on Continuing Education in Pharmacy.Approved for 0.1 CEU by l’Ordre des
pharmaciens du Québec.
The Pharmacist as a Certified Diabetes educator
By Jennifer Iwanicki, B.S.P, C.D.E.
|Upon successful completion of this lesson, you should be able to:1. Understand why diabetes is a serious disease
2. Understand the need for diabetes education
3. Understand what Certification in Diabetes Education means and how to become a Certified Diabetes Educator
4. Understand the role of the pharmacist in diabetes education and the value of becoming certified
The population of Canada is both aging and living longer, and the number of persons with diabetes mellitus is increasing with it.1 Diabetes is a serious and costly public health problem.
Patients with diabetes should be properly educated in self-care and have access to an inter-disciplinary health team. Certification in diabetes education provides an opportunity for health professionals to develop expertise in diabetes.
The pharmacist, usually the most visible and most visited health care professional, is in an ideal position to promote the ongoing self-care and self-education of the patient with diabetes. Pharmacists interested in diabetes should consider becoming a Certified Diabetes Educator.
THE NEED FOR DIABETES EDUCATION
Diabetes Mellitus is a very common metabolic condition associated with serious complications, which cause significant morbidity and mortality. Diabetes affects the health of between four and six percent of Canadians.2 Type 1 diabetes affects about 10% of all people with diabetes and Type 2 affects about 90%. Over 1.5 million Canadians have been diagnosed with diabetes.3 For each case that is diagnosed there may be another one undiagnosed, resulting in potential Canadian prevalence figures of approximately 10%, i.e., diabetes may be affecting approximately 3 million Canadians. 4It is estimated that by the year 2004, one in four Canadians over the age of 45 will have diabetes.3
Not only is diabetes a common and growing public health problem but it is also a very costly one. Diabetes is a prime cause of coronary heart disease and stroke and a leading cause of adult blindness and kidney failure.4 Diabetes is responsible for 25% of cardiac surgery, 40% of end stage renal disease, 50% of all non-traumatic amputations and is a leading cause of death by disease in Canada. Ninety percent of people with diabetes have peripheral vascular disease.3 The World Health Organization (WHO) estimates that four to five percent of health budgets are spent on diabetes-related illness. A person with diabetes incurs two to five times higher medical costs than a person without diabetes. The annual estimated (direct and indirect) cost of treating people with diabetes in Canada is $5 to $6 billion.
The Diabetes Control and Complications Trial (DCCT) was one of the most important clinical studies performed in the field of diabetes. The study demonstrated that elevated glucose concentrations correlate with the onset and progression of chronic microvascular complications. The DCCT found that lowering blood sugar reduced eye disease by 76%, kidney disease by 50%, nerve disease by 60% and cardiovascular disease by 35%.5 Although the initial cost of intensive therapy is two to three times greater than conventional therapy, long-term costs are significantly less. The Canadian Diabetes Association (CDA) endorses the recommendations of the study and suggests that glycemic control, as close to normal as can be safely achieved, should be a goal of therapy in both Type 1 and Type 2 diabetes.2
The Canadian Diabetes Advisory Board believes a substantial part of diabetes care is patient self-care. People with diabetes should be educated before being delegated the responsibility for the daily management of their condition. Optimal diabetes care by the patient and provider can prevent or delay the development of complications. Diabetes programs should be integrated and not work in isolation.4 The Standards for Diabetes Education in Canada state that all individuals affected by diabetes have the right to access diabetes education, that they are primary members of the care team and their care is best provided by an interdisciplinary team of health professionals who collaborate to achieve client-centred goals. This education is a continuous process in which the needs of the individual change throughout life.6
Care of Canadians with diabetes is highly variable. Some receive care from trained multidisciplinary diabetes health care (DHC) teams while others do not.7 Diabetes requires 24-hour-a-day management by the individual, with education being essential to achieving that responsibility. However, 70% of people with Type 2 and 30% of people with Type 1 diabetes never receive education.3
In Canada, a health professional with a special interest in diabetes may become a member of DES. The Diabetes Educator Section (DES), established in 1973, is a multidisciplinary professional section of the CDA, committed to excellence in diabetes education, through education, service, advocacy, and research as they relate to the practice of diabetes education. Members of the DES support the philosophy and goals of the CDA and support the Standards for Diabetes Education in Canada. DES respects, values and encourages self-management and the collaboration of the members of the DHC team. DES views diabetes education as a life-long, continuous process for both the patient and the educator.8
Further, in 1991 DES established certification in diabetes education. To become a Certified Diabetes Educator (CDE), an eligible health professional must successfully pass a written multiple-choice examination with a mark of at least 70%. Certification provides an opportunity for health professionals to enhance their own professional development and is not the same as licensure, registration, or continuing education within a profession, but represents a recognition that diabetes education is a specialty which transcends professions. Certification exceeds minimum entry level requirements and recognizes experience and excellence in the field of diabetes education.9
To write the exam, the health professional must have worked full-time for two years in their professional field during the last five years, and spent at least one day (7.5 hours) a week or 400 hours per year in directed diabetes education of persons with diabetes and/or health care professionals for two of the last five years. A pharmacist is one of the health professionals eligible to write the exam.9
PREPARING TO CERTIFY
Over the past few years pharmacists have become increasingly interested in gaining certification. Most DES members have traditionally been nurses and dietitians. The involvement of pharmacists in local DES chapters has been met with various responses, ranging from a warm welcome to some resentment. The negative feedback is due to the state of health care in Canada. Across the country one hospital after another has cut back significantly on diabetes services. When pharmacists’ interest in diabetes education coincided with these massive health care cuts, they were seen as a threat in some circles. Pharmacists who become active members of their local DES chapter, and respect the role of each member of the DHC team, will have no difficulty in developing positive liaisons.
The Certification Handbook states that due to the potential for conflict of interest, direct diabetes education cannot be provided in a retail store setting. Some pharmacists believe they are ineligible to write the exam because of it. The CDECB has explained that the intent of the statement was about the retail sale of diabetes products. Selling these supplies, without any dialogue with the patient about their diabetes control, does not constitute direct diabetes education. The intent was not to exclude community pharmacists who meet the eligibility criteria from writing the certification exam.
Any pharmacist considering writing the certification exam should become a member of DES. Members receive journals, articles and invitations to upcoming events. Becoming involved with your local DES and attending meetings will allow you to start networking with other health professionals. They will share their work expertise and any insight they have into the exam.
Because the exam is experience-based, you need to look in your workplace for ways to expand your own knowledge. The patients with diabetes you already know will provide a wealth of information. You might start by consulting one-on-one with these patients to review their current care. Or, you can host clinic days to learn about new trends and meet new patients. Most importantly, look within your own practice to ensure you meet the criteria of a minimum of 7.5 hours a week in direct diabetes education.
Study groups have proven helpful for exam preparation. Those who work in the field of diabetes education often know each other through well-established methods of networking. Within these circles certification is frequently discussed. Working as a study group allows opportunities to share experience and expertise. Reading materials can be shared and discussed. Members report that group study is motivational and helps relieve anxiety. When study groups are used, almost all participants achieve certification.10
For almost every person, the prospect of an academic examination is an intimidating experience. The possibility of failure prevents many adults from seeking new opportunities and challenges. No doubt this is the case for those who contemplate the process of certifying as a diabetes educator.10 With the exam only offered once a year there are other professionals in the community writing the exam as well. You can offer support and encouragement to each other.
ROLE OF THE COMMUNITY PHARMACIST
The role of the community pharmacist has changed and evolved over the years.
For pharmacy, the disease state management approach seen today moves beyond product-oriented services such as generic substitution, therapeutic substitution and formulary compliance, and focuses on services to improve clinical outcomes. Adherence monitoring, patient education, drug therapy management, and other patient-focused services are used in disease state management to improve outcomes which, in turn, lead to reductions in overall health care utilization and expenditures. In disease state management, all elements of the health care delivery system work together. Pharmacists work with patients and other health professionals to design individualized therapeutic plans that seek to achieve specific outcomes.11
Disease state pharmacy works extremely well when it comes to the care of the patient with diabetes. The shift of focus from prescriptions and medications to the patient, condition and outcomes is in accord with the Standard for Diabetes Education belief that diabetes education focuses on the individual and works to achieve client-centred goals.6
The pharmacist, usually the most visible and most visited health care professional, is in an ideal position to promote ongoing self-care and self-education to the patient with diabetes.12 A person with diabetes will visit their pharmacist seven times for every one time they visit other members of their health care team. The community pharmacist is easily accessible to people with diabetes. It is estimated that 90% of diabetes care products are purchased in pharmacies. Pharmacists have the opportunity not only to identify, assess, monitor, educate and refer patients but also to sell them the products that assist them in optimizing their care.13
The biggest challenge to any pharmacy practice will be to exactly determine the role of the pharmacist within the DHC team. A pharmacist needs a clear understanding of which roles fall into the scope of pharmacy practice and which patient concerns need to be addressed by another member of the DHC team.
The role of the Pharmacist Diabetes Educator may be outlined in this way:
- Medication counselling and monitoring
- Blood glucose monitoring training and on-going assessment
- Supplying diabetes care products and literature
- Advice on acute complications
- Third-party coverage set-up and understanding
- Identifying needs and referral to the DHC team
- Support and encouragement
Medication counselling and monitoring
Pharmacists are the experts on medications. Many patients with diabetes need treatment for other conditions such as hypertension, hyperlipidemia, obesity and depression.13 Pharmacists need to monitor all the medications a patient is taking, watch for any adverse reactions, interactions, and review compliance. Patients must have a clear understanding of their medications and the consequences of non-compliance. Medication compliance continues to be a problem for patients taking multiple medications and the pharmacist can make many suggestions to help. The pharmacist needs to know about directions given by the other DHC team members especially directions concerning insulin and medication adjustments. Insulin adjustment is best done by a trained professional, but the pharmacist can answer many basic questions about insulin.
In addition to prescriptions, a pharmacist must be able to advise a patient about over-the-counter medications. Pharmacists must know which products are appropriate for their patients and how they might affect diabetes control. In the past, many products that required a prescription are now available to patients through their pharmacy. Recently, there has been an explosion in the interest in herbal and natural products. More than ever before, the pharmacist is called upon to address over-the-counter medication concerns and he or she must ensure the safety and appropriate use of these products for all patients.
Blood glucose monitor training
Blood glucose monitoring is a critical component of the self-care of the patient with diabetes. Many issues arise when a person needs a monitor and the pharmacist is in the best position to address those issues. In the past, nurse educators trained patients in the use of monitors and made suggestions. Because these products are now offered in the community pharmacy, nurse educators prefer to send patients to the pharmacist for complete training.
There are many considerations for proper monitor selection. The pharmacist must first assess the patient’s needs. Other things to consider include the patient’s general attitude, third-party coverage, support from the company and ongoing cost.
The pharmacist must continuously evaluate the patient’s progress and documentation, and the patient’s understanding of how to interpret results and ensure the monitor’s accuracy. Not uncommonly, new patients will test frequently when first diagnosed. After the patient has lowered his or her blood sugar levels, they will test less often, sometimes stopping altogether. Motivating a patient to continue to monitor blood sugars throughout life becomes a big challenge for a pharmacist.
Time constraints are a serious barrier for pharmacists. Proper monitor training can take over half-an-hour, assuming there are no interruptions. However, pharmacists often have to assess a patient’s needs in a matter of minutes. Patients traditionally drop into the community pharmacy and believe they will receive all the service they need at that time. Frequently, a pharmacist is unable to train completely at that time, on that day. Appointments work, but only if the patient is willing to return. As an educator, the biggest concern is when a patient leaves and never purchases a monitor. A pharmacist needs to quickly decide on the patient’s needs and what can be followed-up at a later date. Your experience will be helpful in speeding up the selection process. Once the patient has a monitor many questions can be answered on the phone or at a later date.
Supplying diabetes care products and literature
Patients purchase most of their diabetes supplies from their community pharmacy. The pharmacist specializing in diabetes must be familiar with all products available, whether they are new products or products rarely used and hard to find. Pharmacists need to maintain objectivity about all supplies because it is the individual with diabetes who must be allowed to decide what is best. The pharmacist’s role is to inform patients about what is available, demonstrate new products, and suggest how these products might be helpful. If the patient decides to continue using dated technology, the pharmacist must respect that decision. Other members of the DHC team will call upon you to source hard-to-find products. The pharmacist must be an expert on how to use the products and how to find them.
Patients have long relied on their community pharmacy for literature information as well. Pharmacists receive pamphlets and hand-outs on almost any topic, medication and disease. Not only do we provide literature, we also sell many self-help magazines and books. More than ever before, patients are trying to stay current and learning “everything they can.”
Advice on acute complications
Patients with diabetes who receive education after diagnosis are taught how to deal with acute complications such as hypoglycemia and sick-day management. Often, patients don’t experience these challenges until some time in the future and likely will forget what to do. A large number of patients never receive any advice at all. The pharmacist should know how to address these concerns quickly to avoid an emergency situation. Once the advice is given, the patient should be encouraged to visit the rest of the DHC team for any other problems that might arise.
Third-party coverage – set-up and understanding
DES supports advocacy regarding patients with diabetes. Many people with diabetes have third-party coverage either from private plans or provincial plans. Not all third-party plans are the same. Pharmacists must help their patients understand any insurance coverage they have and what is available to them. Some provinces also offer additional coverage to patients with diabetes. Pharmacists must not take it for granted that patients are aware of what is available to them. It is better a patient hears about a program twice then never at all.
Identifying needs and referral to the DHC team
Patients ask pharmacists a myriad of questions every day. Pharmacists may identify a need requiring referral to another member of the DHC team. Imagine what a difference the pharmacist will make if a patient is referred to a physician to treat a leg ulcer and that, in turn, prevents amputation! Pharmacists have an opportunity to make a difference to the health of their patients by identifying those who have never received any diabetes education and inform them where their local diabetes education centre is located and how to get a referral. Many centres in the country now offer self-referral for group classes.
Support and encouragement
Diabetes is a lifelong disease and education is a lifelong process. Patients move in and out of different stages. The support and encouragement they receive from their health care team is very important in their progress, not only when they are moving forward, but also after they have slipped back – when they most need reassurance.
The pharmacist has always been a trusted health professional. Because we see our patients frequently, we often become friends. We learn about their personal lives, see their children grow up, join in their sorrow and share our lives with them. Our compassion and encouragement is sincere and makes a real difference in motivating patients with diabetes.
FOSTERING GOOD RELATIONSHIPS
Physicians with more direct exposure to pharmacists tend to be more positive about pharmacists’ contributions, as evidenced in a report issued by the U.S. Inspector General’s Office of Evaluations and Inspections. The report notes, “physicians and pharmacists who practice in rural or small communities appear to interact more effectively with one another than those in large communities, because they are more familiar with one another and share a higher proportion of patients in their respective practices.” The development of this essential familiarity is facilitated through direct contact among pharmacists and physicians practising within the community.11
The same can be said for all health care professionals in the DHC team. A co-ordinated care approach, with collaboration between all members of the team, increases the likelihood of positive patient outcomes. Pharmacists may share objective monitoring information, adherence data and other pertinent information with the team by phone, letter, fax or e-mail. A pharmacist who fosters relationships with the DHC team will improve their own profession and certainly improve the health of their patients.
THE VALUE OF DIABETES CERTIFICATION
Becoming a Certified Diabetes Educator will be valuable for a pharmacist in many ways. You will be exposed to many different health professions and develop a greater understanding and appreciation of everyone’s role. You will be in a better position to refer your patients and become familiar with all the necessary services located in your community.
Because self-care is central to diabetes care, certification prepares a pharmacist to assist patients who adjust their insulin and medications, who decide on protocols and who make changes to their current regimens. The shift to the role of advisor will prepare you for changes in the future in other disease states.
Because Canada is a vast country, diabetes services are not consistent. Patients who live in remote areas may not have access to every health professional they require. Pharmacists who become certified in these remote places will help lessen the inequity in care for patients with diabetes.
CDE is a national recognition of excellence in the field of diabetes education. Currently there are very few certification programs available to health professionals. The incidence of diabetes is growing more rapidly than the education of health professionals. A CDE’s opinion and advice is held in high regard and respected.
Diabetes education for people with diabetes and for health care providers is essential if we hope to realize the goal of preventing or delaying the onset of diabetes, as well as its related complications. Diabetes is a public health issue and requires the co-ordinated efforts of all Canadians if we are to win the ongoing war against diabetes.15 Pharmacists who become Certified Diabetes Educators will become experts in the field of diabetes and be in an even better position to make a significant impact on the health and well-being of their patients with diabetes.
For information on DES membership or the latest Certification Handbook, mail or fax your request to: CDECB, 2 Fisherman Dr., Unit 11-O7A, Brampton, Ont. L7A 1B5. Tel.: (905) 846-9891. Fax: (905) 846-9805.
CDA: Canadian Diabetes Association
CDE: Certified Diabetes Educator
CDECB: Certified Diabetes Educator Certification Board
DCCT: Diabetes Control and Complications Trial
DES: Diabetes Educator Section
DHC: Diabetes Health Care
WHO: World Health Organization
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