Tuesday, August 12, 2008

Feedback on DM & PCMH Integration, Where the RNs Come From, Physician Reality Check & the CDE Roles

The Disease Management Care Blog wants to share some email feedback and insights from its recent talk at the Annual AADE Meeting. The email’s author is a registered dietitian with inpatient, large medical group and disease management vendor experience. She now works as a director of a diabetes management center – obviously someone with lots of ground level insight:

In its AADE presentation, the DMCB speculated that the future of population-based health will bring blended versions of disease management and the patient centered medical home. There’s gratifying agreement on that idea but the feedback below also notes there’s no underestimating the role of electronic records:

1. You are on target- that a “combined model”, is where things will go. Some unification of Population Health Management with the chronic care model/medical home would make sense- although the way to make it happen depends on an improved EMR to help with communication, and claims.

Wonder where all those call center R.N.s come from? The DMCB shared anecdotes about nurses being sucked out of local community hospitals. This is a reminder that there are other pools of qualified individuals who, by the way, are also navigating a very dynamic job market:

2. My experience at a “calling center”, early in my disease management career revealed RNs who were employed that would otherwise be on disability themselves or unemployed because they were no longer able to work in the hospital. The physical demands of the inpatient positions were beyond what they could meet. 50, 60, even 70 year old experienced RNs were working in the centers and helping health plan members from the telephone. Your comment about calling centers “sucking” the nurses out of the local hospital staffs was not accurate in my experience- where 70 RNs were in a center. It is also nice for RNs to have alternate career options, and can be productive despite their physical limits. That phenomenon may also vary depending on the geographical area. Hospitals are suffering nationwide & under a fiscal crunch like never before. The “culture” or environment working in a hospital is not the same caring one it once was. Business is in the face of healthcare each and every day. I imagine (because I am not an RN) all professionals in health care need to be flexible and able to adapt to a changing healthcare environment to a degree.

Uh oh, changing environment? As someone with a mom still proud of her son the doctor, the DMCB couldn’t help itself in its AADE presentation. It stressed the physicians’ changing yet still important leadership roles. Here’s a dose of reality: if physicians think they should command status just because they’re physicians, they may need to think again. The world is changing:

3. Historically M.D.’s have made more money on treating the ill vs. keeping people well. Today’s issues are perhaps a reflection of globalization of all economies- including medical care as a commodity. In Israel teachers are paid higher salaries than physicians. Wellness (lower obesity and less disease) in many other countries command a greater percentage of spending per capita than in the US. Other healthcare systems don’t spend too much in end-of-life care and instead invest far more in prenatal care. None of these common-sense approaches require a lot of physician support.

Well, this was an AADE meeting and my hosts were CDEs. But the DMCB was being more than just nice. It truly believes health educators, coaches, teachers, guides, helpers etc. are going to command a higher status (and compensation) in population-based approaches to chronic illness. It would appear, however, that the DMCB should do a better job of including all classes non-physician professionals in its comments. Furthermore, not everyone buys into the CDE certification process. Is there a role for less rigorously credentialed persons if the need for patient education is so pressing and outcomes are not all that dissimilar?

4 . You commented about the CDE as the “top of the food chain” for diabetes education- holding them at the highest regard- and you only included RNs in the reference. CDEs are also registered dieticians, pharmacists, social workers & other disciplines. And there is much literature on the shortage of diabetes educators in a large part due to the RIDICULOUS application process involved in obtaining a CDE, there are real administrative barriers to obtaining this specialty designation. Thousands of experienced clinicians provide diabetes education each day using the exact same teaching models and high quality comprehensive education and care. They should not be valued less in terms of care delivery. There are many people who practice as diabetes educators, have the criteria for applying to be eligible to sit for the exam- but say “why bother,” skills, are the same. My program’s and practice outcomes show my skill and my patient satisfaction scores are high.

Thanks for taking time to read this- & ps- my older son (age 14) wants to be a surgeon …

The DMCB thanks Eva Gonzales for the fabu email and the permission to share it. As for being a surgeon, the DMCB will share an anecdote: When a world famous internist came to give Grand Rounds at an even more famous medical center, the internist opened his erudite presentation by telling the audience a little bit about himself. ‘My grandfather was a surgeon,’ he said. ‘My father was a surgeon too, as was my uncle,’ he added. ‘My brother is a surgeon. But I pursued a career in internal medicine. You can see, therefore,’ he added after a pause, ‘that I was the first person in my family to be a doctor.’

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