The Crisis in Diabetes Education: Essential Care That's Riddled with Problems, and What We Can Do to Fix It

Amy Tenderich is host of the popular web log www.diabetesmine.com.

| Nov 15, 2007

Diabetes educators are no less than a lifeline for patients, providing vital insights into the self-care behaviors that keep diabetes in check: managing blood sugar, dosing medications and insulin, exercising, and understanding all the numbers involved.

Yet many patients never get referred to these specialists at all. Even when they do manage to get a doctor's referral for diabetes education, insurance may cover only a few hours per year of this critical counseling - not nearly enough to learn how to manage the disease for a lifetime.

Ironically, certified diabetes educators (CDEs) are more overworked than ever, struggling to reach existing patients even as diabetes reaches epidemic proportions. According to the National Centers for Disease Control, diabetes drains the U.S. economy of over $130 billion each year. That's more than three times the annual amount spent on diabetes patients all across Europe.

While new diabetes drugs and high-tech treatment devices are coming to market faster than ever, recruiting of new educators is almost at a standstill. This is happening for two reasons: First, the current certification process essentially serves as a barrier to becoming a CDE. Second, health insurance companies simply don't pay for enough hours with a CDE, a policy that has led to the closure of many diabetes education centers.

No matter how you slice it, the field of diabetes education is facing a crisis. There are only about 15,000 CDEs in the U.S., yet nearly 21 million Americans are already affected by diabetes, and the number is growing every day. Who will help all these patients manage their disease? In order to serve them all, every educator would have to see at least 1,400 people four times a year: this works out to more than 22 people every single weekday.

Why these disconnects? Many problems stem from the U.S. healthcare system itself. Insurance reimbursement favors acute care rather than prevention, and there is a fragmented, every-clinic-for-itself approach to procedures and funding.

But one fundamental drawback is the fact that diabetes education is not supported as a stand-alone profession at all. What patients perceive as professional diabetes educators are really nurses, dietitians, exercise physiologists, and other healthcare professionals. They have all earned the CDE title by clocking 2,000 hours of hands-on work with diabetes patients over two years and then taking a comprehensive certification exam. Without the hours of work experience, they are not eligible for the exam. This "backwards" process of accreditation makes recruiting new educators difficult at best. And even formal certification doesn't provide CDEs with any standard procedures for how to teach patients. Every hospital and each individual educator has to find their own way.

It's high time for a major overhaul of the diabetes education infrastructure. Queried about the specifics of such an overhaul, educators, physicians, and a variety of healthcare stakeholders suggest the following changes:

  • Create a sensible career path for new recruits, including some type of mentorship
  • Streamline patient access to educational services
  • Garner consistent support from both physicians and insurance providers for diabetes programs
  • Establish accepted best practices for diabetes treatment that are clearly communicated throughout the field
  • Drive more proactive participation from the patient community

Let's take a look at some ways to accomplish these goals.

PROBLEM: No Sensible Career Path for Becoming a CDE

The existing process of becoming a diabetes educator was patched together twenty years ago to certify a group of healthcare professionals who were already educating diabetes patients. These pioneers wanted official certification for the work they were doing, and they got it. But now that initial set-up has become a barrier to healthcare professionals wanting in.

Today the field is governed by two organizations - the American Association of Diabetes Educators (AADE at www.diabeteseducator.org), founded in 1973, and the National Certification Board for Diabetes Educators (NCBDE at www.ncbde.org), founded in 1986. The NCBDE governs the comprehensive CDE certification exam.

"There's no college curriculum to become a diabetes educator. Everyone comes to it in different ways," says Joyce Bohren, CEO of the NCBDE. "Maybe you get assigned to work in a diabetes education program…[but] it's not something you're going to get a bachelor's degree in. And you already have to be a licensed healthcare professional to become certified."

The four-hour certification exam is quite clinically oriented, including multiple patient problem-solving scenarios for the applicant to untangle. But the dilemma of gathering field experience in advance of formal schooling remains. To make it even trickier, the required work hours must be in a paid professional "diabetes education" position. In other words, you have to work as a diabetes educator before you can become one. Many institutions don't want to hire people without certification, so the situation becomes a Catch-22.

SOLUTION: Reform the Process of Training and Certification

  • Tiered certification: Different levels of certification should be established, including an entry exam like those required to become a CPA or lawyer, followed by a higher-level certification for seasoned veterans. A first step in that direction was taken a few years ago when the AADE and the American Nurses Credentialing Center (ANCC) joined forces to establish the BC-ADM (Board Certified-Advanced Diabetes Management) for CDEs with advanced academic degrees. Now it's time to look into reforming the certification process on the entry-level end, according to Martha Funnell, a prominent CDE from the University of Michigan who runs her own educator training program. The average diabetes educator is at least fifty years old, she says. "I feel like we're going to be gone soon if we don't change something."
  • Mentorship: Trainees should be assigned to a mentor who could show them the ropes, says Beverly Thomassian of Diabetes Educational Services in Chico, California, another CDE who leads her own educator training seminars. "I tell people who want to get started in this field…[to] hang out with other educators. This is where you start learning about how to talk about diabetes in an understandable way that makes sense to people-using motivational language versus fearful language," she says.
  • Student teaching: The governing organizations should establish a formal student teaching program or "specialty training" program, like the one young nurses undergo in hospitals when specializing in such disciplines as critical care or labor and delivery. This formal structure would also make it easier for volunteer hours to be counted towards certification. The program should emphasize effective teaching style as well as content, because no diabetes counseling program will succeed if patients find it boring or useless. "We need to deliver it in a way that keeps them coming back," Funnell says.

PROBLEM: Patients Don't Have Enough Access to Educational Services

According to current AADE President Donna Rice, access to educators is the biggest problem. "It's not the shortage of educators, but how we use them. A physician doesn't have to see every patient. Rather, patients could go directly to the educator," Rice says. "Nearly every hospital has a diabetes education program accredited by the American Diabetes Association. But the way the system's traditionally set up, it doesn't support access."

Physicians are so busy that they often don't refer patients, Rice says, and health insurance policies don't allow patients to self-refer. If patients choose to bypass the doctor referral, they forfeit insurance coverage, which means paying hundreds of dollars out of their own pocket for each hospital or clinic-based session. Most patients simply can't afford this ongoing investment.

SOLUTION: Bring Patients and Educators Together in the "Real World"

  • Point of care service: To improve access, Rice says, the AADE is focusing on placing the educators where the patients are: in the offices of primary care physicians. (Endocrinologists see only about ten percent of diabetes patients; the other ninety percent are treated by family physicians.) The AADE is planning a pilot study beginning in 2008, in which educators will be contracted to work part-time with multiple family physicians, Rice says.
  • Reimbursement for phone-based counseling: Currently insurance companies don't pay for education provided by phone. Dr. Linda Siminerio of the University of Pittsburgh Diabetes Institute and others are calling for health plans to reimburse for advice rendered over the phone by nurses and educators. This would be far less costly than multiple on-site visits and could prevent many emergency room visits, Siminerio says.
  • Retail clinics: Diabetes-specific clinics could be created, modeled after the MinuteClinic and MedExpress clinics located in Target, Wal-Mart, and CVS chains around the country. "Family physicians don't get compensated for counseling patients on diabetes management…so the delivery model needs to be reinvented. What about a basic diabetes clinic that's open seven days a week, right where people do their shopping?" suggests David Kibbe, MD, head of the American Academy of Family Physicians (AAFP) Health IT Center.
  • Deputies, webinars, and group sessions: "Since we can't grow five times as many educators overnight, why not consider deputizing other people, who might not be certified, to handle certain portions of diabetes education?" says Michael Weiss of Patient Centered Solutions, LLC, and former chair of the national board of the American Diabetes Association. He also recommends increased use of Internet teaching tools and group sessions to increase patient access to educators' knowledge. "We need to figure out how one person who reaches ten patients now can start reaching fifty patients."

PROBLEM: Doctors and Insurance Providers Aren't Supporting Diabetes Education

As an emerging segment of the healthcare profession, CDEs simply haven't gained enough clout to push their agenda through the system, experts say. Diabetes educators as a group lack the internal support they need from both doctors and insurance providers.

Many doctors are uninformed about the value of diabetes education, and they sometimes push back on other healthcare professionals whom they view as interfering between them and their patients. But educators don't have the authority to make medication dosing adjustments or other treatment recommendations on their own. Everything is subject to approval by physicians, pharmacists, or administrative committees. This is especially frustrating since those folks often aren't as up-to-date on the latest diabetes treatments as the educators themselves, Thomassian says.

Meanwhile, health plan coverage for diabetes education is sorely lacking. While diabetes education is required by law in at least 45 states, some plans cover as little as two hours of counseling for the lifetime of the patient. This lack of coverage, which makes it nearly impossible for diabetes centers to operate at a profit, has forced a number of otherwise-successful programs to shut down.

For example, the Beth Israel Medical Center diabetes program in New York City closed its doors in 2006, after operating at a loss for several years (see the New York Times' "In the Treatment of Diabetes, Success Doesn't Pay," January 11, 2006). When hospitals suffer budget deficits, diabetes education is often the first thing to be cut back - the case recently at the Barnes-Jewish Hospital in St. Louis, Missouri, and facilities like it all over the country.

It's easy to understand why hospitals must shut down programs that lose money. They're simply responding to market forces, in this case originating from insurance companies, which seem to have no motivation to pay for diabetes education. Oddly enough, insurers do cover acute care such as kidney dialysis or limb amputation. Yet they refuse to cover the proactive diabetes education programs that would save them the soaring costs of these severe complications in the long run. (For example, dialysis treatment costs $15,000 a month for one patient, yet diabetic kidney disease is completely preventable.) Why so?

The reasons seem to be purely economic. Currently, many patients switch insurance providers every few years; betting on this fact, the current insurer has no incentive to pay for preventive treatment like diabetes education, even though it would save costs in the long run. Also, many patients who develop complications later in life end up on Medicare or Medicaid, so again the commercial insurance companies have little incentive to invest in preventive diabetes care.

For this reason, the AADE and other groups have launched a campaign to utilize a "Chronic Care Model" for diabetes. The model calls for viewing diabetes education as an obligatory ongoing process throughout the life of the patient, rather than as a onetime optional event.

SOLUTION: Educate Doctors, Lobby Insurance Companies, and Think Outside the Box

  • Lobbying: The CDE community needs to stop waiting for outside assistance and take lobbying for support into its own hands, according to Michigan CDE Funnell. They should start with convincing their own colleagues, the physicians, to take up the cause. "We haven't gotten out of our little space enough to sell ourselves to the doctors. We should pitch pay-for-performance to illustrate what a difference diabetes education makes in patients' lives," she says. "Also, the AADE needs to do more lobbying to insurance providers- not just for reimbursed benefits, but also to do away with the need to work through a physician every time. This shouldn't be a barrier."
  • Doctor education: CDEs should hold at least a one-hour overview course for doctors at their institution each year, according to several CDE community leaders. The course could review the latest updates in treatment standards, such as new blood glucose goals or measures of creatinine for calculating kidney health. This would help keep the doctors up-to-date and involve them in the diabetes education process.
  • Think outside the box: Innovative programs could turn to outside funding sources like Health Evolution Partners, a new San Francisco-based venture capital firm looking to back treatments and services that "keep people out of institutions." "We're going to be investing in things that can reduce the crushing costs of healthcare," says Dr. David Brailer, who heads the equity fund.

PROBLEM: Vast Differences in How Diabetes Is Treated

Surprisingly, there is no standard protocol for how to work with diabetes patients. The AADE does publish an 800-page reference manual, along with guidelines that it calls the "AADE 7." It also offers biannual seminars called "Core Concepts." But few educators get the time off or funding necessary to attend these events. Moreover, each hospital and diabetes center has its own way of applying this information to patient care.

"The problem is there aren't any established best practices. They're called best practices, but more often they're just a consensus of ideas from really experienced people than an actual protocol for the medical side of things," says Dr. Richard Jackson, Director of Medical Affairs, Healthcare Services, at the Joslin Diabetes Center in Boston.

Jennifer Caouette, a nurse currently working with Medtronic and hoping to become a CDE (see sidebar), illustrates this point: "Some hospitals prefer to put all new type 1 patients on injections of NPH and Regular insulin. Other hospitals start all new patients on insulin pumps right away. It really depends on how advanced the program is. You could get completely different knowledge even in two hospitals across town from each other."

Keeping up on treatment advancements is a major challenge for overworked CDEs. They must renew their status either by repeating the big exam every five years or by gathering fifteen units (hours) of educational credit every year via seminars from NCDBE-recognized providers. Many educators manage the latter simply by attending one of the major annual conferences, such as the AADE Annual Meeting, where they can easily garner eighteen credits within three or four days.

Whether this annual four-day crash-course approach is really the best method for training educators is debatable. How much new content can be absorbed that quickly, especially with new medicines and technology emerging so fast? And attending lectures on new treatments is only part of the game. To be good teachers, educators also need to understand how patients learn best.

"We're stuck in the medical model. That's not the right model. It needs to be more of a public health/ communication/ education model, in which more emphasis is put on information sharing," Chico CDE Thomassian says.

SOLUTION: Standardize Treatments and Tools and Focus on Patient Outcomes

  • Stagger training: Some experts suggest doing away with the single marathon session and breaking up the educators' unit requirements throughout the year. In addition, the AADE should encourage expanding the use of Internet tools like its online Specialty Practice Groups , where educators can swap ideas and suggestions directly via message boards.
  • Standardize tools: "Best practices are tied to tools," Joslin endocrinologist Jackson says. "We need to develop standards of teaching methods that are proven to work- meaning they help change patient behavior-supported by specific tools that are known to be effective." As an example, he cites Healthyi Conversation Maps, posters that facilitate group discussion around diabetes care issues. Such tools force educators into an open-ended dialogue and away from a traditional didactic lecture, Jackson notes.
  • Focus on the patient: A shift away from a "compliance" model to a new "patient empowerment" model is already underway, experts say. "We're putting a big emphasis on educators not being judgmental and not just 'delivering the material,' but rather asking patients, 'what's important to you today?' The idea is less lectures, more interaction," says Malinda Peeples, immediate past president of the AADE.
  • Measure outcomes: It's not easy to evaluate the effects of diabetes counseling. Some programs use surveys to assess patient knowledge before and after, but knowledge doesn't always correlate with doing better, Jackson notes. A best practices protocol should include a method for measuring healthier outcomes, such as how often the patient sees the doctor, takes medication, or eats healthier, he says. The most important thing to assess is whether the patient feels better or feels motivated after a diabetes education session.

PROBLEM: Patient Apathy

A focus on outcomes is good news for patients because it means more targeted follow-up and plenty of praise for successes such as a drop in A1c. Many centers already have programs to send letters and make phone calls to patients who haven't shown up for a while. They also send out A1c and other lab test reminders in the mail, and they're making efforts to record the "quality of life" improvements they see when patients receive ongoing support.

But for diabetes education to succeed, it's also up to patients to take an active stand. Too many patients don't bother to find out about diabetes education programs in their area. Sometimes they simply assume that their insurance won't cover it, or they attend one session and then drop out, Jackson says. If patients don't demand this kind of care, they won't get it. And it's essential that they provide feedback - and not just complaints - to the referring doctor. Patient feedback is currently the only way physicians can monitor the value of such programs.

SOLUTION: Diabetes Patients Taking Charge
  • Request an educator: Patients should ask their doctors to refer them to a diabetes educator. Alternatively, they can find one on their own at www.mydiabetespartner.org. In that case, they will still have to insist on a formal referral from their doctor. If the doctor refuses this request, they might want to change doctors.
  • Report back: Patients should let their physicians know how they benefited from working with an educator. If all doctors ever hear are complaints, they can only assume that CDE services are useless. Only patients can really illustrate the value.
  • Lobby the authorities: As a community, patients can write letters to decision-makers and institutions, calling for more and better diabetes education. They can start with the Congressional Diabetes Caucus, the National Diabetes Education Program , which focuses on public awareness campaigns, and HealthierUS.gov, a national health improvement campaign.

Diabetes Education Innovators

A few groups have managed to bypass all these roadblocks and bring diabetes education to where it's needed most. A few examples of these successful independent programs are:

  • TCOYD (Taking Care of Your Diabetes): A nonprofit outfit run by Steven Edelman, MD, out of San Diego, California, TCOYD offers one-day diabetes seminars around the country. For only about $35 per person, the day includes a host of practical sessions, one-on-one counseling from experts, a product expo, and a ballroom-style luncheon worthy of the entry fee on its own.
  • The Diabetes Bus: This award-winning nonprofit initiative takes diabetes self-management classes to rural communities of North Carolina where no diabetes programs exist. Class was initially held for free on the bus in physician parking lots. It is now also held in physician offices and in hospitals where diabetes programs have shut down due to non-profitability.
  • Divabetic: A New York-based diabetes outreach program that offers free classes around the country, Divabetic has an especially upbeat fl air. The program was inspired by Luther Vandross and created by his assistant, Max Szadek. It is now sponsored by Novo Nordisk.
  • Conversation Maps Educator Training: With funding from Merck & Co., the makers of Conversation Maps, Healthy Interactions, will be conducting free training for more than 3,000 diabetes educators over the next three years.
  • CDEs Training CDEs: Enterprising educators like Thomaissan and Funnell have launched their own programs for training new educators, with particular emphasis on "patient-centered care." A few local AADE chapters are also starting to organize regional training, such as the San Francisco Bay Area's new "Becoming an Educator" sessions.

At a system level, however, Thomaissan and Funnell agree: "The way we're doing diabetes education now isn't working. A lot has to get fixed on several levels." All the stakeholders can help. See the sidebar on page 28, "Laying It on the Line," to learn what you can do to help diabetes education thrive.


Laying It On The Line - What Each Group Can Do To Help Diabetes Education Thrive

The Governing Organizations - AADE and NCBDE: Remove the barriers to becoming a certified educator by loosening up pre-certification requirements, creating an entry-level certification, and instituting an internship or mentorship program for budding educators. Establish a "student teaching" requirement to help newbies learn best practices firsthand.

Primary Care Physicians: Make it standard practice to refer all your diabetes patients to an educator. Or consider contracting a CDE part-time to work on-site with your patients. Create some sort of feedback mechanism, like a quick survey form, to evaluate patients' experience and outcomes after seeing the educator. Be sure to ask your patients whether the education has increased their motivation to engage in self-care.

The Diabetes Educator Community: Learn about the business side of being an educator. Consider lobbying to be part of your job-lobbying for doctor referrals, for financial support within your clinic, and for supportive healthcare legislation. With patients, focus not only on what they learn, but on how they learn best. Make courses interactive and fun, perhaps by organizing a diabetes educational cruise, a support group, or a bike ride.

Hospital and Clinic Administrators: If at all possible, make it a priority to obtain the Joint Commission of Accreditations of Hospitals (JCAHO) accreditation for inpatient diabetes care, which proves that your standards are up to snuff (details can be found at www.jointcommission.org). Encourage your financial staff to lobby insurance providers for reimbursement of all diabetes services, including unlimited education that lasts until each patient understands how to achieve and is motivated to practice healthy diabetes self-care. Then provide the option of regular refresher courses.

Health Insurance Providers (aka Payers): Institute standard reimbursement for monthly visits to a diabetes educator at least twelve times per year (which will help prevent the high cost of treating complications down the line). To make access easier for patients, make it a "self-referred benefit," eliminating the need for patients to beg their physicians for a referral. Promote your company's diabetes successes by publishing statistics related to your diabetes care programs; for example, report your rates of diabetes complications, strokes, kidney disease, and average A1c's. Patients want to know how diabetics fare long-term with your health plan, and they should be able to find out which insurers have the best outcomes with regard to type 1 and type 2 longevity.

Patients: Ask to be referred to a diabetes educator. Insist on it, in fact. Then be sure to report back to your doctor on your experience - including the good stuff , not just complaints. In order to keep diabetes education programs from being cut, lobby the Congressional Diabetes Caucus chairperson at www.house.gov/degette/diabetes/index.html.


A Budding CDE's Story

Becoming a CDE is mainly a process of learning by doing. Health professionals must complete a minimum of two years (2,000 hours) of professional diabetes-related practice and hands-on work with diabetes patients before they even qualify to sit for the certification exam. The conundrum for young CDE hopefuls is that they often can't get jobs because they don't carry the CDE title, but they can't earn the title until they've completed the work hours.

"To be honest, it's a pretty frustrating process," says Jennifer Caouette, 25, a Boston-based nurse who lives with type 1 diabetes herself and has been working toward her CDE title for three years now. "To already be in a defined [diabetes educator] role is a tricky situation when you don't have any credentials to back you up."

The certification board website (www.NCBDE.org) does a pretty good job of helping candidates prepare for the exam, Caouette says, but many people have difficulty ever getting to that point because the board is so specific about the type of work experience required. New candidates' work hours are often rejected if they don't fit those specific criteria.

Caouette, who plans to take the CDE exam this fall, is worried that her own hours might be rejected because her job title at Medtronic is no longer 'diabetes educator,' even though her role is to train patients on diabetes technology and management.

In fact, the CDE title is so difficult to obtain that many hospitals and companies like Medtronic have given up requiring it for new hires, Caouette notes. "Now they hire a lot of people and say they should earn the CDE within two years…but it's still a grueling process."

"The club's become a little too exclusive," says Michael A. Weiss, of Patient Centered Solutions, LLC, and former chair of the national board of the American Diabetes Association. "Patients are hungry for information, but they often don't get referred to educators at all. We need to fix the issue of access to good education for both patients and educators."

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Categories: A1c Test, Blood Glucose, Blood Sugar, Diabetes, Diabetes, Insulin, Insulin Pumps, Novo Nordisk, Professional Issues, Type 1 Issues, Type 2 Issues


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Comments

Posted by Anonymous on 15 November 2007

It's about time someone has spoken out about the difficulties of becoming a CDE. I am currently a CDE, however it was a very difficult certification to obtain. I was employed at a community hospital with no formal diabetes education program. My job responsibilities included many other aspects, so diabetes education was only a small part. I had to rely on family practioners to refer to me their patients for teaching. It took me 10 years to accumulate the 2000 hours needed to just sit for the 4 hour exam. That is riduculous! It I did not have such a passion for teaching patients about diabetes and saw the tremendous need in our community, I would not have pursued.

Posted by Anonymous on 15 November 2007

Yes these things are all problems, but the biggest issue is INSURANCE REIMBURSMENT. I am a CDE and I work for the government so everyone can come to see me who is in our health care system. My friends and relatives in the private sector get pills or insulin and that is it. Maybe a drug company diet sheet. If insurance will pay for people to see a diabetes educator, then I truly believe that the other problems will work themselves out. There are hundreds if not thousands of nurses and dietitians and Pharmacists out there who are eligible for certification. Right now, however, it doesn't do anything for them. So what is the incentive? No matter how educated or certified you are, you can't get reimbursed for diabetes education. Which is very sad when you consider that they pay for 12 months of avandia which may be 150-250 per month (total for year is 1800-3000 per year). If they just paid a CDE 150-250 dollars a month for 2-3 months for a 2-3 sessions, then they might not need the Avandia for the whole rest of the year. That is a HUGE cost savings when you multiply that by the millions of diabetes. The cost savings from Diabetes Education does not come just from long term prevention of dialysis or neuropathy, but from short term cost savings in treatment. I have been a CDE for 7 years (nutritionist for 20) and I can tell you much noncompliance is associated with lack of knowledge of the big picture of diabetes and symptoms, as well as lack of understanding about the diet and what modifying carbs means! We could be doing so much more, and we would be if they would reimburse.

Posted by Anonymous on 15 November 2007

Excellent article on CDE's. You point out how change needs to occur so that more people interested in becoming CDE's can accomplish this task. We need to see opportunities for beginning CDE's to accomplish this goal. The current system is not working and diabetes is not going away.

Posted by JeffBethIsraelNY on 15 November 2007

Great story and very informative on the diabetes crisis in this country and how we are not winning the war...yet on this dreadful paralyzing and killer of a disease.

I would, however, live to inform the writer and readers that Beth Israel Medical Center announced yesterday (11/14/07) at a big event at the hospital (that included a speech by CBS News' Katie Couric) that the hospital has opened the Gerald J. Friedman Diabetes Institute, a $600 million facility on Beth Israel's main campus in lower Manhattan. More than 700 people have already been enrolled as of 11/15/07 (see the New York Daily News' "Education in diabetes making the difference for many" October 28, 2007).

Posted by Anonymous on 15 November 2007

I agree with Amy's passion and the article, for the most part. I love the mentoring program idea. I do have reservations about who does what education. The pharmacy certification in diabetes education only requires 10 hours of study. They advertise themselves as "Diabetes Educators", but all they are really doing is education and training on medication use, meters, and insulin devices. Ironically, they charge $80 an hour, while we CDE's get reimbursed by Medicare and others at the rate of $32 an hour for individual, less for group, and we offer comprehensive life style modification education, in addition to the "training".

There is also a move toward using unlicensed medical office personnel to provide education. I believe this can work, if a CDE is overseeing the program, but it can be dangerous if that is not the case.

Most physicians will NEVER attend a one hour update if instructed by nurses, unless it is mandatory for staff privileges. In this day of hospitalists, most physicians choose not to have staff privileges. Our institution has a 6 hour once a year diabetes update for credit for family practice physicians and we finally broke 100 attendees, but most were nurses, dietitians, and residents, rather than the commumity physicians we tried to reach. In our state, physicians do not need CE's for relicensure, so there is no incentive to keep up if they do not see hospital patients.

When I got my CDE in 1997, it was an ordeal, but I did it and I have never let it lapse. AADE is my family's vacation and the only week I get off each year. But it is worth it. I am proud of my CDE and I consider myself a professional nurse and educator, not just an employee of a medical institution. I feel all educators from elementary school up, in all fields, as well as "health care professionals" no longer feel they are professionals and expect their employers or institutions to pay for their updates and classes to keep current or advance knowledge in our field of expertise. I recently got my MSN Ed., having been inspired by Ginger Kanzer-Lewis, one of the early founders of the AADE. These pioneers had passion and charisma, as well as a solid base of knowledge. I do not see that in our young new members. They want the job, then will strive for the knowledge, but without the passionm, they will never deliver the message as it needs to be delivered.

Everyone wants something for nothing. I don't mind passing on my skills, but I do like to eat, and therefore must be employed. When patients decide they need to pay to learn the methodology and work to achieve the goals, then we will be a valued profession.

Posted by Virginia on 15 November 2007

The problem with CDEs is that they tend to preach the
ADA junk on diet. The Richard Bernstein book helped me reduce my A1c from 7.2 to 6.0 in a month and later to around 5.5.

There is a real shortage of medical people who understand the Bernstain diet and why it works. More CDEs is not the answer, unless they can do this.

Posted by Anonymous on 16 November 2007

Thanks Amy for addressing this issue.

Your choice of a young nurse educator for this article was excellent. I was fortunate to work with Jennifer recently and she is a rising star in the diabetes community. Her passion for teaching young people, particularly adolescents, to live with the disease can only be matched by her talent. Unfortunately the barriers for her to obtain her CDE are so high it has become almost unattainable for her.

As the Nursing Coordinator at Camp Joslin, a summer camp for children with diabetes, she dedicated three months each year to educating over 500 children, young staff, nursing and medical students about life with diabetes. She did this through group and individual sessions, clinical and experiential sessions and NONE of this can count for her CDE.

This is a big problem when people who are so dedicated to the community they serve can not accumulate the credentials to be able to serve the same community. I estimate that she worked at least 5-6 hours per day for 10 weeks in direct patient education, and several more in educating her staff.

It is a shame when we discuss how we must rething the traditional model of clinical care and create new models of patient empowerment and blending patient lifestyle with their disease, and yet the programs that do just that diabetes camps do not count as training hours. If Jennifer was to have stayed with Camp Joslin it would never have been possible for her to earn the hours necessary to sit for the exam.

Posted by rbucklew on 16 November 2007

I want to brag on the CDE course I took in Nov 2004 from the Diabetic Center at Research hospital in Kansas City Missouri. The nurse and dietician classes were wonderful, with encouragement, positive attitude, and invaluable information. I feel like I could have never made it without those classes. Portion sizes were taught in an unforgettable and simple way. Time between classes to practice and write down foods eaten. I was a new diabetic and they gave me a monitor and taught me how (and WHY) to use it. Everything organized in the perfect way to learn and practice. I cannot rave enough about the teachers and the whole organized structure of classes.

Posted by Anonymous on 17 November 2007

thank you for the article. i have recently graduated nursing school but my goal has always been to become a diabetes educator. i am working on a pediatric floor and also working w/ a CDE at my hospital's endo clinic. even though everyone is excited to have someone who wants to do educating it has been very difficult to get the "ball rolling". now i'm not even sure the hours i am putting in at the endo clinic will count toward my 2000 hours.

Posted by Anonymous on 19 November 2007

Amy is correct when she writes that insurance reimbursement favors acute care rather than prevention, and we see this over and over, and yet everyone complains about the expense associated with chronic disease care and uncontrolled diabetes -- you have to invest if you want to prevent these issues.

I do feel the CDE certification process is in need of review. Over 80% of the content is focused exclusively on type 2 diabetes issues, and there is almost nothing on health issues facing people with type 1, such as hypoglycemia unawareness and how there are actually training programs (Blood glucose awareness training or BGAT) which can help them. Instead, CDE's look for patient fault in counting carbs, dosing insulin, overlooking nutritional facts (such as fat content) instead of acknowledging what is a genuine physiological issue which impacts T1DM patients.

The bottom line is this: classroom approach to type 2 training is being rolled out by virtue of necessity, and while its hardly ideal, we cannot expect educators to do more than this in the current environment. Government assistance should be addressing these issues, especially given all the complaints about how much diabetes costs the Feds and State governments, yet the President has advocated cuts in the healthcare budget. Can we say disconnect?

Posted by Anonymous on 19 November 2007

It was truly refreshing to read this article. Thank you for bringing the issue to light. The current CDE requirements truly create barriers to putting qualified educators into practice. It especially creates barriers for educators in rural hospitals where it is difficult to log the 2000 hours in practice when there is so much restriction on what you can count. I think we are leaving out some professionals out there who have alot to offer in the way of diabetes education. Also, the part about lack of physician buy-in is priceless. We need to get the docs acquainted with the role of an educator early on in their medical education.

Posted by Anonymous on 20 November 2007

Great article!

And even though my bias may be showing ;), I think that the list of Diabetes Education Innovators is missing one crucial one: dLife. I'm an in-house editor for dLife and decided to take this job because I feel that this company is making a huge difference in the lives of people with diabetes. As both a member of the diabetes community (type 1 for over 21 years) and an editor for dLife, it's sites like these that make education easier to access, both for patients and medical professionals alike.

Great list of resources - just wanted to round it out!

Posted by Anonymous on 21 November 2007

I am currently a RN student and a type 1 diabetic for over 20 years. My goal is to become a CDE but the way the rules are it seems almost impossible. I plan to further my education and earn a masters and possibly become a NP. I may just forget the CDE and go for the BC-ADM.

Posted by Ladybird on 29 November 2007

What a wonderful article! Thank you! I, myself have read and read on my own,to educate myself about diabetes, am a type 2. But not all of us are the same. We need "experts" to teach us about this killer called Diabetes. Most diabetics don't even know about portion control, they feel that can eat anything they want to if they are on meds.

Posted by Anonymous on 30 November 2007

I think because it is so difficult to get the 2,000 hours to get the CDE many have "cheated" and just had a friend/colleque sign off on the required hours on the CDE application. I know of at least 2 people that did this. I don't think the hours/requirements should change because I think you need to know that when you go to a diabetes educator that the person is experienced and at least with the CDE you would hope that the person is competent. Also going to a ADA recognized teaching program gives the consumer some assurances of compentency. I agree that the biggest crisis is the lack of insurance coverage for our services. I am proud to be a CDE and would love to mentor younger professionals into the field but not "give it away." I feel it will dilute the CDE credentials if you allow persons to get it without the actual teaching experience of two years. This would utimately then reduce the experience that the consumer will recieve if this is allowed.

Posted by Anonymous on 1 December 2007

Great article! How about making the rule for testing to include anyone with a college degree (or whatever) as long as they are diebetic, T1 or T2? Isn't this the reason websites and blogs and newsgroups seem to be flourishing? Whi are you going to ask a insulin requirement for a shift-worker, an over worked CDE or the person who works shift in the asme building?
Just wanting to make a point that sometimes healthcare limits itself trying to being an exclusive club.
Best, John

Posted by khanchette on 4 December 2007

Excellent article, Amy and thanks for mentioning our Diabetes Bus Initiative. You have addressed the BIG ELEPHANT'S in the room of diabetes management. As a CDE for these last 17+years, I also need to mention that if AADE had had their way 5 years ago, The Diabetes Bus would not be serving 105 people a month. Coming into diabetes education with a non-traditional degree (Masters in Health Education) I had to originally become "grandfathered" in. Never having let my CDE lapse, they tried to take it away when I renewed in 2002 and had passed the exam for the fourth time!-due only to my non-traditional degree, this after already being a CDE for 10 years! I had to get a letter-writing campaign going until they reluctantly approved it. Think of all the innovative people who could be part of the diabetes solution right now but have been turned down for CDE status over the years!Shame on AADE for contributing to the problem.

Kim Hanchette, MEd, CDE
Founder, The Diabetes Bus Initiative

Posted by Anonymous on 5 December 2007

The CDE credential is not an entry level credential and should not be "watered down" to diminish eligibility and the credential itself. Becoming certified is a VOLUNTARY process and people can be diabetes educators without being credentialed. Experience in the field is essential before becoming certified. 1000 hours and a minimum of two years experience is really a minimum requirement for credentialing. People with diabetes want experienced educators to work with them, not novices.

Posted by Anonymous on 11 December 2007

For clarification, AADE is NOT the governing body of the CDE credential - the National Certification Board of Diabetes Educators (NCBDE) is. Please stop accusing AADE of all problems related to the CDE credential - call, write and express yourself to NCBDE!! Enm

Posted by Anonymous on 14 December 2007

"Catch-22" is exactly the phrase I've used re: the CDE certification process! Though I am a Master's prepared certified pediatric nurse practitioner who has cared for kids with diabetes for over 40 years, has worked diabetes camps for over 15 years, has raised a son (now age 22) diagnosed at age 8 weeks, I was not allowed to take the CDE exam because most of my work was not for pay. Luckily the BC-ADM became available, and I earned that credential. For sentimental reasons I would also like the CDE, since my mother was one of the originals, taking the exam the first time it was offered, in 1986.
The need for patient education is overwhelming, and growing. Reform of the system is long past due!

Posted by Anonymous on 14 December 2007

I developed and implemented a diabetes program at one of the hospitals in our city. When I retired, I decided to bring the educational component to the community. Many people with diabetes do not have the appropriate insurance to cover the cost of hospital programs nor the personal funds to pay for it.

I now coordinate and teach two series of classes--one devoted to self-management, the other directed toward the clients who are termed as having pre-diabetes.

Materials,handouts, etc. are financed through a community grant. I volunteer my time.

The program is entering its fifth year. Over four hundred people have attended the classes. Eighty-to eighty five percent of the physicians refer their patients to the community program. I believe it to be a successful endeavor and one way to "think outside the box".

Posted by Anonymous on 15 December 2007

CDEs are a waste of time and money. Better information about diabetes can be found on the internet for free. Enough already with spending yet more money on "prevention" or "treatment" or "education" and start spending those resources on "cures". Our medical industry is totally impotent when it comes to curing chronic disease. The last thing we need in our already too expensive health care industry is yet another layer of people that don't cure anything and only add to costs.

Posted by bird54 on 16 December 2007

Hi Amy Tenderich,
I agree that there is a "Crisis in Diabetes Education", but for different reasons. Joy Pape recently recommended your article saying, “It used to be so easy to teach people what diabetes is and how to manage it. But the truth is, we just didn't know how much we still don't know. Once again, we need to change our teaching materials about what diabetes is, what causes it, and how to treat it.”

I wonder...if it used to be so “easy” to treat diabetes, then what has changed? Is it that we really know “more” than we did before, or is it that we have overlooked the obvious?
Diabetics are told by their physicians that they have a “disease.” And of course, a disease needs to be “treated.” And since "...we have almost 21 million people with diabetes but only about 15,000 CDEs..." we assume that the answer is that we need more CDEs to treat this epidemic.

The answer may not be that we need more CDEs, but that we need to look at diabetes in a new way. We assume that diabetes is a disease because we are told by our physicians that it is. What if diabetes is not a disease at all, but a natural and normal response to an overabundance of food? Look at the Pima Indians. They have the highest rate of diabetes and morbid obesity in the world. Yet, their ancestors, with the same genes, were healthy and lean. Their “thrifty” genes served them well during times of famine and drought. When food was plentiful, they gained weight. When food was scarce, they lost weight. People in the past moved in and out of diabetes as their food supply increased and diminished. Our bodies are programmed to store fat in anticipation of famines. Our problem is that we live in a time where there is an abundance of food. We cannot continue to eat as if we are preparing for a famine.

Most diabetics consume more calories than they burn. They continue to overeat, thereby feeding their own fat cells, which in the past would have benefited them. Today, without a famine to put a lid on the weight-gain, they continue to gain. Many take drugs and insulin to force feed the cells which are already overloaded. Some resort to stomach bypass surgery to force themselves to eat less. Are we living in the Dark Ages? Do people need to chop out their stomachs in order to reverse their diabetes? That’s insanity!

What if diabetes is not a disease at all, but a normal response to an overabundance of food? What if the cure is so simple, that we, in all of our knowledge have overlooked it? What if the answer really is “easy”? What if the cure to diabetes is to eat less often? What if diabetics could cure their diabetes by intermittent fasting? What if people could reverse their diabetes by drinking only fresh water as meal replacements, and eating only when they were hungry, instead of overeating because they are told by their health care practitioners, “Never skip a meal. Always eat breakfast. Eat many small balanced meals throughout the day.” So they do that, and they watch themselves get fatter and fatter. Then they wonder, “How did I get diabetes? I followed all the rules!”

Diabetes is not a disease. It is a natural response to an overabundance of food. If you want to cure your diabetes, just eat less often and fast regularly. Don't wait for a famine to cure you, make your own famine!

Posted by Anonymous on 4 January 2008

Thnak you Amy for a great article. Like many I am interested in becoming CDE but the 2,000 hours in a paid position is a barrier. I am willing to voluntar under a CDE to obtain the 2,000 needed to sit for the exam. At the facility I work at there is no CDE or any diabetic education. I have been trying to rectify this by bring material for the nursing staff and attending any meeting I can on diabetes.

Posted by bird54 on 10 January 2008

I would like to edit my last comment about the "thrifty gene" theory after reading Gary Taubes book, "Good Calories, Bad Calories." James Neel originally proposed the idea of the thrifty gene theory but later changed his mind. He decided that diabetes and obesity in the Pima Indians was due to our Western diet high in sugar and carbohydrates. It is not an overabundance of food or overeating that causes obesity and diabetes, but malnutrition. In the past, the Pimas had an overabundance of food, but in the form of fish, wildlife, and vegetables, not sodas and white flour.
Research shows that eating meat and saturated fat does not cause obesity, heart disease or diabetes, but is actually the body's preferred foods.

Posted by Anonymous on 13 June 2008

This article is quite thought-provoking. I have diabetes and currently can't get access to an educator because there simply isnt one available in my area. It is very frustrating to learn that the system itself makes this important partner even less likely to be available in the future as the rate of diabetes diagnosis continues to explode. Good care is a huge preventor of the major complications, and health care costs, associated with this disease. CDEs should be a regular part of normal "good care". Thanks for letting me contribute to the discussion.

Posted by Anonymous on 15 August 2008

Thank you for understanding and supporting the NEED for diabetic educators, even if only as a screened,trained diabetic volunteer to provide information and links to resources needed for diabetics.
As a parent of a diabetic (for 25 years) it is very important that families also be educated and understand what is happening, why it is happening, and what to do when it is happening. Doctors and nurses, unless they are diabetics have no idea what parents/families live with on a daily basis, and have never been prepared for.

The worse things always happen on weekends, holidays, and nights when there is no one to call and ambulances are very expensive. No one tells you about things like diabetic siezures and what to do until an ambulance arrives, or when at the hospital emergency rooms you are expected to know all the answers.

Some of the best and most helpful information I received came from the diabetic wife of a doctor in a local support group. Maybe older diabetics could be screened, trained, as LDE's "Limited Diabetic Educators" to present new, current information in an easy to understand, encouraging format, with the support of the medical community and resources.

We all need someone to turn to in those darkest, fearsome hours of emergencies.

Diagnosis and diabetic treatments has come a long way in 25 years.
Keep up the good work!!!!!

Posted by patricialong on 23 October 2008

I am curious to get feed back as to how many CDE work in a hospital setting ?

Posted by Anonymous on 19 January 2009

I am a CDE employed by a hospital based diabetes education program and I have type 1 diabetes. When I was first diagnosed, I met with an RN, CDE who was overweight and quite unsympathetic. After that meeting, I vowed that I would be a CDE and one much better than she. In all honesty I really did not think attaining the CDE credential was all that difficult. I am an RD and left my department, tranferred to the diabetes education dept and got the 2000 necessary teaching hours and took the exam 2 years later. The exam was alarmingly easy considering the material presented in the core cirriculum that studied SO hard. I was thrilled to learn that I passed the exam but was a little shocked when I learned that I would not get a raise for my achievement. I agree with some of the information in this article but I think that lack of insurance reimbursement is the by far the biggest problem with diabetes education. Next would be physician buy in. If it doesn't make them money they don't want any part of it. So Sad. Hopefully when insurance companies start paying for performance that will change but currently there is little incentive for MDs to send their patients for diabetes education. Docs think that telling their patients to stop eating sugar and white foods oh and "take this pill" is sufficient information. Nevermind telling the patient WHY you should CONTROL blood sugar levels. The population I work with is primarily very LOW LITERACy so to expect these people to read it on the internet as one person said is unrealistic. NOT to mention a lot of what's on the internet is BOGUS. (I do LOVE LOVE LOVE the dLife site and think it is the by far the BEST site out there for diabetes info. Far superior to the ADA site!) Plus, diet therapy for diabetes is not necessarily one size fits all. And to expect people to follow something as ridgid as Dr. Bernstein's diet is even more unrealistic. I come from the land of sweet tea by the gallons and fried fatback biscuits for breakfast. You have to meet these people where they are and educate them about the basics of food. Start from the ground up basically. Some days I get very frustrated with my job but for the most part find it very rewarding. Yes, there should be more CDEs in some parts of the country but the ones in my area are VERY underutilized for reasons mentioned above. Frankly, I don't think that just anyone should be a CDE either. Just because someone has diabetes does NOT make them fit/qualified or whatever you'd like to call it to teach someone else diabetes self-management. I see nothing wrong with the current CDE requirements but there needs to be more value/emphasis placed on USING a CDE to begin with.

Posted by Anonymous on 2 June 2009

Well, I'm a year and a half late, but THANKS so much for this article! It put so much of what I'm experiencing into perspective. I was wondering if I was the only one feeling this way. I am currently employed in the field of homeless housing and considering going back to school for a degree in nursing to become a diabetes educator. Having already spent a lot of time and money getting a BS and a masters degree in fields unrelated to nursing, this would be a major commitment. I would much more readily do it if I could grasp what it will take to become a diabetes educator. I've interviewed quite a few educators, but it's still very unclear to me, other than the troublesome specialties, hours - actually being reduced - etc., which are unfortunately, all too clear. Can someone please explain for instance, why a podiatrist or occupational therapist is eligible, but a public health professional is not? Isn't that what public health professionals do - educate the public about health issues...? Not surprisingly, when I asked the AADE this question, they hung up on me. Thanks for your help. I think it's a shame, because I think I'd be good at it, and I have a useful background - I've had type I for 20+ years. Lots of experience with highs, lows, syringes, pumps, sensors, swabs, pens, logs, exercise, A1Cs, etc. I'm actually seething a little bit after reading this article because it confirmed my fears about the AADE and other groups in this system. I need to apologize here because I think this response is coming off as too much of a rant, but... Sadly, this system reminds me all too much of the pitfalls of housing and homeless services that I would like to escape: In my current field, many different organizations and agencies negatively affect the performance of other groups that have related goals, in the name of protecting their own fiefdoms. I had hoped making this career change would help me escape that sort of thing, but I guess this would be a new battle to take up. If anyone is willing to talk about pathways to becoming a diabetes educator, I would love to chat and greatly appreciate your input. Thanks again for the great article.


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