients were almost half of PRM in2012. In 2017, diabetes will overtake CHF and the monitoring willgrow by 67.5 percent from 2012 to 2017. The next fastest group ofRPM will be patients with mental illness. Demand for this monitoringcomes from patients and private insurers, which seek to reduce costlyhospitalizations. All of these trends build on an even larger one, anaging population beset with chronic conditions.
The ACA will bring financial incentiveinto play to promote RPM and this will mean rewards for physiciansand hospitals that comply. In addition to sharing payment for anepisode of care, they will earn a bonus, or take a pay cut, dependingwhether they come under or exceed a cost target. With the financialincentives and penalties that the ACA can and will enforce, hospitalsand physicians will have money reasons to physically monitorpatients. Then there are those providers that want to remotelypatient monitor at home for improved care whether there are monetaryrewards or not.
The one factor not included in thisarticle if the role of the Food and Drug Administration and how fastthey will be approving these remote monitoring devices. Thiscould be the flaw in the current thinking, but this should not delayprogress for long as CMS and most insurance payers are on board andlooking to the benefits this will provide.
Currently, the task of reviewing RPMdata falls to nurses at third party triage and call centers services. They then alert the relevant physician to flagged changes. Currently, under the existing fee-for-service reimbursement, there isno incentive to take remote medical data that will not result in abillable office visit. Under the ACA, there will be many financialincentives for physicians to change their way of doing businessincluding penalties.
Presently, remote-monitoring systemsare relegated to call centers, but this will change as pressure isput in place for the electronic health records (EHR) to be capable oftracking this data. Yes, the manufacturers of EHR systems arebalking; however, congressional pressure is being applied quiteliberally to force them to make their systems more responsive toreceiving RPM data and working together (interoperability) tocorrespond with competing EHR systems. This can only be positive asthe Health and Human Services and Centers for Medicare and Medicaidare applying pressure saying their systems will not meet usefulstandards, as they exist. The pressure is to make all systems“telehealth-ready.”
National Standards for DSME and DSMS – Part 4
To contact us Click HERE
Part 4 of 6 Parts
The sixth standard states, “Awritten curriculum reflecting current evidence and practiceguidelines, with criteria for evaluating outcomes, will serve as theframework for the provision of DSME. The needs of the individualparticipant will determine which parts of the curriculum will beprovided to that individual.”
Here again, the door is wide open fordiscrimination. CDEs are nefarious for deciding that individualsdon't need some part of training when a mandate will work just fine. This means that the patient with diabetes is not taught something orpossibly a key that is necessary in the self-management of diabetes. If the patient cannot figure out from the mandate what needs to beaccomplished and why, they are left in the dark and wondering whatthey missed. I know this by the questions I receive in emails. People with type 2 diabetes are asking why is this so important or isthis really necessary. You can bet I ask if they have had any timewith a CDE. No all have, but those that have had time with a CDE,say they were told to do it with no explanation.
Another part of this that makes mewonder at the training of CDEs is the number of times people askquestions that should have been covered in an assessment. The time Ihad an individual say they had just seen a CDE and the question waswhat do I do now. He had asked the CDE what to do for depression ashe was feeling very low and in addition to just having a diagnosis ofdiabetes, the previous week he had buried his wife of 46 years. Hisquestion was not answered and the session was ended without anyindication that the CDE would talk to his doctor or anyone. As hesaid in his email – it was as if she could not get out the doorfast enough.
Even my suggestion to call his doctordid not get him any help and it took almost two weeks to find someonehe could talk with and actually give him the help he needed. He wasdoubly blessed that the person he got set up with also had type 2diabetes and knew what he was talking about.
Why the next section is talked aboutreally has me wondering, especially since most people with diabetesare not being serviced by CDEs and the people with prediabetes are notseen by CDEs. Yes, a very few have consulted with CDEs if they area relative or close friend of the family. I even had one of thesepeople email me telling me that they had been educated by a CDE, butthey refused to answer the question of how close they were related orif they were a friend of the family.
“Individuals with prediabetes anddiabetes and their families and caregivers have much to learn tobecome effective self-managers of their condition. DSME can providethis education via an up-to-date, evidence-based, and flexiblecurriculum.”
“Thefollowing core topics are commonly part of the curriculum taught incomprehensive programs that have demonstrated successful outcomes: 1. Describing the diabetes disease processand treatment options2. Incorporating nutritional management intolifestyle3. Incorporating physical activity intolifestyle4. Using medication(s) safely and formaximum therapeutic effectiveness5. Monitoring blood glucose and otherparameters and interpreting and using the results for self-managementdecision making6. Preventing, detecting, and treating acutecomplications7. Preventing, detecting, and treatingchronic complications8. Developing personal strategies to addresspsychosocial issues and concerns9. Developing personal strategies to promotehealth and behavior change”
The above areas are important andshould be part of the content in a carefully planned program, butunless an assessment is performed and the program adapted to theindividual, the curriculum may miss the target and not be absorbed bythe individual. When a proper assessment is done and the approachesto education are interactive and patient centered, then it should beeffective. Also necessary is the development of action-orientedbehavioral goals that are creative and experienced based in deliverymethods are effective. This should indicate that mandates are noteffective, but they are too often used.
The seventh standard states,“The diabetes self-management, education,and support needs of each participant will be assessed by one or moreinstructors. The participant and instructor(s) will then togetherdevelop an individualized education and support plan focused onbehavior change.”
The idea of individualized education isthe key to this standard. This could or should be what every CDEstrives for in the education. This seldom is the case because noassessment is done and the education is handed out almostwillie-nillie based on the CDEs attempt to hurry through theeducation. Because the assessment is also a key to giving educationon an individualized basis, I am quoting what is important in anassessment.
“Theassessment process is used to identify what those needs are and tofacilitate the selection of appropriate educational and behavioralinterventions and self-management support strategies, guided byevidence. The assessment must garner information about theindividual’s medical history, age, cultural influences, healthbeliefs and attitudes, diabetes knowledge, diabetes self-managementskills and behaviors, emotional response to diabetes, readiness tolearn, literacy level (including health literacy and numeracy),physical limitations, family support, and financial status. Theeducation and support plan that the participant and instructor(s)develop will be rooted in evidence-based approaches to effectivehealth communication and education while taking into considerationparticipant barriers, abilities, and expectations.”
The assessment and education plan,interventions, and outcomes must be documented in the patient’srecords. This will facilitate and provide assistance to others onthe patient's healthcare team and increase the likelihood that allthe members will work in collaboration. This will create anatmosphere of learning and success for the patient resulting inimproved quality of care.
This information is from the National Standards for DSME and DSMS.
Part 4 of 6 Parts
The sixth standard states, “Awritten curriculum reflecting current evidence and practiceguidelines, with criteria for evaluating outcomes, will serve as theframework for the provision of DSME. The needs of the individualparticipant will determine which parts of the curriculum will beprovided to that individual.”
Here again, the door is wide open fordiscrimination. CDEs are nefarious for deciding that individualsdon't need some part of training when a mandate will work just fine. This means that the patient with diabetes is not taught something orpossibly a key that is necessary in the self-management of diabetes. If the patient cannot figure out from the mandate what needs to beaccomplished and why, they are left in the dark and wondering whatthey missed. I know this by the questions I receive in emails. People with type 2 diabetes are asking why is this so important or isthis really necessary. You can bet I ask if they have had any timewith a CDE. No all have, but those that have had time with a CDE,say they were told to do it with no explanation.
Another part of this that makes mewonder at the training of CDEs is the number of times people askquestions that should have been covered in an assessment. The time Ihad an individual say they had just seen a CDE and the question waswhat do I do now. He had asked the CDE what to do for depression ashe was feeling very low and in addition to just having a diagnosis ofdiabetes, the previous week he had buried his wife of 46 years. Hisquestion was not answered and the session was ended without anyindication that the CDE would talk to his doctor or anyone. As hesaid in his email – it was as if she could not get out the doorfast enough.
Even my suggestion to call his doctordid not get him any help and it took almost two weeks to find someonehe could talk with and actually give him the help he needed. He wasdoubly blessed that the person he got set up with also had type 2diabetes and knew what he was talking about.
Why the next section is talked aboutreally has me wondering, especially since most people with diabetesare not being serviced by CDEs and the people with prediabetes are notseen by CDEs. Yes, a very few have consulted with CDEs if they area relative or close friend of the family. I even had one of thesepeople email me telling me that they had been educated by a CDE, butthey refused to answer the question of how close they were related orif they were a friend of the family.
“Individuals with prediabetes anddiabetes and their families and caregivers have much to learn tobecome effective self-managers of their condition. DSME can providethis education via an up-to-date, evidence-based, and flexiblecurriculum.”
“Thefollowing core topics are commonly part of the curriculum taught incomprehensive programs that have demonstrated successful outcomes: 1. Describing the diabetes disease processand treatment options2. Incorporating nutritional management intolifestyle3. Incorporating physical activity intolifestyle4. Using medication(s) safely and formaximum therapeutic effectiveness5. Monitoring blood glucose and otherparameters and interpreting and using the results for self-managementdecision making6. Preventing, detecting, and treating acutecomplications7. Preventing, detecting, and treatingchronic complications8. Developing personal strategies to addresspsychosocial issues and concerns9. Developing personal strategies to promotehealth and behavior change”
The above areas are important andshould be part of the content in a carefully planned program, butunless an assessment is performed and the program adapted to theindividual, the curriculum may miss the target and not be absorbed bythe individual. When a proper assessment is done and the approachesto education are interactive and patient centered, then it should beeffective. Also necessary is the development of action-orientedbehavioral goals that are creative and experienced based in deliverymethods are effective. This should indicate that mandates are noteffective, but they are too often used.
The seventh standard states,“The diabetes self-management, education,and support needs of each participant will be assessed by one or moreinstructors. The participant and instructor(s) will then togetherdevelop an individualized education and support plan focused onbehavior change.”
The idea of individualized education isthe key to this standard. This could or should be what every CDEstrives for in the education. This seldom is the case because noassessment is done and the education is handed out almostwillie-nillie based on the CDEs attempt to hurry through theeducation. Because the assessment is also a key to giving educationon an individualized basis, I am quoting what is important in anassessment.
“Theassessment process is used to identify what those needs are and tofacilitate the selection of appropriate educational and behavioralinterventions and self-management support strategies, guided byevidence. The assessment must garner information about theindividual’s medical history, age, cultural influences, healthbeliefs and attitudes, diabetes knowledge, diabetes self-managementskills and behaviors, emotional response to diabetes, readiness tolearn, literacy level (including health literacy and numeracy),physical limitations, family support, and financial status. Theeducation and support plan that the participant and instructor(s)develop will be rooted in evidence-based approaches to effectivehealth communication and education while taking into considerationparticipant barriers, abilities, and expectations.”
The assessment and education plan,interventions, and outcomes must be documented in the patient’srecords. This will facilitate and provide assistance to others onthe patient's healthcare team and increase the likelihood that allthe members will work in collaboration. This will create anatmosphere of learning and success for the patient resulting inimproved quality of care.
This information is from the National Standards for DSME and DSMS.
24 Şubat 2013 Pazar
Obama to Decide Whether to Expand Military's Animal Cruelty Policy
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The Department of Defense is asking President Obama for permission to expand the military's current animal cruelty policy to include abandonment and to also apply to personal pets rather than just those owned by the military. The constant relocation and reassignment of military families has resulted in many pets simply being left behind, abandoned, and unattended. Stars and Stripes is reporting that the problem is so great in places like Hawaii and Germany that local shelters are reluctant to adopt pets to Americans and/or military families at all.
The military is further concerned that the problem will worsen as United Airlines, the airline contracted to transport military personnel, refuses to permit certain breeds of dogs, such as American Staffordshire Terriers, on their planes, and will not waive this restriction for the Defense Department.
While I fully support holding those who choose to have a pet responsible for caring for that pet and accountable to the authorities for not doing so, I would also suggest that the military drop United Airlines and contract with another carrier so those with "banned" family dogs can travel without the additional heartbreak of the loss of a pet or the expense of funding their own flights on another airline. It seems an unnecessary stressor for those who would otherwise not abandon their pet.
In fact, if all pet lovers chose, in sympathy, to fly with different airlines - maybe we would see an attitude change from United.
The president is expected to decide this spring.
The Department of Defense is asking President Obama for permission to expand the military's current animal cruelty policy to include abandonment and to also apply to personal pets rather than just those owned by the military. The constant relocation and reassignment of military families has resulted in many pets simply being left behind, abandoned, and unattended. Stars and Stripes is reporting that the problem is so great in places like Hawaii and Germany that local shelters are reluctant to adopt pets to Americans and/or military families at all.The military is further concerned that the problem will worsen as United Airlines, the airline contracted to transport military personnel, refuses to permit certain breeds of dogs, such as American Staffordshire Terriers, on their planes, and will not waive this restriction for the Defense Department.
While I fully support holding those who choose to have a pet responsible for caring for that pet and accountable to the authorities for not doing so, I would also suggest that the military drop United Airlines and contract with another carrier so those with "banned" family dogs can travel without the additional heartbreak of the loss of a pet or the expense of funding their own flights on another airline. It seems an unnecessary stressor for those who would otherwise not abandon their pet.
In fact, if all pet lovers chose, in sympathy, to fly with different airlines - maybe we would see an attitude change from United.
The president is expected to decide this spring.
"Something's Happening Here - What It Is Ain't Exactly Clear..."
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I wasn’t going to write about this – but – it has beenbothering me. Last week, the aspca (NOTa national umbrella organization) subsidized adoptions across the country for acouple of days. The subsidy allowed some shelters to give away pets, or tocharge 10 or 20 dollars for the pet. So whyhas this been nagging at me?
I began to wonder why they are really doing this. Promoting adoptions is the obvious answer butis it the correct one? You and I will never know – but here is what I think.The aspca has been and is under fire for fundraising in everyone’s neighborhoodand amassing approximately 188,024,402 million dollars in New Yorkto the detriment of all the other spcas and the animals they serve. They getaway with it because consumers believe that they are the “national office” and thatevery spca in the country is a chapter which receives funding from them. Not true. Each spca is a separate and independent legalentity and it could affect the aspca’s ability to raise funds if they disclosedthat. In fact, out of that near 185,000,000million dollars, they grant out fewerthan 6 million but spend over 25 million on fundraising.
So, they throw pocket change at this adoption promotion,publicize the hell out of it and generate more smoke for the mirrors.
But was it a good event that helped animals? In Californiathey worked mostly with government pounds where adopters are not screened andall one needs is the fee to take home an animal. At no charge or even with anominal charge many animals very likely went to hoarders, backyard sellers, and other entitiesthat had only plans to resell the pets at a huge mark up. How many sales werean impulse grab where the pet was returned or simply turned out? It is easy to empty ashelter but not so easy to have the adoption stick and actually find the pet ahome. It is neither a success nor even an adoption if the pet is not kept. Doyou think the aspca is tracking that or is even concerned about that? I don't know, but if so, the event business model would have been different. Of course there are those of us who would cherish a pet for life that we found on the street or received at no cost. I am not talking about us.
I think that my disquietude comes from the fear that manyof these animals might be in awful places as a result of the aspca’s publicrelations effort to appear to be funding animals in areas in which they solicitdonations and provide nothing in return.
They could be throwing couch cushion change to seem to besomething they are not, while perhaps tossing pets to the very real wolves.
Please donate locally.
I wasn’t going to write about this – but – it has beenbothering me. Last week, the aspca (NOTa national umbrella organization) subsidized adoptions across the country for acouple of days. The subsidy allowed some shelters to give away pets, or tocharge 10 or 20 dollars for the pet. So whyhas this been nagging at me?
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| Courtesy spcaL |
So, they throw pocket change at this adoption promotion,publicize the hell out of it and generate more smoke for the mirrors.
But was it a good event that helped animals? In Californiathey worked mostly with government pounds where adopters are not screened andall one needs is the fee to take home an animal. At no charge or even with anominal charge many animals very likely went to hoarders, backyard sellers, and other entitiesthat had only plans to resell the pets at a huge mark up. How many sales werean impulse grab where the pet was returned or simply turned out? It is easy to empty ashelter but not so easy to have the adoption stick and actually find the pet ahome. It is neither a success nor even an adoption if the pet is not kept. Doyou think the aspca is tracking that or is even concerned about that? I don't know, but if so, the event business model would have been different. Of course there are those of us who would cherish a pet for life that we found on the street or received at no cost. I am not talking about us.
I think that my disquietude comes from the fear that manyof these animals might be in awful places as a result of the aspca’s publicrelations effort to appear to be funding animals in areas in which they solicitdonations and provide nothing in return.
They could be throwing couch cushion change to seem to besomething they are not, while perhaps tossing pets to the very real wolves.
Please donate locally.
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