Through population health, diabetes educators can offer ‘care at scale’
HOUSTON — Population health provides a framework for diabetes care and education specialists to raise their value in optimizing care and education, beyond the traditional role of diabetes self-management education services, according to a speaker here.
“The role of the diabetes educator has changed or needs to change with the evolving health care landscape,” Kellie Rodriguez, RN, MSN, MBA, CDE, director of the Global Diabetes Program at Parkland Health and Hospital System in Dallas, told Endocrine Today. “Value-based health care cares less about what we do and more for the outcomes that result from what we do. Our language must be outcomes-focused, and we need to embrace the opportunities that the population health framework gives us — assessment, care prioritization, engagement, communication, intervention and outcomes. The very same framework we use for individual patients needs to be applied to the broader population for whom we have opportunities to drive positive outcomes for people with diabetes, our care teams and our organization.”
Diabetes care and education specialists — no longer referred to as “certified diabetes educators” — must move from the mindset of a traditional diabetes education program to one that embraces an “integrated diabetes service-line,” Rodriguez said during a presentation at the American Association of Diabetes Educators annual meeting. That means connecting complex clinical evidence into the “complex, lived worlds of people with diabetes and our communities.”
“We are the required integrator for care delivery,” Rodriguez said in an interview. “The opportunity — or not — lies in our hands.”
Rodriguez said the skills learned as diabetes care and education specialists are the same skills needed for effective population health management.
“It is not something new we need to learn,” Rodriguez said. “Our multidisciplinary richness and passion for person-centered care provides the ability to translate this to a larger scale. Our ability to bridge and connect is a critical element for successful population health management.”
To aid the transition, educators should begin to move away from a dependence on the fee-for-service payment model, or traditional DSMT G-Codes, and look for alternate outcomes-based payment sources, she said.
“The health care landscape has changed, outcomes-based payment is here to stay,” Rodriguez said.
Rodriguez said there are several steps diabetes care and education specialists can take right now to work in a population health framework, starting with a focus on using outcomes-focused language in organizations.
Educators can also take these additional steps:
- Assessment — Rodriguez recommended educators help their respective health systems develop holistic electronic health records with embedded health assessment tools and registries to better understand the person with diabetes, moving beyond clinical assessment to what she said really drives outcomes: social determinants of health;
- Risk stratification — “Help to define those at greatest risk, needing greatest intervention,” Rodriguez said. Educators can assist in the development of multidisciplinary care pathways that connect people and populations with diabetes to the resources they need, both inside and outside of an organization, when, where and how they need it;
- Engagement — Identify strategies to optimize patient, care team and system engagement and connection, Rodriguez said. This can be done via technology solutions and incentive programs. “Workforce training and leveraging optimization to gain system buy-in and capability is a crucial opportunity for our specialty,” she said;
- Communication — Embrace alternative means of communication based on the needs of the person, care team and organization, Rodriguez said, by looking for opportunities to move from traditional face-to-face and mail communication to greater utilization of telecommunications via the internet and text messaging;
- Person-centered interventions — Provide people with diabetes what they need, when they need it and how they need it, based on a continuum of low-risk wellness models, through to high-risk managed care models, Rodriguez said;
- Outcomes — Help to determine appropriate outcomes and ways to influence them beyond pure clinical measures to ones that include operational and process measures to improve effectiveness and efficiencies, care team and patient experience. “Use the EHR to gather and drive data,” Rodriguez said.
Brick and mortar education, Rodriguez said, needs to be just one part of the diabetes service-line, which encompasses not just education delivery, but care delivery.
“That’s where the vision comes from,” Rodriguez said. “How can we move beyond the DSMES box? How do you build value? It begins with you. We are not a good group to showcase who we are and what we do. If you want to do what you like to do, you have to be viable. You have to have a business brand.”
“We have to look not only at care person by person, but care at scale,” Rodriguez said. “The multidisciplinary richness of who we are is what makes us exceptional.”
Rodriguez K. F05. Presented at: American Association of Diabetes Educators; Aug. 9-12, 2019; Houston.
Disclosure: Rodriguez reports no relevant financial disclosures.