by: Joan Bardsley, CDE, FAADE, MBA, RN; Teresa Pearson, MS, RN, CDE, FAADE; Susan Weiner, MS, RDN, CDE, FAADE
Why is having a population health summit important to our members?
Right now we face a challenging time in healthcare as trends point toward a need for systems management of disease, as opposed to episodic care. Diabetes educators need to examine and re-evaluate their roles to determine how to best meet the needs of the diabetes population in this new climate. Currently diabetes educators are underutilized throughout the health care system, and may not be able to bring the necessary resources to all people who would benefit from our support and expertise. Presently only 10% of persons with diabetes are referred to DSMES programs, which leaves most individuals with diabetes receiving their education elsewhere, if at all.
It is critical for diabetes educators to contribute to these changes as experts in the field of diabetes; we need to be proactive in establishing best practices for diabetes education, clinical management and prevention within a system that focuses on risk and outcomes. An improved understanding of emerging technologies and telehealth systems will help diabetes educators look at ways to re-define their roles as well as proactively meet the needs of the diabetes population.
How was population health defined by the presenters?
The presenters’ definition held a common thread established by the CDC, focusing on the distribution of health outcomes within a population, the range of personal, social, economic, and environmental factors that influence the distribution of health outcomes, and the policies and interventions that affect those factors.
The CDC views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community — public health, industry, academia, health care, local government entities, etc. — to achieve positive health outcomes. Population health “brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.”
Additionally, the Quadruple Aim was a central theme to all speakers. They defined population health in the context of an organization’s accountability for the cost, quality and experience outcomes for their defined population and provider experience. Many of the presenters discussed the importance of health outcomes, patterns of health determinants and interventions from health care providers and community members.
How do you see diabetes educators fitting in new population health models of value-based care?
This is an opportunity for diabetes educators to step out and lean in to the new population health care model. It will require diabetes educators to reach out and broaden their partnerships across health care systems and entities that are exchanging data and information in varied settings. Diabetes educators need to demonstrate how their work helps practices, programs and organizations attain their overall diabetes-related performance measures. While there is not yet a specific performance measure for DSMES, it is imperative that educators be able to articulate their value within the context of population health goals.
Abundant research is available to demonstrate the impact of the diabetes educator, the value of the education provided, and an analysis of what educators actually do. Educators will have an expanded role and be recognized as the experts in identifying individuals at high risk, developing focused interventions based on stratification and geared at outcomes. In this value-based model, a registry of people with diabetes will be identified. These people will then be assessed as a group based on the performance measures and prioritized based on gaps in care and where they are in relation to the population goals. Once the population is stratified, the organization will provide standardized interventions for each level of risk.
Educators will have to work closely with professionals to ensure no one falls through the cracks. Diabetes educators will never be able to see 100% of the people with diabetes, so this collaboration is essential to the overall success of an organization in relation to diabetes outcomes.
The use of technology and data analytics will define and support diabetes educators’ role as experts in connecting people with diabetes, health care teams and communities in community based, clinical and non-clinical settings.
What are the proposed next steps coming out of the Population Health Summit at AADE18?
In addition to creating a population health COI, AADE is in the process of formulating a language/practice paper around population health. The goal of that paper is to develop a definition of population health as it relates to diabetes care. In addition, there are ongoing discussions around development of a communication plan to express AADE’s focus on population health and a vison of population health specifically for people with diabetes. Both the paper and the communication plan will provide guidance for diabetes educators on how they can express their value in new models of care.
Stay tuned! More to come!