SOME CALL IT “the silent killer” since many people do not even know that they have diabetes until they either go blind, have kidney failure, contract nerve damage or suffer a stroke. With its potential for numerous debilitating and sometimes fatal effects, it is a frightening disease. And judging from statistics, it is not going away any time soon (see sidebar on page 50).

One of the best ways to combat it, experts say, is through education. Realizing that, some home medical equipment providers are offering education and training to their diabetic customers. And in the process, they are gaining community exposure and potential for additional sources of revenue.

How do they put a diabetes education program together? Four HME providers share their methods.

Beyond Screening

ALARMED BY THE growing number of diabetes cases, Hauppauge, N.Y.-based Better Living Now officials decided they had to do something. So they started offering at-risk diabetes screening. But that didn't seem enough. So BLN stepped up its efforts and implemented a diabetes education program.

The company set up an on-site information center featuring diabetes-related handouts and brochures that it obtained from various glucose meter companies and the American Diabetes Association on a number of topics, including exercise, nutrition and meal planning, testing and using different blood glucose meters,. It ensured that its customer service staff was properly trained, bringing in manufacturers to demonstrate the use of glucose meters and insulin pumps and also inviting speakers from the American Association of Diabetes Educators and the ADA. It also enlisted its staff podiatrist, registered nurse and two pharmacists to help out with the education efforts.

“Most of the staff gets an overview of diabetes,” says Sharon Anders, director of sales and marketing, who is also a diabetic. “Anybody that calls here would get the proper answer from the girls in the customer service area. If not, they can't work here because we're all professionals and we're dealing with the hospitals and nursing homes and a lot of geriatric patients. We can't take a chance that they're going to be giving erroneous answers.”

BLN also sponsors various special programs, such as free foot screenings during National Diabetes Awareness Month in November. And it helps get the word out about diabetes by providing education at the Long Island office for the aging and a major local mall.

Day By Day

WHILE SOME HME companies such as BLN provide diabetes education in their own stores, Southern Discount Drugs and Diabetes Shoppe takes a different approach by offering education at doctors' offices and clinics.

The Charleston, Miss.-based HME provider calls its sessions “diabetes days,” which generally last from 10 a.m. to 4 p.m. On these days, which are generally held twice a week, the Diabetes Shoppe sets up two rooms. In one room, trainers talk about equipment, such as monitors, shoes and other supplies. In the other, experts talk with patients about various clinical issues, such as diet and exercise. Patients are free to come and go, since the days are loosely structured with no set lectures.

“Our diabetes days are not as formal as something you would get at a hospital when you're going there for nothing but diabetes education,” says Kevin Waldon, director of sales, who has been a diabetic for 20 years. “A lot of times, it's even more effective because it's not that 16-hour, two-day class that you're sitting in and hearing stuff that you may not even need to know. Some people are very knowledgeable about diabetes so all they want is, ‘what's the latest monitor that's out and give me a brochure’. Other people don't know the difference between diabetes and emphysema. So we just take each case individually and work with them accordingly.”

According to Waldon, most of the clinics that the Diabetes Shoppe works with hold a couple of diabetes days a year, but some even sponsor them once a month.

Employing Expertise

OTHER HME PROVIDERS, such as Mobile, Ala.-based Complete Patient Services, take yet another approach to diabetes education by hiring a certified diabetes educator. Called CDEs, they are health care professionals who have worked with diabetics for at least 1,000 hours and who take a certification exam every five years.

Complete Patient offers a series of six monthly sessions with two to three classes per day. Each session lasts about 90 minutes and covers a different aspect of diabetes, such as meal planning, medications, monitoring, stress management and exercise. While the classes are conducted mostly by a CDE, Complete Patient also has other staff, such as wound specialists and dieticians, on hand to address certain issues.

Once the sessions are completed, Complete Patient arranges follow-up for the patients, primarily in the form of support groups. Putting together such groups, however, can be challenging, especially for those sessions that are done out of state.

“Usually we like to find someone in the area that can follow or continue with a support group after these sessions are over with,” says Linda Johnson, president of clinical services. “And they are not always easily found. So sometimes we have to get a social worker that has had classes on diabetes, and then they'll have a follow-up like a support group that is usually once a month.”

People in the groups, she says discuss what they learned in class, their problems with diabetes and how they deal with them.

Face-to-Face

THE SUGAR CONTROL Center also has a CDE lead its diabetes education, but rather than group settings, the Bethpage, N.Y.-based HME provider conducts most of its education through hour-long, one-on-one sessions. There is no set timetable or agenda for the sessions, which explore patients' goals and their progress in dealing with diabetes.

The sessions, says Dorene Small, a clinical nurse who has been teaching diabetes education classes for 17 years, are ongoing. “It depends on what the patient's needs are,” she says, adding, “It's what you want to accomplish and how ever many sessions it takes to accomplish it.”

Small occasionally puts together some special group programs at the Sugar Control Center in which she discusses such subjects as carbohydrate counting and introducing soy into diets. She also invites outside speakers, including hypnotherapists, dieticians, social workers, and other health professionals.

Sincerity and Commitment

WHILE MOST PROVIDERS say it is difficult to calculate precisely the financial impact diabetes education has had on their businesses, they generally concur it has been beneficial, both in terms of increased revenues and greater visibility in the community. It has given some providers leverage in negotiating managed-care contracts and it also adds another customer service element that patients appreciate.

“I'd have customers coming into the store telling us that they'd been to other places, and they just weren't getting the same information, they didn't have the variety,” says Small. “Patients like to feel that the people they're dealing with are sincere and have their concern at heart even though they're selling a product. They're coming for products, but they're also coming in for the education. And they'll say, ‘I could get this somewhere else for less but I want to come here because you spend so much time with me.’”

Commitment is the key to being successful in diabetes education, providers say.

“The main thing I would recommend would be to make sure that the staff who would be going out there selling or doing the education is properly trained, knows what they're talking about, has a passion for it and is not simply going through the motions or the scripts that you can come up with in doing diabetes education,” says Waldon. “That's what makes the difference. What stands out is this person cares, this company cares, they're not just trying to sell supplies, they're trying to improve the quality of life of these people, and they're doing it through sales and education.”

Additional information about diabetes can be found in HomeCare's February 2001 issue. Just log on to www.homecaremag.com and pull up the back issue archive.

Education Standards Too Tough?

The American Diabetes Association has established national standards for diabetes self-management education programs that are reimbursable by Medicare. HME providers, however, say the standards are so stringent it is difficult to put together an ADA-recognized program.

“The ADA is pushing multi-disciplinary, and that's one of the big problems because one person can run a program all by themselves,” says Pat Linekin, chairperson-elect of the home care specialty practice group for the American Association of Diabetes Educators. “A nurse can do the whole thing by herself. But you can't have that in a recognized program. You've got to have a team with at least a registered nurse and a registered dietitian. It's just a lot of things to do, someone has to get paid to do it, and all of that makes it not profitable. It's just ridiculous, and they're making it impossible.”

ADA officials disagree, saying that the ADA set up the standards in order to ensure that the diabetes education is of the highest quality.

“Actually, I don't think [the standards] are [strict], to be very truthful,” says Dolly Bronzini, director of education at the ADA. “The standard tells us what is a quality diabetes education program. And if we're going to be doing a service for our patients, then we would want that service to have quality. It's a very difficult issue because in order to have a program recognized by the ADA, it has to have quality education. We had to find someplace where that quality measure is, and the national standards fit that.”

Diabetes educators and activists also believe that other groups are just as capable of establishing standards for education programs that would be covered by Medicare.

“It's not fair for one non-profit organization to control what is considered the standard of care for the whole nation,” says Linda Pearce, president of the AADE home care special interest group. “In many states, you've got state health departments and other accrediting bodies that could handle the same thing as far as assuring the quality that's there. It shouldn't be one national organization recognizing all the diabetes education in the country.”
— R.P.

Revenue and Growth Rate Forecasts for the U.S. Home Diabetes Market

Year	Revenue in millions
	Blood Glucose Testing	Insulin Therapy Devices
1999	$1,157	$104
2000	$1,303	$114
2001	$1,452	$126
2002	$1,600	$139
2003	$1,744	$154
2004	$1,880	$171
2005	$2,006	$190
Compound Annual Growth Rate (2000-2005):
Blood Glucose Testing: 9.0%
Insulin Therapy Devices: 10.7%
Source: InteLab Corp.

Diabetes Facts and Figures

• 15.7 million people, or 5.9 percent of the U.S. population, have diabetes. While about 10.3 million have been diagnosed, the remaining 5.4 million people are not aware that they have the disease.

• Approximately 2,200 people are diagnosed with diabetes each day. About 798,000 people will be diagnosed this year.

• Diabetes is the seventh leading cause of death (sixth leading cause of death by disease) in the U.S. and contributed to 198,140 deaths in 1996.

• The total annual economic cost of diabetes in 1997 — the latest available study — was estimated to be $98 billion. That includes $44 billion in direct medical and treatment costs, which represents 5.8 percent of total personal health care expenditures in the U.S., and $54 billion for indirect costs attributed to disability and mortality.

• The per-capita costs of health care for people with diabetes amounted to $10,071.

Source: American Diabetes Association