Association of Diabetes Care & Education Specialists

News & Publications

Lay Educators: Is it a scary thought?

Apr 12, 2012

We are all aware of the statistics: the incidence of diabetes continues to rise dramatically worldwide. There are 18.8 million people that have been diagnosed with diabetes in the United States with an additional 7 million who have diabetes and have not yet been diagnosed (CDC, 2011). Each of these individuals could benefit from time with a diabetes educator, and many could use frequent visits to help support behavior change and consistent reinforcement for monitoring and taking the appropriate medications. 

Not all patients are referred to diabetes educators for a variety of reasons, but already our caseloads are high, and reimbursement poor. We want all persons to benefit from education, but is it possible to do so with limited providers and limited reimbursement? 

One issue, of course, is lobbying for more reimbursement to help draw in more individuals interested in diabetes care. Mentoring new health care providers in the field, as initiated by the National Certification Board for Diabetes Educators (NCBDE) in 2011, is also a way to establish a bigger base of knowledgeable providers.

However, at this time, manpower is short, and access to a diabetes educator is limited. Over the last few years, there have been numerous research studies to evaluate the effectiveness of utilizing lay and peer educators. This may be a bit disturbing to some, as these providers do not have the extensive training and education of an individual who has obtained certification as a diabetes educator. 

There does, however, appear to be evidence that this may be an effective route to help provide more services to more people in need. That with oversight by diabetes educators to assure standards are met, trained lay and non professional health care workers may be able to provide basic diabetes education, and for less cost. 

In order to maintain high standards, these individuals must understand diabetes, and be able to communicate correct information to individuals referred for education. One way for them to obtain education is through the AADE certificate program for Level 1 educators.  Having community health workers adequately trained provides the patient with access to education through a wider range of access points. Accessing appropriate websites may also enrich their understanding such as ADAJDRF and CDC.

I think for many, it is difficult to embrace this  idea. However, with oversight by well qualified diabetes educators, this concept may help to reach millions more individuals with diabetes and pre-diabetes. Now that is a thought worth considering!

If you are utilizing the help of peer educators and non professionals in your programs, please share your thoughts with all of us!


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  1. May 10, 2012

    Dr. Cox, I could not agree with you more on this topic. I have just completed by final year of medical school at Drexel University in Philadelphia, and I am going to be spending next year earning my MPH. I don't need to tell you how alarming the diabetes epidemic truly is for our country, and how little physicians appreciate the importance of collaborative case coordinated management of diabetes. I could not and still cannot understand why we are seeing diabetic patients (particularly the minority population) for the first time when they present with ESRD and require dialysis. Moreover, why is it that an uninsured and underserved diabetic can have his/her dialysis paid for by this healthcare delivery system, but a glucameter...patients are on their own for that. In medical school we are not taught what it means to work as a team; how to communicate with our colleagues and our patients. The medical education culture continues to perpetuate a fatalistic and paternalistic approach to chronic disease management. The time has come to demand accountability from leadership at the top levels, including this organization. As an example, I have spent the past six months working to develop an inter-professional pilot program with Temple University School of Dentistry. I saw the crowded dental clinics as an opportunity to access my community; I had dozens of free (and quite knowlegable ) "lay health workers" who wanted to be a part of this pilot.... medical, dental and nursing students. I was persistant, and I met with anyone who would listen (including multiple meetings with the Chancellor Emeritus of Drexel University College of Medicine and the Dean of Temple Dental School) to sell my idea. (anyone with insight, I would love to hear it... email me: As of today, I have hit a roadblock that is proving more challenging to overcome than obtaining financial support: finding a CDE. With the support of Keystone Mercy Health Plans, I allocated the money to pay the CDE to come to the dental school at temple to provide monthly diabetes education classes and to serve as mentors to budding health professionals like myself in overseeing the student involvement and teaching us what it truly means to treat a disease as complex as DM. When I couldn't find anyone, I paid the money to join the AADE in the hope that maybe I could take the coursework for certification, only to find out that I had to enter my medical liscence # to apply... and I wont have that at least until next week's graduation. I have read the literature, Dr. Cox, that you are reffering to regarding the effectiveness of "lay health wokers" in diabetes education and care coordination. I am very familiar with it, in fact, and not only does it support your suggestion, it provides us with evidence based medicine that, to an extent, requires us alll to implement. (I am not going to cite the studies, a quick pubmed search or google search is all that is required for those interested). When we look at the alarming incidence of prediabetes and diabetes (not to mention obesity) it becomes obvious that the fragmented care physicians provide is insufficient. Quality Improvement initiatives such as the Patient-Centered-Medical-Home (PCMH) model clearly outline the invaluable role of those who understand how to relate to a diabetic patient. Health profession students that are interested in truly impacting change are, in my opinion, an untapped resource. The paucity of CDE's is, in large part, due to the fact that the AADE's leadership has no mechanism in place to ensure that the RN who volunteers her time to educate patients in the community about diabetes obtain some sort of certification (I see the post of the RN who does this without certification below). I worry that diabetes education will become overly exclusive. This not only deprives our most vulnerable population, but it also keeps tomorrow's health providers like myself from learning the skill-set required to be different from the current status-quo. Let's work together, as a team, to provide quality care for our patients. I urge everyone to allow for the implementation of innovative ideas such as Dr. Cox's that is well supported in the top-teir medical journals. (for the individual that asked for citations they are all available on the IHI website, I'd like to know what people think of this post, as I lack the experience that you all have. Maybe I'm totally off base... I'd still like to hear... Thanks, Sam Zarbiv
  2. Apr 20, 2012

    Thanks for your comment. Lay health workers are already being used in chronic disease management. Partly because of this, AADE developed guidelines and competencies to provide more structure for all people engaged in diabetes education. - Margaret Maloney, AADE Publications Manager
  3. Apr 19, 2012

    That's great, Iris! Maybe you can report back on their/your experience as they go through the program?
  4. Apr 19, 2012

    Diana and Carla, our practice has decided to get a group of medical assistants the Level 1 certificate to enhance our diabetes care especially now that we are part of an Accountable Care Organization
  5. Apr 16, 2012

    There are several issues to address here. First is that diabetes education is an underutilized benefit of many health plans, including Medicare. Even fewer people attend if they lack insurance. This is a subject that should be addressed more globally by AADE, through advertising campaigns and feet on the ground promotions. And yes, I know we have done this before, but obviously if it had worked, we would not have programs closing and the education benefit utilization would be rising. Second, it would be helpful to cite the research to which you make reference, regarding the use of lay people. If the number of participants in a study is small and the outcome measurement is vague, subjective or short term, this research will be given a different weight, than if it quotes long term, larger studies with validated measures in the use of lay people. Third is the subject of reimbursement to CDEs. Unless a CDE is billing Medicare for another service, such as medical care or medical nutrition therapy, one cannot bill Medicare for DSME/T. This leaves many CDEs who could be providing diabetes education in a clinical setting or in a private practice (as the primary provider) without a means to bill for this service, at least as it relates to Medicare. And yes, I do know that a facility can bill insurance without the CDE actually having a provider number. I realize AADE has lobbied Congress to introduce reimbursement bills at each new congressional session, but as I have followed this for years, it seems those bills don’t make it out of committee. What are we doing wrong? Manpower would be less short if CDEs had a way to earn an income based on their credentialing. Remember, please the CDE credential is the same, whether the (same) credentialing exam was taken by an MD or RD or RN or PharmD. Why should some CDEs be able to bill for the same service (DSME/T) and some not? Specifically regarding the use of lay people to deliver diabetes education, the benefit you cite is that the non professional health care workers can deliver basic diabetes education at a lower cost. One very large program that promotes the use of lay people has them deliver highly scripted messages in class format. The information is accurate, but because these programs are designed to be delivered by other than diabetes educators, questions that relate to a personal experience or a personal need cannot necessarily be answered, ie, no deviation from script (e.g. Why does my meter always read “400?”). People are referred back to their providers or to a diabetes educator, after they have attended or while attending a 6 week class. Other programs (curricula) designed for lay individuals to deliver may not be so scripted and so there is a possibility that those delivering the message may pull from their own experience, which may or may not be accurate information. The statement about CDEs overseeing (“Oversee”= present at each session taught by a lay person vs. making sure everyone has the same training and complies with no deviation from script). Such program oversight begs the question: Who pays the CDE to oversee the program if we cannot get health facilities to pay a CDE to deliver a program that meets the accreditation standards? If a CDE is overseeing the program it is the license of the CDE (the license, not the certification) that is on the line, each time a lay person delivers an inaccurate or potentially dangerous message. Do I think we need more CDEs? I absolutely do think so. I think the RN who made the comment about finding it difficult to become a CDE is correct. It is an arduous process, but well worth it. Nevertheless, we do need to review the requirements for sitting for the CDE exam. I think first and foremost the AADE needs to make sure that CDEs are able to do what we worked so hard to be credentialed to do. I think watering down the message by letting anyone deliver it is NOT the answer. I believe that CDEs will deliver more diabetes education in the community and to the underserved people if they can provide this education as independent practitioners. We can then use lay people to help us in our own programs.
  6. Apr 16, 2012

    Thanks for your comment, Iris. Currently, this is a certificate program, not a certification program. It's intended to provide diabetes-specific training for the CHW or other healthcare works who meet the Level 1 designation practice and educational criteria. In order to progress as a diabetes educator, they would have to go back to school to earn a degree.
  7. Apr 13, 2012

    Would the AADE career path the appropriate vehicle for lay workers (aka community health workers) to become certified?
  8. Apr 12, 2012

    I think it is a fantastic idea. It is a difficult process to become certified or I already would be. Utilizing people like me who already volunteer extensively with diabetes education in their communities is a fabulous idea. I would love to have some level of certification.

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