Diabetes educators step up

Becoming a diabetes educator was more than just a way to add letters after his name, said South Carolina pharmacist Tommy Johnson. Two major events motivated him.

“After I graduated from pharmacy school, my grandmother was diagnosed with type 2 diabetes. At the time, I knew very little about diabetes, except that people took medications which at the time were insulin and sulfonyureas, and they were usually overweight and were supposed to check their blood glucose levels.”

And the second event? “The second event originated during the diabetes workshop of a national professional organization meeting, where several pharmacists related how we should be more involved in educating patients about target blood sugars and how their medications worked, and in monitoring blood sugars and checking their feet.”

When he returned home after the workshop, Johnson, who was employed in an independent pharmacy, began looking at patient profiles. “It was a real eye-opener,” he said

“I saw that about 60% of the people who came in had diabetes, and the more questions I asked them, the more I realized how little they knew about their condition. And I realized I did not know much more than they did, so I started seeking ways to learn.”

Today, Tommy Johnson, PharmD, CDE, BC-ADM, FAADE, has earned several credentials in diabetes education, including the distinguished fellowship from the American Association of Diabetes Educators (FAADE), awarded to individuals for their outstanding contribution.

Earning the Certified Diabetes Educator credential is what opened the door for him, said Johnson, when it came to providing diabetes education and being recognized by prescribers.

A dedicated patient education advocate and professor of Pharmacy Practice at South Carolina’s new Presbyterian School of Pharmacy, Johnson worked hard to convince the school to include an outpatient diabetes-education program developed by the American Pharmacy Association (APhA). Students who pursue this elective coursework can now earn a certificate in its Pharmacist & Patient-Centered Diabetes Care program.

One-on-one

Combining education and community service, Johnson and fourth-year pharmacy students visit a free medical clinic once a week to teach diabetes education, using what he emphasizes is a “personal approach.”

“I work with people one-on-one. We have an hour-long session. I help with meal planning and medication adjustments; I find out where they are with their medications and their labs; and I can recommend on the spot to a nurse practitioner or a physician if changes need to be made, such as titrating their insulin doses.”

But people learn in the way that’s right for them, he cautioned, and learning settings need to reflect that. “Some people learn better one-on-one, some learn in groups. Some people are intimidated by groups, some people thrive in groups. It’s an individualized learning process.”

Moreover, standard diabetes-education dictates doled out by physicians, such as “Don’t eat this” or “Stay away from that,” Johnson said, do not take into account some life circumstances.

“We have seen patients who live in shelters or who are homeless, and they can’t control what they eat. We have to make it work for them. They are all individuals. It’s not a cookie-cutter one-size-fits-all approach.”

The individual focus is rewarding. One grateful patient told Johnson, “I learned more in 10 minutes with you than I learned in 10 weeks at another place.”

Teaching by listening

Johnson wants students to be participants, “not sponges in the chair,” he said.

“I like to start my one-on-one session with them by asking, ‘What would you like to learn?’ instead of me talking for an hour.”

Together they review the patient’s charts, provider notes, and lab reports. “I ask them, ‘What do you think the patient challenges are going to be? What other information did we not cover today? Do you think the person understands or needs things?”

In patient education, listening rather than preaching can be more revealing than official records.

“We had one man who had a very high A1c of 18. He was just released from jail and he had been without insulin for two weeks. When he came in, the meter literally was off the charts, over 600. We got him stabilized and gave him rapid-acting insulin. We found out that he had gone to the ER the day before and they hadn’t given him anything.”

Another time, said Johnson, “One of my patients had high blood pressure. When we talked about it, she said she had just bailed her daughter out of jail.”

Medication, he said, is only part of teaching people to manage diabetes. “Explaining how to read labels; introducing terms that are poorly understood, like ‘sugar-free,’ ‘carb-free,’ and ‘light foods’; discussing the need to control sodium; and dealing with literacy are all part of the job,” he said.

In diabetes education, community pharmacists can “really make a difference,” said Johnson. “We are the underutilized healthcare professionals. But few pharmacy schools spend the time [on diabetes education]. There is so much to cover on chronic conditions and so much more to diabetes than time to cover it - typically only four to 10 hours of this education over four years,” he said.

To become a certified diabetes educator takes time and dedication, said Johnson, but the personal reward is well worth it. “A good start,” he added, “is the APhA certificate program we offer students here.”

Building empathy

Kelly French, MPH, echoed Johnson’s thoughts. The associate director of education programs for APhA, she said its diabetes-education training program was first offered in the late 1990s. Since then, “more than 10,000 pharmacists have completed the certificate training,” and many go on to more advanced training.

“We’ve been offering this program as a web-based module since 2009, and we have partners throughout the country we work with,” said French. The APhA national faculty trains local faculty, who can then administer the 23-hour program, which consists of “15 hours online home study, and eight hours of live seminar education.”

A unique aspect of the program, French said, is that “the self-study is a go-at-your-own-pace process. It introduces the concepts, and then when you’re ready, the live seminar applies the concepts in a hands-on atmosphere, where you get to learn injections, glucose testing, foot exams, and so on.”

Helen Ali-Sairany, BSc, PharmD, RPh, is APhA’s associate director of content development. Outlining the five home-study modules, she said that Module 1 is a focus on disease mechanisms, causes and risk factors. Module 2 examines lifestyle changes. “We always try to teach that lifestyle comes before pharmacotherapy,” she said. It includes diet, weight loss, and exercise.

“Module 3 shifts to medication and talks about different treatments, such as noninjectables, oral meds, different drug classes. It’s presented in lay language, as you would talk to patients, so they understand the advantages and disadvantages of each drug class.”

Module 4 addresses comorbidities. “Eighty percent of diabetes patients have a comorbid complication, so we focus on the management of neuropathy, hypertension, and aspirin for cardiovascular therapy.”

Module 5 covers the actual role of the pharmacy in the management of diabetes as well as the process model for
patient care.

Next, students attend the live seminar.

“What we see most of all in this hands-on arena,” said Ali-Sairany, “is that it increases empathy for patients. Students can say, ‘I now know what an injection feels like’ - and what patients must deal with.”

“We see a big increase in their confidence level,” which, she said, was something that makes the APhA program a good steppingstone to advanced credentialing opportunities.

A two-bucket process

David Pope, PharmD, CDE, is the co-founder of Georgia-based CreativePharmacist.com and its chief of innovation. The arena of diabetes-education credentialing “basically involves two buckets,” he said.

For bucket one, the pharmacist acquires individual status by obtaining one of two credentials: Certified Diabetes Educator (CDE) or Board Certified in Advanced Diabetes Management (BC-ADM). “It is important to have additional training that shows you are proficient and have gone the extra mile. But you can’t bill for DSME services [diabetes self-management education] on an individual basis, since we’re not yet approved providers.”

Bucket two is organizational, he went on. “This is recognition for your pharmacy, clinic, or hospital, which can then apply to become an accredited center for diabetes education, a designated DSME site.”

This is a very desirable position for a pharmacy, said Pope. Payers who want the best quality may send patients to a recognized accredited center for diabetes education, and they will reimburse that provider.

For the payers, there is a definite payoff. When diabetes patients receive high-quality counseling, have measurable improved outcomes, and express high satisfaction, it may boost the payers’ Star Ratings when CMS audits their quality measures.

Payers with four and five stars have the best chance of being retained in the Medicare program and of obtaining good marks from the government. “This is a win-win for everyone,” Pope said.

But getting there is a complicated process for a pharmacy, involving reams of paperwork and navigation of a complex program. “What we do here at CreativePharmacist is to help these entities get through the system to successfully reach their goals,” he said. When Pope and co-founder Dan Lawson launched CreativePharmacist in 2009, their vision was to empower pharmacists, especially independents, to improve chronic disease rates of “local populations in hard-to-reach areas of America.”

The certification process requires the facility to “have an advisory board to look at your outcomes,” said Pope, and to “review your local population to see if you are reaching people in need.

He continued, “You have to take a required number of patients through your 10-hour program using an approved curriculum and measure their cognitive results. How much did they know going into the program? How much do they know when they come out of it? You have to track specific data, and you need a curriculum, materials, data sets - and all this has to conform with the approved standards.”

The CreativePharmacist service helps pharmacists “exercise their clinical muscle to become engaged with patients and help improve their outcomes,” and get paid for this specialty education. “There is both a clinical and a business reason to pursue this accreditation,” Pope said.

In the process of getting the pharmacy accredited, the company uses what he describes as a Match.com type of relationship to connect pharmacists with their local populations and to identify and partner with the patients who are living with chronic disease. Then, Pope said, his service provides an assessment of how the pharmacy can optimize its care and improve outcomes to fulfill the education requirement for accreditation, using the full suite of CreativePharmacist’s education-curriculum materials, online portals for patients and pharmacists, and a proprietary electronic medical record to collect and archive aggregate medical data.

This “white-glove guidance throughout the entire process” is designed to ensure that the applicant pharmacy becomes accredited, he said.

The power of the pharmacist

Becoming a diabetes educator is an exciting personal and professional growth process, but to date it has not always been about getting paid. However, Pope is enthusiastic about the future of pharmacists as they band together to improve the health of the country.

“Where else can you just walk in, and see and talk to a healthcare professional on the spot? And get real help and answers from someone who knows your history? We have that connection, and we can be the model for change.”  

Barbara Hesselgraveis a freelance writer in Baltimore, Md.

Training and certification

There are two officially recognized certifications available for individual pharmacist credentials.

The Certified Diabetes Educator (CDE) credential is conferred by the National Certification Board for Diabetes Educators, a not-for-profit organization. Certification is good for five years and requires a minimum of 1,000 practice hours or 75 clock hours of diabetes-related continuing education.

The Board Certified in Advanced Diabetes Management (BC-ADM) credential is offered by the not-for-profit American Association of Diabetes Educators. Applicants must complete a minimum of 500 clinical practice hours in advanced diabetes management.

Both certifications are earned by individuals and require a graduate degree from an accredited program. However, as pharmacists are not “recognized providers,” the credentials do not provide for any payment or billing to individuals who render this education service. Individuals with these certifications may bill for services provided through a recognized entity (see below).

A second category is accreditation of entities. This can include pharmacies, hospitals, licensed home health agencies, outpatient community clinics, and others.

One recognized credential is the Diabetes Self-Management Education (DSME), provided and recognized by both the American Association of Diabetes Educators (AADE) and the American Diabetes Association. Sites that are accredited must first demonstrate that their modules conform to the National Standards for Diabetes Self-Management Education (NSDSME).

The National Community Pharmacists Association (NCPA) offers a turnkey course that educates pharmacists on accreditation, intervention performance, and more, through pharmacy accreditation available to members and obtained through the Diabetes Accreditation Standards-Practical Applications (DASPA) course. This NCPA course is aligned with the Diabetes Education Accreditation Program (DEAP), AADE’s accreditation program.

These entity-approved accreditations allow the pharmacy to bill for services and obtain reimbursement from the Centers for Medicare and Medicaid Services (CMS).

For more information, go to:

American Pharmacists Association

1. The Pharmacist and Patient-Centered Diabetes Care education program

http://bit.ly/aphaeduc

2. The Pharmacist and Patient-Centered Diabetes Care certificate training program

http://bit.ly/aphaprogram

American Association of Diabetes Educators

Diabetes education page

http://bit.ly/aadepage

National Community Pharmacists Association

Diabetes Accreditation Standards - Practical Applications

http://bit.ly/ncpadaspa