by Ginger Kanzer-Lewis RN, BC, EdM, CDE

This is the first of two articles that talk about new ways to deliver patient education. This article looks at how we’ve been delivering patient education in traditional systems for many years and then presents alternatives to that model. It’s not a criticism of that system, but identification that there’s a new way to go - bigger, broader and, I believe, more effective for patients in this day and age.

While I am approaching this as a diabetes educator, I know this will work for all kinds of patient education. We did this for cardiac patients, pre-op surgery patients, and quit smoking programs in several hospitals where I have worked as director of education.

For many years those of us in patient education, especially diabetes education, have realized that a “team” of health care professionals could do a better job than one clinical professional of educating people with diabetes. Patient education programs started with a nurse, usually in staff development or “in-service,” who was asked to help the nursing staff with patients hospitalized with diabetes or cardiac disease.

It began with nothing because there was nothing. No books or guidelines existed and pharmaceutical companies had not yet identified that there was a need for people to learn about their drugs or durable medical equipment. Most of the early diabetes educators or people who started teaching people with diabetes were nurses.

“Most of the early diabetes educators or people who started teaching people with diabetes were nurses…[someone in administration] turned to you, waved their magic wand, and you were now in patient education.”

I like to call them “puffs” and this has nothing to do with that well known brand of tissues. It is because someone in administration noticed that you were teaching patients or staff, you were working in staff development or nursing education, or you were a dietitian who discovered that a patient had a learning need. They turned to you, waved their magic wand, and you were now in patient education. Puff!

Many nurses working alone at the time discovered how complex diabetic diets were and how much diet meant to new diabetics, as they were called in those days. Their solution to this dilemma was a key step forward in the development of the team approach. They began to solicit the help and knowledge of dietitians, a bright and caring group of people who weren’t called upon often by nurses in non-teaching facilities. At the time, community hospitals had administrative dietitians, but only to help food service departments plan the “special diets” for patients.

I consulted my friend, Mary Austin, RD, for her memory of the early days. She said that dietitians were teaching patients about diet and would seek out nurses who could help them when they got out of their scope of practice. Mary Austin is an past president of AADE as I am and brings her perspective as a dietitian and that is certainly important for this subject. You see right here how valuable it can be when two people from different disciplines collaborate on an idea.

The old model

As things progressed, we discovered how wonderful pharmacists, social workers, psychologists, and of course physicians could add to the knowledge imparted to our patients. This evolved into the healthcare diabetes education team and it has worked very well. In this model, healthcare professionals usually worked for a specific organization or practice and had a vested interested in the outcome. It was good to have partners. But the world has changed and we need to change as well.

The old team was and is wonderful, but there were some conflicting issues to consider. It is made up of people who represented a discipline and they could be territorial or have their own agenda. They may work for an organization that has specific overriding goals that may be competitive rather than collaborative. Materials and programs developed for that organization become the property of the organization. Sometimes competition is mandated from management, and though many of us had no difficulty sharing ideas or materials with peers, it could be politically incorrect or dangerous for job security if it was discovered. I remember sharing materials with educators across town, but my administrator may not have been happy had he known about it.

This was a wonderful beginning but it needed to evolve into something better.

The new model

The new patient education team or model needs to include all these diverse professionals, but it also builds a broader network. Instead of a multidisciplinary group of people within one organization, it is a community wide group of facilities united to meet the needs of people with diabetes in that community. This new model is healthcare without walls.

Each group needs a hub and I see that being the acute care setting. The hospital, clinic or medical group has the original multidisciplinary group of primary care providers. Often this is the entry site for the patient and it usually makes the initial diagnosis. But healthcare without walls goes beyond the hub because all disciplines are included and different types of agencies are involved.

“There’s a horrible example that occurred last year when a school principal pulled an insulin pump off a child because he thought it was a pager. Did someone go to that school and educate everyone about the child and his pump?”

For example, the person with diabetes needs to have access to education in the local pharmacy where they fill their prescriptions from their local clinic, hospital, physician, dentist, or podiatrist. Or when patients leave the hospital, they need to be followed by their personal physician’s office staff who have the responsibility to continue their diabetes education.

We need to address:

• Who educates the office staff who usually have ongoing relationships with their patients?
• Who teaches the visiting nurse service or home care people?
• Who follows through in the nursing home or assisted living center?

How is it done?

The primary diabetes program takes on the responsibility of training the staff of all facilities in the community. Here are some important questions to consider:

• When you send a child home from your program, have you educated the nurses and teachers in his school? Are they prepared to accept and assist this child in their environment? There’s a horrible example that occurred last year when a school principal pulled an insulin pump off a child because he thought it was a pager. Did someone go to that school and educate everyone about the child and his pump?
• Do you do grandparent or babysitter classes for the family of children? Who helps those people give support to overwhelmed parents?
• What about the nursing home staff that cares for the elderly patient that you transferred back from your hospital? Do you do diabetes update classes for their staff before there’s a problem with your patient? Recently, I’ve been doing consulting for a group of nursing homes and I did an audit in one facility. I found that 40 of their 60 patients on insulin are still getting one dose of NPH per day. I had a long discussion with their medical director and did a short education program for all levels of their clinical staff.
• What about visiting nurses, public health staff, and home nurses in your area? Have you done an update recently for their people? What is the sense of teaching patients in a hospital and/or clinic and sending the patient home with a referral for follow-up care when the provider uses different language or even contradicts your advice or information. Remember that “little bit of sugar stuff”? There are lots of new medications to keep up with coupled with the fact that this group has to know so much about all kinds of patients.
• Have you brought the pharmacists in your area together for a short meeting to discuss the current trends in diabetes care? Do they know what meters you recommend so they keep them in stock? Do they know the current reimbursement issues for strips and meters? Many patients are losing money because healthcare providers don’t know how to get funding for their needs and the patients end up paying out of pocket. I include reimbursement sessions in all of my diabetes programs for both the professionals and the public.
• How about a CEU program for general practitioners in your area? Would your endocrinologist join you in conducting a program for the medical staff in a local community hospital? It could get him more referrals and build a collegial relationship between you and the local physicians. I have no endocrinologists in my rural location in the Florida Keys, so I need to work closely with the physicians in the area to diplomatically update them on current trends in diabetes care.
• Have you worked with the public health department in your county? They have resources for you and can get the message out to the community about this important health care resource. I worked on several task forces with the public health agencies in New Jersey and had input when they set their goals and priorities for the year. I worked with wonderful people from many diverse agencies and learned a great deal about planning for a community.

A lot of work but a lot of benefits

If you are choosing to implement this model:

1. How do you sell it?
2. What are the benefits to the patients, facilities, communities and all the health care providers mentioned?
3. What is the pay off?

In this model, everyone needs to use the same language, education materials, and more importantly have the same philosophy. This creates consistency, eliminates confusion, and creates a solid circle of support for patients. The patient becomes the center of the team and feels a part of the decision making group.

We can then establish goals and measure outcomes. And when we all know the plan of action and the intention of the plan, everyone has a stronger commitment to assist the patient in keeping to the plan. This also helps eliminate the covert saboteurs. These are the well-meaning people who want to help but haven’t a clue that they are obstructionist when they tell the patient to just avoid concentrated sweets.

The present is driving the future of health care and patient education. The advent of new technologies is driving the system.

The present is driving the future of health care and patient education. The advent of new technologies is driving the system. New meds, meters, pumps and surgical techniques require more sophisticated education and the expansion of team relationships. In all healthcare fields there is new research that opens opportunities for new teamwork.

There are new systems that require the expansion of the team. Outcome studies have proven that the team is more effective than any one discipline. We are into disease management and practice evidence-based practice. We are translating the research into clinical practice and it takes all kinds of people in all kinds of settings to do the work that used to be much more limited.

More Payoffs

We update and educate other healthcare professionals
We have documentation that less than 10% of people with diabetes see diabetes educators or endocrinologists. This fact alone makes it essential that we contribute to the knowledge of the people who are actually seeing the other 90% of these people.

We satisfy patients and families
They are more confident when they believe their healthcare providers are competent in the field and that a communication network exists between their healthcare specialists.

We satisfy accrediting agencies
When they survey your program and see the commitment to patient care and the support you are providing your clients, they are very pleased. These relationships meet the patient education requirements from the Joint Commission.

We satisfy managed care agencies
Their goal is quality care at low costs. When their beneficiaries are given good care at good prices, they are much more apt to negotiate better contracts with your facility.

We satisfy professional concerns
Meeting the requirements of professional associations for continued education and for continuing education credits gives all of us an opportunity for growth and development.

Will you fit into the new team?

I do not have all the answers but the first step is to ask good questions. Here are some to consider:

• Have you acquired the skills and knowledge to meet with all of the members of the new team as a patient advocate?
• Can you convince your administration that expanding your team to the community is within your scope of practice and the right thing to do?
• Have you the political savvy to find the funding for this expansion in today’s constrained funding environment?
• Have you the marketing skills to sell this idea to the people who need to be sold?
• How are you going to convince your local school system to let you in?

It’s a big job and whether its diabetes, AIDS, or multiple sclerosis, we can no longer limit our roles to the four walls of our offices and classrooms. Good Luck!

The article contains material excerpted from my book, “Patient Education: You Can Do It!” ADA 2003