The 2009 Diabetes White Paper: The Back Stry and Assessing Where We Are Tday Anne Daly, MS, RD, BC-ADM, CDE Directr f Nutritin and Diabetes Educatin Springfield Diabetes & Endcrine Center Springfield, IL 22 Abstract The rle f the registered dietitian (RD) in diabetes self-management educatin (DSME) and diabetes medical nutritin therapy (MNT) is well defined and unique, yet it cntinues t evlve with changes in diabetes care. Questins frequently arise abut the RD s practice rle within diabetes care teams. The 2009 Diabetes White Paper is an excellent resurce that prvides clarity and directin abut the rle f RD versus nn-rd members f diabetes care teams when prviding educatin abut incrprating nutritin management int lifestyle. Diabetes Care and Educatin (DCE) members and thers in the diabetes cmmunity shuld becme familiar with this paper and use it as a reference. Intrductin RDs have a defined and unique rle in diabetes care that differs accrding t whether the service invlves MNT r DSME. Medicare Part B prvides cverage fr services that are cnsidered cmplementary but distinct prgrams that RDs are eligible t prvide (1). Standards The Natinal Standards fr DSME are designed t define quality DSME and t assist diabetes educatrs in a variety f settings t prvide evidence-based educatin. The Standards serve as guiding principles fr DSME. Due t the ever-changing health care envirnment and nging develpments in diabetesrelated research, the Standards are updated apprximately every 5 years by key rganizatins and federal agencies within the diabetes educatin cmmunity. In June 2007, an updated versin f the Natinal Standards fr DSME was published in Diabetes Care (2). The mst significant changes appeared in Standard 5, which described the cmpsitin f the DSME prgram instructrs. Standard 5 n lnger required a DSME entity t have bth an RD and registered nurse (RN) prviding DSME training. Rather, ne r mre instructr(s) wuld prvide DSME and at least ne f the instructrs will be an RN, RD r pharmacist (RPh). Initially, the new Standards created a wave f cntrversy. A primary cncern fr the authrs f the Standards was t imprve access t diabetes educatin. They insisted that their recent evidence analysis did nt reveal any evidence t supprt the cncept that educatin prvided by mre than ne discipline was any mre effective than that prvided by a single discipline. They als cnsidered the required minimum f tw disciplines t be a barrier t the financial viability in sme very excellent DSME prgrams. The reactin within the diabetes cmmunity t the revised Standard 5 was mixed. On ne hand, the pprtunity fr RDs, RNs, and RPhs t manage as a single-discipline prgram was welcmed by many. The revisin in Standard 5 ffered RDs an pprtunity t market themselves fr referrals frm prgrams being managed by nurses r pharmacists. Hwever, thers expressed cncern that the revisin culd lead t individual practitiners wrking utside their scpes f practice. Standard 5 states that if a patient s needs are utside an instructr s scpe f practice and expertise, the prgram must ensure and dcument that the patient s DSME needs are met. Sme cncerns raised were: 1) Wuld patients truly receive quality educatin when taught by a single-discipline instructr? 2) Wuld DSME prgrams cntinue t be multidisciplinary? and 3) Wuld sl instructrs still cllabrate with ther disciplines as needed? Academy f Nutritin and Dietetics Respnse The Academy f Nutritin and Dietetics (the Academy) was cncerned that the 2007 Standards had the ptential fr a negative impact n RDs. In additin, the Academy had sme cncerns abut hw the term medical nutritin therapy was being used in dcuments frm utside the dietetics prfessin, such as the new revised Standards fr
Figure 1. Medical Nutritin Therapy Prvided by RDs Reprinted with permissin frm the Jurnal f the American Dietetic Assciatin, 2009;109;528 539. DSME. Academy leaders felt cmpelled t take a practive stance by creating a dcument designed t define the rle f the RD in DSME versus MNT fr the prfessin and prevent further cnfusin within the diabetes cmmunity. A task frce was appinted in December 2007 t develp a White Paper t address and clarify these issues. The charge f the task frce was t publish a dcument that culd help clarify the distinctin between what RDs d when they prvide DSME versus MNT and even mre imprtantly, describe the rle f a nn-rd diabetes educatr in the nutritin cmpnent f diabetes care. The challenge fr this grup was t develp a paper that wuld ffer sme answers t the many questins frm RDs and thers in the diabetes cmmunity abut practice rles and give directin fr hw the new standards culd be implemented withut adverse effects t quality f care. One area f great cncern was the need t describe the rle f members f diabetes care teams wh are nt RDs, such as RNs, RPhs, and thers. In the diabetes field, RDs have spent years demnstrating the effectiveness f using multidisciplinary diabetes educatin teams and building strng and effective relatinships. One f the first decisins was t determine what term(s) best describes what ccurs in accredited DSME prgrams related t the cntent area titled incrprating nutritinal management int lifestyle, ne f nine cntent areas required in the curriculum. The Medicare-accredited DSME prgram includes 1 hur f individual assessment and 9 hurs f grup class time. After sme discussin, the term selected was nutritin educatin. The task frce develped an algrithm utlining the steps invlved in nutritin educatin cnducted within a natinally accredited DSME prgram. This prcess, which culd be cnducted by any diabetes educatin team prvider, includes an assessment f previus diabetes educatin with regard t nutritin, dcumentatin f findings, and instructin n basic nutritin educatin tpics. The algrithm prvides a specific list f basic nutritin tpics that a DSME prgram wuld typically include (Fig. 2). The final step f the algrithm is t refer the patient t an RD if individualized MNT is indicated. cntinued n next page 23
Figure 2. Nutritin Educatin as a Key Curriculum Cntent Area in Recgnized Diabetes Educatin Self-management Prgrams. 16 Figure 6. Nutritin educatin as key curriculum cntent area in recgnized diabetes self-management training (DSMT) prgrams. a MNT medical nutritin therapy. Reprinted with permissin b RD registered dietitian. frm the Jurnal f the c CMS Center fr Medicare & Medicaid Services. American Dietetic Assciatin, 2009;109:528-539. 24 The table in Figure 1 was develped that utlines the steps f MNT prvided by licensed/certified (as applicable RDs. The American 536 March 2009 Vlume 109 Number 3 Diabetes Assciatin s (ADA) Standards f Medical Care f Diabetes (3) clearly state that persns with prediabetes and diabetes shuld receive RD-prvided individualized MNT as needed t achieve treatment gals. The inclusin f MNT as a standard f medical care highlights the critical and unique rle f the RD in diabetes services. MNT incrprates the steps f the Nutritin Care Prcess, and this therapy relies heavily n fllw-up and feedback t assist patients with changing behavir(s) ver time. Final Diabetes White Paper In Octber 2008, the final Diabetes White Paper Defining the Delivery f
Figure 2. Nutritin Educatin as a Key Curriculum Cntent Area in Recgnized Diabetes Educatin Self-management Prgrams (cntinued). Figure 6. (Cntinued). Reprinted with permissin frm the Jurnal f the American Dietetic Assciatin, 2009;109:528-539. Nutritin Services in Medicare Medical Nutritin Therapy vs. Medicare Diabetes Self-Management Training Prgrams was psted n the Academy s website and subsequently was published in the Jurnal f the American Dietetic Assciatin in March 2009 (4). Althugh the authrs have received psitive feedback regarding the usefulness f the paper, sme in the prfessin may have verlked its publicatin. Questins frequently arise n the DCE listserve and elsewhere abut tpics that this paper addressed. The ADA has been mnitring data n single- versus multidiscipline prgrams since the 2007 Standards were implemented. Initial 2009 data shwed a significant increase in prgrams perating as a single discipline, which accunted fr apprximately 16% f prgrams at that time (persnal cmmunicatin, March 2009 Jurnal f the AMERICAN DIETETIC ASSOCIATION 537 cntinued n next page 25
Terry Unger, RD, CDE, the American Diabetes Assciatin, September 18, 2011). These are likely prgrams that culd have faced clsing their drs if nt fr the pprtunity t run as single-discipline prgrams. The remaining 84% f prgrams cntinue t include multidisciplinary teams f instructrs. Additinal data abut the cmpsitin f prgram instructrs cntinue t be evaluated. The Rle f the Registered Dietitian, Diabetes Educatr in the Patient-Centered Medical Hme Cecilia Sauter, MS, RD, CDE Prject Manager University f Michigan Health System Ann Arbr, MI 26 Cnclusin At this time, a new cmmittee has been cnvened t review and revise the 2007 Natinal Standards f DSME. In the cming year, be sure t watch fr the updated Standards in either Diabetes Care r The Diabetes Educatr. The ability t recgnize, understand, and deliver the tw distinct but cmplementary services f DSME and MNT will ffer individuals with diabetes the greatest pprtunity t receive quality care thrugh bth services. References 1. Sectin 300 Diabetes selfmanagement training services. Medicare Benefit Plicy Manual. Washingtn, DC: Centers fr Medicare & Medicaid Services website. http://www.cms.gv/ manuals/dwnlads/bp102c15. pdf. Published 2004. Accessed September 2011. 2. Funnell MM, Brwn TL, Childs BP, et al. Natinal standards fr diabetes self-management educatin. Diabetes Care. 2007;30:1630 1637. 3. American Diabetes Assciatin. Standards f medical care f diabetes 2011. Diabetes Care. 2011;34(suppl 1):S11 S61. 4. Daly A, Michael P, Jhnsn E, et al. Diabetes white paper: defining the delivery f nutritin services in medicare medical nutritin therapy vs. medicare diabetes self-management training prgrams. J Am Diet Assc. 2009;109;528 539. Abstract Health care refrm has psitined the patient-centered medical hme (PCMH) as a ptential slutin t meet increased demand fr primary care. The greater need fr primary care is related t the grwing number f peple with chrnic cnditins and related burgening csts f their care. The registered dietitian, diabetes educatr (RD, CDE) is an integral cmpnent f the PCMH and has many rles in this mdel, including self-management supprt, training the medical team abut self-management, crdinating shared medical appintments (SMAs), and prviding medical nutritin therapy (MNT). Overview The nature f health care in the United States has changed ver the past century, with peple living lnger and the prevalence f chrnic disease increasing. Such changes are accmpanied by an increased need fr primary care prviders, but at present, there is a shrtage f primary care prviders. Furthermre, trends shw an increased number f medical students chsing specialty care rather than primary care (1,2). This difficult situatin is cmpunded by the csts assciated with chrnic disease, which accunt fr mre than 75% f the natinal health care expenditure (3). In 2008, health care expenditures ttaled $2.3 trillin, which was three times the $714 billin spent in 1990 (4). Studies have shwn that the health utcmes f patients imprved when they were treated by primary care prviders rather than specialists assuming the rle f primary care, and csts were lwer (ne third less) in the primary care setting (5). In additin, mrtality decreased by nearly 20% (5). Despite their csteffectiveness, primary care prviders have limited time t spend with patients. In the current system, a prvider wh has a typical patient lad f 2,500 peple wuld need t spend 7.4 hurs per wrking day t prvide all recmmended preventive care plus 10.6 hurs per day t prvide all recmmended chrnic care (6,7). Thus, it appears that delivery f patient care must change t meet the demand, and the PCMH is a lgical alternative. Patient-Centered Medical Hme A PCMH is nt a place but a team-based mdel f care led by a physician wh prvides cntinuus and crdinated care thrughut a patient s life. The practice is respnsible fr prviding all f the patient s health care needs r arranging care with ther qualified prfessinals. This includes prvisin f preventive services, treatment f acute and chrnic ilnesses, and assistance with end-f-life issues. First used by the American Academy f Pediatrics (AAP) in 1967, the term medical hme has evlved ver the
Figure: The Chrnic Care Mdel. Reprinted with permissin frm: Imprving Chrnic Illness Care. http://imprvingchrniccare.rg/index.php?p=the_chrnic_care_mdel&s=2. Accessed January 2, 2012. years (8). The American Academy f Family Physicians (AAFP) began using the term in 2002. Arund this time, Dr. Ed Wagner and his team at the McCll Institute develped the Chrnic Care Mdel (CCM), which fcuses n imprving the care f the persn with a chrnic cnditin (9). The primary premise f the CCM is fr an infrmed, invlved patient t have prductive interactins with a prepared, practive practice team (Figure). The patient is expected t take actin in his/her wn care and be well infrmed. The practice team has access t and can track the patient s clinical data thrugh clinical infrmatin systems. They base their clinical decisins n evidence-based guidelines in a system that prvides effective and efficient clinical care. This is supprted by a health system that partners with the cmmunity (9). The AAFP incrprated the CCM int its Annual Clinical Fcus n the management f chrnic illness t bring the elements f chrnic disease care t family practice in 2007. The American Cllege f Physicians and the American Ostepathic Assciatin aligned with the AAFP and the AAP and develped the Jint Principles f the Patient Centered Medical Hme. These principles were adpted by the American Medical Assciatin in 2008 (10). The Jint Principles f the PCMH are: Persnal physician Physician-directed medical practice Whle persn rientatin Care is crdinated and/r integrated Quality and safety Enhanced access t care Payment t supprt the PCMH Team-based care: Nurse Practitiner/Physician Assistant Registered Nurse/Licensed Practical Nurse Medical Assistant Office Staff Care Crdinatr Registered Dietitian/Educatr Pharmacist Behaviral Health Specialist Care Manager Scial Wrker Cmmunity resurces Diabetes-related cmpanies Others 27
Patients with chrnic cnditins require medical management, selfmanagement training, and nging supprt t achieve successful utcmes. The PCMH has recgnized this and has incrprated these aspects f care. Self-Management Supprt and Training The CCM and the PCMH share the prcesses f disease preventin and management f cmrbidities. The RD, CDE is essential fr imprving health utcmes f patients and reducing csts. Fllwing the recmmendatins f the CCM, patients receive self-management supprt t prepare and empwer them t take care f their disease, enabling them t play central rles in their wn health care (11). The PCMH expects the entire team t be part f the self-management supprt f the patient. As part f the PCMH team, the RD, CDE, can assist patients in develping their wn self-management plans. This can ccur in a variety f settings, including grup Diabetes Self- Educatin Training (DSMT), SMAs, r meeting with the patient individually fr MNT. Because the entire PCMH team engages the patient in multiple settings, ften addressing selfmanagement, the RD, CDE plays anther rle, which is t serve as a resurce in training the staff and prviding nging supprt t the team. Shared Medical Appintment (SMA) The SMA r grup visit is an imprtant aspect f the PCMH that differs substantially frm the traditinal medical encunter. An SMA ccurs when multiple patients are seen in a grup fr a rutine physician visit r fllw-up evaluatin. Such visits are prvided in a secure but interactive setting in which patients have imprved access t their physicians as well as additinal members f the health care team. Further, they can share experiences and infrmatin with ne anther. The physician can cncentrate n medical prblems while ther team members are simultaneusly cnducting preventive screening, reviewing labratry results, and prviding educatin. Typically, 10 t 20 patients take part in the sessins, which last abut 2 hurs. Usually 30 t 40 minutes are devted t grup discussin, including time fr develping actin plans. Several studies have dcumented benefits f the SMA, including prviding a prductive setting fr self-management supprt and imprving clinical values such as glycsylated hemglbin, lipid measurements, and bld pressure cntrl as well as quality-f-life and quality-f-care indicatrs (11 13). The SMA grup discussins frequently are facilitated by a health educatr, wh can be an RD, CDE, especially when the SMA invlves patients with diabetes. The mst imprtant aspect f the grup discussin is t prvide the patient with useful and helpful infrmatin. Using adult learning principles and prmting a lively and interesting discussin aids in keeping patients engaged. Tpics can be selected in advance r based n questins generated by grup discussin. Mre details n setting up and billing fr SMAs can be fund in Kelly (2010) (12). The Mre Traditinal Rle RDs have always played integral rles in the care f patients with chrnic diseases, whether via a traditinal referral mdel r as part f a planned medical visit. An RD wh is part f the PMCH can rganize diabetes experiences, such as a Diabetes Day. Piatt and assciates (14) reprted n a prgram in which prviders were encuraged t have designated diabetes days. On these days, the diabetes educatr was available t all patients with diabetes as well as t the prvider fr cnsultatin. The prgram resulted in an imprvement in clinical as well as behaviral utcmes. In this mdel, the diabetes educatr billed as DSMT. Anther diabetes day mdel is t have the patient seen by the health care prvider, RD, and/r registered nurse (RN) n the same day. The patient is first seen by the RN fr an assessment, evaluatin, and educatin. The RN prvides a shrt summary t the prvider f assessment results and what was cvered in educatin. This allws the prvider t fcus n identified medical needs rather than educatin. The patient als sees the RD fr MNT, including meal planning and selfmanagement supprt. N matter which mdel is used, plicies, prtcls, and algrithms shuld be develped by the prvider that allws the RD, CDE t wrk clsely with the patient t adjust insulin and imprve clinical care between appintments. Of nte, such wrk must be perfrmed within the RD s scpe f practice. The PCMH has identified case management and frequent 28
cmmunicatin with the patient between appintments as imprtant cmpnents f a successful prgram t imprve the verall health f the patient. Accrdingly, ne f the jint principles f the PCMH fcuses n payment refrm t prvide reimbursement fr services that had nt been reimbursed in the past. Summary It is imprtant fr the RD, CDE t becme invlved with his r her prfessinal rganizatins (Academy f Nutritin and Dietetics, American Assciatin f Diabetes Educatrs) t aid in psitining themselves as valuable cmpnents f their PCMH team. The RD, CDE, is a key player in DSMT wh assists the patient, trains the PCMH team n self-management supprt, crdinates the SMAs, r wrks with patients in a mre traditinal rle. The RD, CDE, is well equipped fr these activities and fr playing a vital rle in the PCMH. References 1. Lee TH, Bdenheimer T, Grll AH, Starfield B, Treadway K. Perspective rundtable: redesigning primary care. N Engl J Med. 2008;359:e24. 2. Rittenhuse DR, Shrtell SM. The patient centered medical hme: will it stand the test f health refrm? JAMA. 2009;301:2038 2040. 3. Natinal Center fr Chrnic Disease Preventin and Health Prmtin. The Pwer f Preventin. Chrnic disease the public health challenge f the 21st century. Centers fr Disease Cntrl and Preventin website. http://www.cdc.gv/ chrnicdisease/pdf/2009-pwerf-preventin.pdf. Accessed January 27, 2012. 4. Centers fr Disease Cntrl and Preventin. Chrnic Diseases and Health Preventin. 2010. http:// www.cdc.gv/chrnicdisease/ verview. Accessed Octber 1, 2011. 5. Franks P, Fiscella K. Primary care physicians and specialists as persnal physicians: health care expenditures and mrtality experience. J Fam Pract. 1998;47:105 109. 6. Yarnell, KSH, Pllack KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enugh time fr preventin? Am J Public Health. 2003;93:635 641. 7. Ostbye T, Yarnall KSH, Krause KM, Pllack KI, Gradisn M, Michener JL. Is there time fr management f patients with chrnic diseases in primary care? Ann Fam Med. 2005;3:209 214. 8. Lipscmb R. Understanding the patient-centered medical hme. J Am Diet Assc. 2009;109:1507 1508. 9. Wagner EH. Chrnic disease management: what will it take t imprve care fr chrnic illness? Eff Clin Pract. 1998;1:2 4. 10. Teters J. The patient centered medical hme: what is it and why it s imprtant t dietetics practitiners J Am Diet Assc. 2009;109:1843 1846. 11. Cresp R, Shrewsberry M. Factrs assciated with integrating selfmanagement supprt int primary care. Diabetes Educ. 2007;33:S126 S131. 12. Kelly KL. A future challenge fr the CDE/RD: integrating practice int shared medical appintments. On the Cutting Edge. 2010;31(4):27 31. 13. Stein K. The grup appintment trend gains tractin: hw dietetics fits int a new mdel f health care delivery. J Am Diet Assc. 2011;111:340 353. 14. Piatt GA, Orchard TJ, Emersn S, et al. Translating the chrnic care mdel int the cmmunity: results frm a randmized cntrlled trial f a multifaceted diabetes care interventin. Diabetes Care. 2006;29:811 817. CPE Credit ANSWER KEY See the CPE credit self-assessment questinnaire n page 30. 1. c 2. d 3. c 4. d 5. d 6. a 7. c 8. d 9. c 10. c 29