Close-up of a young woman taking a blood sample from her finger with a glaucometer (Photo: Thinkstock) (Photo: Thinkstock)

Those of us invested in chronic care models for diabetes patients know the importance of the human touch. The results of years of research points to the importance of in-person, one-on-one education and training. So why isn’t it working in the field?

I recently had the opportunity to survey patients belonging to a Fortune 500 provider network. The answer to one question in particular — did you ever receive diabetes training in person? — came as a shock.

Only half, roughly, said yes. Within that group, some diabetes patients had not received any in-person training in 20 years. They usually retained basic information about blood glucose – what it is, when to check it, and how. Some nutrition information, like how to differentiate “good” foods from “bad,” also stuck. Unfortunately, that might have been all they remembered.

(Related: The Chronic Disease Avalanche)

“Self-management” has been in our lexicon for decades, but developing and implementing a sustainable model that satisfies patients, businesses and providers has been slow. Medicare has covered diabetes self-management education (DSME) and training since 1998, but fewer than 2% of eligible patients are taking advantage. In the meantime, the availability of self-management tools has expanded profoundly, yet statistics show that only 58% of eligible adults have ever attended a DSME class.

Those numbers paint a dire picture, but let’s be clear: for providers to reduce the cost of diabetes reimbursement to patients, a focused approach is required.

Only a small group of patients – 18% of members with diabetes, according to statistics compiled by the American Diabetes Association – account for 40% of payer costs. These patients are not proactively engaging in a vital self-management regimen. Many will have dropped their prescribed treatment within the first six months of diagnosis, if they initiate a care plan and receive their prescriptions at all. This is why providers are left feeling overwhelmed.

As the CEO of Fit4D, a diabetes coaching service that directly connects certified diabetes educators (CDEs) to patients by offering personalized, one-on-one care, I’ve come to appreciate the importance of reimbursing patients for diabetes education and training. Many patients find the cost of treatment a major obstacle.

I also understand why payers hesitate to buy in. Their attitudes typically fall into one of two camps. One group cares deeply about improving their patients’ health. Maybe these providers recognize the gap between the need for DSME/training and actual adherence, but aren’t sure how to bridge it. What I hear from the health plans is that they are offering the diabetes training and some form of disease management, yet engagement is low. For the DSME classes, this requires people to take the time off from work or find coverage for their families in order to travel to these in-person classes, which may be a far distance from home. The classes may be great, but, if only 3 out of 1,000 potential people show up and the provider is investing in this, it’s not worth the investment.

For disease management, payers often use call centers, target the patients who are poorly controlled, and have single-digit engagement at best. The payers are challenged by low engagement here, too. This does not allow these payers to scale the service with human interaction, build trust and offer any type of clinical depth to increase the engagement.

Both groups fail to recognize the importance of the human touch, and the complex reasons why patients don’t always take advantage of the tools available to them. For example:

  • Some evidence demonstrates that a group education setting, in which diabetes patients hear from others who share similar experiences, offers meaningful benefits. However, some patients simply aren’t comfortable with the idea of talking about their diabetes in a group. Others can’t fit a group meeting into their schedule — either they’re too busy, or the closest facility is too far away.
  • Geography can be a problem when trying to meet one-on-one with a certified diabetes educator. In one state I visited, all the CDEs in a provider’s network were located in hospitals. There weren’t enough hospitals — or unaffiliated, independent CDEs — to meet the demand. There are fewer than 20,000 CDEs in the United States, and close to 30 million Americans with diabetes.
  • Telehealth technology, in which a patient video conferences one-on-one with a CDE, addresses this problem. In theory. In practice, patients have to be willing and able to use a video-enabled device. Seniors suffer double the rates of diabetes compared to the general population, but they are less likely to be comfortable with video conferencing technology.
  • Many patients report their coaching sessions last three hours. Done remotely, this can be cost-effective. But sessions lasting this long offer too much information to digest and retain, and not all of it will be specific to the individual’s needs.

The solution to these issues must incorporate a personal relationship, forged through one-on-one conversations between CDEs and patients.

A CDE is a licensed health care professional who has comprehensive knowledge and experience in diabetes prevention and management. A CDE could be a dietitian, nurse, pharmacist or social worker who has passed the CDE credentialing exam.

The education offered by a CDE at provider facilities has the most potential to reinforce the skills that leads to proactive behavior change.

A 2005 study of Type 2 diabetes patients who met with a CDE in a rural area over a full year demonstrated significant improvement in patients’ knowledge, empowerment, A1C and high-density lipoprotein cholesterol levels. A personal touch is the best way to engage a patient in his or her self-management, and the only way to effectively tailor education to the individual. CDEs corresponding via calls, text messages and emails — depending on the patient’s preference — offer a more cost-efficient model for providers than in-person sessions. Shorter, more frequent sessions make it easier for patients to adhere to their self-management regimen.

By establishing trust and accountability, CDEs can effect lasting behavioral changes in patients. By capturing this relationship in a scalable model of education and behavior intervention, both the short-and long-term cost to providers are reduced.

— Read Getting Paid for Using Telehealth to Keep Women Alive Is Hard: Startup Execon ThinkAdvisor.


David Weingard (Photo: Fit4D)David Weingard is the founder and chief executive officer of Fit4D, a New York-based company that provides 1-on-1, technology-supported coaching services for people with diabetes. He was a Microsoft business development executive, and a triathalon competitor, when he himself was diagnosed with Type 1 diabetes, at the age of 36.