SteveDE

Also, you do not have to be a CDE to provide diabetes education. The CDE certification does not change your license scope of practice.

You do have to have some kind of a log or proof showing at least 1000 hours of diabetes education work. What I used was my payroll hours, when I was clocked in as a diabetes educator, its an "official" list of hours that I can prove that I was working as a diabetes educator in some capacity. Also you have to have at least 2 years of experience in your current professional role, such as a minimum of 2 years as a RD, RN, or etc. You then must apply for, pay for, and pass the CDE test. I understand you have had diabetes for 15 years, but similar to the nclex for nursing, the cde test will attempt to give you as many "gray" areas to confuse you in answering, so I would recommend making sure you get plenty of experience with diabetes education for others, possibly taking a course like Core Concepts through AADE, and networking with other diabetes educators to continue to learn the overall process of education, management of an education program, and anything else diabetes related prior to taking the test. Good luck! Its a great field.

I think what llg posted is reality. I personally believe the best meal plan is one that someone can live with long-term, be satisfied with, actually enjoy sometimes, but keep a balance. Fruits are important, but just like bread, potatoes, and pasta, there must be a balance. While this may not be food, I believe the best meal plan also includes a consistent exercise plan and consistent monitoring, those 2 areas must be fit into the plan. llg stated she works on about 150 grams per day, at the same time, many people know that 225 works for them due to their size, sex, weight control, monitoring, and exercise. So, my answer would be the best meal plan would include CONSISTENT carb. counting/portion size, exercise, weight control, and monitoring. While all of those don't deal with actual intake, I think a highly motivated person will take all of those to form the best meal plan for their needs. Good question!

Yes, more of a guide for titration, I think we have found some good examples to use that will work well for our facility. Thank you for the feedback!

Anyone have an insulin drip policy they would care to share? Thanks!

Carb counting is certainly important, however, a lot of nurses will need to be educated on how to count carbs properly. My main question would be, why isn't the patient counting carbs? Diabetes is a long-term disease, it doesn't stop at discharge, if the patient is not able to count, they or their family need to be educated on how to count and practice some while in the hospital. If the patient is just not willing to count, they need to be educated on the importance of counting, if they still are not willing, they aren't going to do it at home, either. I think it would be best to get a dietician involved, along with the nurses to educate the patient in helping them properly count/manage their carb. intake.

As diabetes educators, we have to realize that our job doesn't "just" deal with educating the patient in how to live with and manage diabetes. Our job is completely diabetes, all the patients I see every day has diabetes, so for the most part 100% of my patient population has diabetes, its not that way in the real world. Other healthcare providers have a 10-20% patient population with diabetes, there job does not "only" include diabetes so they are not going to be as focused and often times not as knowledgeable or up to date. Diabetes is a disease that has had an explosion of new research, new meds, and new tech. stuff that some healthcare workers that don't deal with it on a daily basis are not use to or aware of, it doesn't matter what level of patient care they work with. Our job as diabetes educators, needs to be patient AND STAFF education. It doesn't matter the initials after their name, we all need refreshed, updated, and educated. Unfortunately, poor diabetes care happens in the hospital, people are sick, physically stressed, emotionally stressed, decreased activity, different meal plan, possibly different meal times, and etc. while in the hospital...and then you have staff to deal with...its the worse place to have controlled diabetes due to about 10 different reasons. More education for ALL, not just patients is needed. Also, I would like to respectfully say, a heart attack IS related to diabetes. The body and mind are going to be under enormous stress due to a heart attack, that will affect the blood sugar. Diabetes affects the circulatory system, sugar damages the linings of the arteries, creates clogs...there for you have a heart attack. Many times, many, many times, a patient will require a very different diabetes medication set after such a serious event. Your issues are serious, I would recommend that administration at the hospital be aware of the problems so things can get taken care of properly.

I've never heard the 30 units per site? I would be interested to see where that comes from or if its one of those "urban legends". Many people routinely injection 30 plus units of long acting and meal time units a few times a day, I highly doubt they are going to break those 4-5 daily injections into 8-10 daily injections. I wonder if there is a recommendation for only 30 units per site, if this may be a pediatric recommendation?

Ok, we have a patient we re-started on an insulin pump, this patient has medicare as primary, to get her approved for more than 3 test strips per day, medicare is saying the provider must register on pecos.cms.hhs.gov. This is something we haven't done previously, however, we haven't done much with insulin pumps through our clinic in the past either. The pharmacist even reported, they hadn't heard of it, yet medicare was telling them for approval the prescriber would have to register. Any advice would be greatly appreciated, any experience with this? Thanks!

Thanks for the information!

Just wondering what your feelings or thoughts are on lantus BID for someone with type 2 diabetes. How does this help compared to lantus nightly? I see this as an unnecessary stick for patients, chance for more error, and even a chance for increased low blood sugar. What do you think, it seems to be great once daily, titrate up the dose 1 unit nightly until the target AM glucose is obtained, if needed add meal time insulin, but I don't see a benefit to BID lantus dosing, seems like this is something I am seeing more and more and often times these people are uncontrolled and either simply need a dose adjustment or they need meal time insulin.

Our program is recognized by the ADA, material to be used is the AADE7, so its the same material, however, some patients will need more focus in various areas depending on the situation. I generally structure the usual education as the initial appt. is about 2 hours, follow up 1-3 times for 1-2 hours depending on the situation and whether its 1 on 1 or group. One good book to use is the Living Well With Diabetes, its FREE, which is a bonus, but it follows all of the AADE7 needed material, easy to read, and easy to follow along for patients and educators. Also cornerstones4care has a good program of books you can get for FREE, I think the Living Well with Diabetes is less overwhelming and easier to follow, but all the material is very good. I would recommend getting some of both and getting use to it. With the ADA I use Chronicle Diabetes software for patient tracking and charting.

My first question would be what are his pre- and post-meal blood sugars? What does his glucose do in the middle of the night or before breakfast? While the A1C is reasonable given his limited diabetes education and lack of a longer acting insulin, its still not at goal, and just as important, the A1C is only an average. So he could be 50 at certain times of the day and 350 other times of the day...that would average 200, but those swings in glucose are not healthy, versus someone that might range 160-240 throughout the day, their average would be 200, but their glucose is more consistent. I would highly suggest a long acting insulin to his primary medical provider for complete, consistent coverage. I don't see that he could be consistently at his optimal health, safest health without some basal insulin. I know everyone is different, but there should be a ratio in the neighborhood of 50/50 with basal and bolus. No disrespect to anyone, but just because the MD hasn't ordered it, doesn't mean the patient doesn't need it. I would start with speaking with the MD, asking why he isn't on a long-acting insulin or possibly even recommending to the MD for patient to start a long acting insulin at a small dose, titrate up over the course of a couple of months and see how his A1C and glucose gets closer to a healthy range. Possibly even how he could decrease some of his Humalog insulin with the long acting insulin being started. Sounds to me like the patient has been dosing himself, has relatively "prescribed" his own dosing with little to no input by the MD...the MD needs to get involved.

I recently met with a patient that has used U500 in her insulin pump the entire 8 years she has had an insulin pump and is doing well. She has medicare, so she does not have the CGM either, monitors herself regularly which is needed for safety and success no matter what kind of insulin you use. I work out of a primary office, she has an endo that she follows up with at another clinic that mostly manages her pump. She uses about 30 units of U500 daily, generally is well controlled by using only basal insulin dosing through her insulin pump. She has taken the time to really learn through using her pump as she should, to benefit herself the best, and with consistent monitoring. She does report some occasional lows, but she manages those well by consistent monitoring and understanding how or when to temporarily stop her pump. Her problem now is that her pump is old, she would like an update, and medicare is providing difficulties with approving an updated pump. Her endo's office nurses are trying to talk her into going with MDI with U100, but at least she is smart enough to realize that will mean less control and a lot of difficulty in getting to the right dose when her pump provides a good, consistent basal insulin dose that controls her blood sugar. U500 will be a product used more in the near future due to the massive doses many people are on of U100 that are not getting the control they need. My question would be is it that U500 is dangerous or is it that healthcare workers just haven't taken the time to learn it and see its benefits for those patients requiring massive doses of U100?

Interesting Alisonisayoshi, I have concerns with it long-term, although I've been wrong before. I have wondered about why it couldn't be used for type 1 diabetes since they specifically work on the kidneys. Thanks for the information. Just out of curiosity, is your medical provider giving this to you or are you part of a study group using this with type 1 diabetes?

What are you thoughts on this class of medicine? There are 2 new ones on the market in the last year or two, studies appear to be good, but the idea behind having patients urinate out more glucose seems backwards to me. I understand that they would have less glucose circulating through their kidneys by kicking it out through the urine, but I have mixed ideas. Any thoughts, experiences, ideas on these?

I am looking for anyone with experience dealing with in office CGM. I'm not talking about CGM that goes along with an insulin pump, but where the docking station is IN OFFICE. The patient would come in to the office, have the CGM placed, and then return a few days later for download of information on how their blood sugars have ran over the past few days. I believe this to be worthy assistance in planning proper treatment, safe treatment, and regulating insulin dose/time/type. If any of you have used these, how well do they work? Problems incurred? Cost versus reimbursement? and anything else to help decide the use of this professional cgm. Thank you.

FutureCRNA, nurses and most medical personnel are often unaware of proper diabetes knowledge, however, I enjoy being a diabetes educator in a number of avenues, such as staff education, since most staff have to deal with more than diabetes issues, I can help them learn specifically about diabetes. My post dealt with the correctional system, while I realize there are nurses working in prisons, who do you think might be the majority of staff in a prison? Why do think those staff members may need help in learning about diabetes? I strongly believe there is a lack of proper diabetes knowledge/education in the prison system that creates higher than needed healthcare costs, due to a lack of diabetes knowledge on the part of staff in a prison system (I.E. correction officers that are trained to be correction officers) aren't able to recognize warning signs of diabetes that could lead to violence. (have you ever seen someone in DKA and how violent they can get?, I have, mix that in with someone that may already have violent tendencies such as an inmate and it can quickly create a serious situation, but if caught earlier, it could prevent or limit serious DKA.) Since I was speaking about the corrections system, I think that corrections officers could certainly be in need of diabetes education so they can be aware of warning signs with inmates, but also be able to manage their own diabetes more efficiently so they miss less work/help decrease overtime costs, concentrate better at work/increase safety, and reduce their own healthcare costs, along with being healthier and enjoying their life. Now, this may be off topic, but I've had people (educated people) sitting in my class that have been diagnosed with diabetes for 1 week, 10 years, 20 years, and even 30 years. There are usually 2 things they have in common. One is that they all have diabetes. The second is that all of them know about as much as each other about diabetes, which is very, very little until they leave our class. So, just because you have had diabetes for 21 years, doesn't mean you know everything or that you should be offended when someone tries to educate you on diabetes, if they know what they are talking about.

NO, its a fact finding assignment, I'm well past the homework years.

CDEWannabe.....Side question here since you brought up the bayer contour next meter communication with your pump. I currently have a patient on medicare, had been using a one touch, has strips already supplied for his one touch, but he is starting his insulin pump THIS week and the insulin pump uses the bayer contour next to communicate with. Do you or anyone know if or how medicare would work in supplying this patient with the bayer contour next strips even though he has a good supply of one touch strips?

How do you control diabetes in the prison? Does controlling diabetes issues help control behavior issues? Staff that have diabetes, how do they control their diabetes or are you able to help educate them on how to control their diabetes to increase safety and efficiency? Are there benefits or reasons to help control healthcare costs by properly controlling chronic disease complications?

My first comment is DSME is not just for people newly diagnosed with diabetes. It amazes every day how many people live with this disease for years and decades without any education, without any idea on what diabetes is, how it works inside their body, and why or how they can do certain things on the outside to control whats on the inside. I do believe a more comprehensive approach will provide better outcomes for most (not all) but most people that are able to live their life, but be educated on what changes they need to make will improve. What I've found is the more I am able to follow up with my patients, guide them in proper med. titration, answer questions along the way with monitoring, foods, activity, other provider referrals, etc. the better they feel supported and the better control they have. Flexibility as an educator is a must, while there are specific areas that need explained, everyone learns differently, everyone has different levels of readiness or willingness to learn, its their body, its their body, its their choice.

Hey SteveDE, from what Illinois Medicaid has told me is they do not cover any diabetes education or medical nutrition therapy since they do not recognize nurses or registered dieticians as providers. The only way there is any reimbursement is when the medical provider (doctor, NP, or PA) gives "counseling" during a billable office visit, so during their whopping 15 minute office visit the medical provider can choose to do counseling that they could provide a different E&M code.

Someone wouldn't be "out" with an A1C of 7, I highly doubt there would be a need for A1C on an EMS rig. Anything is possible, its possible that the meter was correct at 7 and they were still alive, probably not for very long, but its very possible. My dad was able to use his elbow to wake my mom up because he couldn't move anything else and his was 13. Also just because a meter says 7 doesn't mean it is exactly 7, there is room for error, it could have actually been a whopping 15 due to margin of error. I would strongly suggest this person have a prescription for glucagon, education, and have support of family/friends.

My understanding is that for the 1000 hours of instruction, you can use your payroll log. If you are on the job as a diabetes educator, you are doing the job of a diabetes educator. If this sounds correct to others, this could be an easier way to keep track and make your 1000 hour requirement.