• Diabetes & Endocrinology Clinical Trials
• Diabetes Mellitus Diabetes & Metabolic Syndrome
• Nursing

• Diabetes & Endocrinology Clinical Trials
• Diabetes Mellitus
• Endocrinology
• Diabetes & Metabolic Syndrome
• Nursing

The increasing number of patients with diabetes and the pressure to make health care more accountable have contributed to the need for more patient-oriented approaches to effectively manage diabetes. Because of this need, health care providers not only pay for health care costs but also directly manage the health plans of their members. Patricia Johnson, RN, University of Pittsburgh Diabetes Institute and University of Pittsburgh Medical Center (UPMC) Health Plan, Pittsburgh, Pennsylvania, USA, and colleagues presented the Leveraging Education and Diabetes Support (LEADS) program, an approach to using certified diabetes educators (CDEs) as a clinical and community resource for health plans.

The LEADS program was intended to develop a chronic disease management model using CDEs as the “hub” resource of a network of insurer-driven diabetes care management services. The program was initiated 2 years ago and funded by the UPMC Health Plan. Two CDEs established best practices for consistent communication, competency development, and support and collaboration with caregivers and patient members.

In supporting the practice-based care managers, the CDEs coordinated, anticipated, and assisted in the care management and support of UPMC Health Plan members in primary care practices. Support included helping physicians address patient knowledge gaps concerning condition, education, and lifestyle management. CDEs coordinated the development of care plans between clinical support staff and primary care physicians. CDEs contacted patients directly and indirectly using both traditional and novel means (eg, in person, e-mail, calls, electronic medical record, telemedicine) to provide education and support.

Supporting the role of the health management lifestyle coaches, CDEs provided diabetes educational resources, assisted in developing care plans for high-risk patients, and coordinated resources among the insurer, the community, and the health system. Supporting the role of the senior care community coordinators, the CDEs provided training and support, such as collaborating with a certified registered nurse practitioner to train senior care community staff in the use of insulin pens.

Direct member support was provided by the CDEs through participation in events at mobile units and mall kiosks, during member retention events, and by helping members connect with health system resources. In the role of supporting the transition coordinators, the CDEs provided ongoing diabetes education and helped connect transition coordinators to community diabetes resources.

The LEADS program helped to establish standardized diabetes management education and training. This program created core competencies in diabetes care and assisted health care providers in recognizing a current evidence-based standard of care for their patients with diabetes. It also increased the confidence of staff in their ability to help these patients, and it improved the communication among staff in different insurer departments, allowing care to be coordinated among staff, the patients, and their health care providers. For high-risk patients who had been identified in the patient-centered medical home, guidance concerning their diabetes treatment and referral for high-risk management resulted in improved blood glucose control.

Facilitating the management of diabetes using CDEs as a central resource should be evaluated for its effect on outcomes, costs, and use of health care resources.

• © 2014 MD Conference Express®