Identifying Competencies for Diabetes Community Care Coordinators

The purpose of the study was to develop care and professional education competencies that address prediabetes, diabetes, and cardiometabolic conditions at the individual and population levels and to promote self-assessment and professional development goals related to the knowledge, skills, and abilities required to effectively work with PWD and related conditions.

There are 130 million Americans currently living with, affected by, or at risk for diabetes. As a result, clinicians, nonclinical providers, and peer supporters are all indispensable in the delivery of person-centered, team-based diabetes care and education. ¹ The Association of Diabetes Care and Education Specialists (ADCES) recognizes the need and opportunity for expanded competencies that include a broad interprofessional team to support integrated and person-centered care to meet the standards for high-quality care for people with diabetes (PWD) and cardiometabolic conditions.

Based on evidence-based outcomes, the American Diabetes Association, the European Association for the Study of Diabetes, and ADCES recommend a person-centered approach to diabetes management that is holistic and includes self-management education and health behavior change for all PWD and related conditions.^1-4 Every person living with diabetes deserves access to the information and resources necessary to reduce the health risk of diabetes and cardiometabolic conditions, which will allow them to achieve optimal quality of life (QOL).

It is critical that each member of the diabetes care team develop the skill set necessary to effectively care for and educate this population. ⁵ To help achieve this goal, in 2020, ADCES implemented a modified Delphi study designed to identify and develop competencies for the expanded diabetes care team. ⁶ The purpose of the study was to develop care and professional education competencies that address prediabetes, diabetes, and cardiometabolic conditions at the individual and population levels and to promote self-assessment and professional development goals related to the knowledge, skills, and abilities required to effectively work with PWD and related conditions.

The targeted audiences for these expanded competencies included the following: (1) community workers who serve as a bridge between populations and health care systems and (2) point-of-care clinicians who care for PWD and related conditions in the general health care system but who are not specialized in diabetes care and education beyond their current clinical training. They represent the front line of health care.

It is important to note that the competencies are meant to expand and augment existing competencies to recognize the expanded role the entire health care team has in providing diabetes care and education. They are not a revision to the existing competencies for diabetes care and education specialists (DCESs) that were published in 2020 or any other interprofessional competencies. ²

The Delphi Method

The Delphi method, an approach used to obtain an expert opinion in a systematic manner, has been used in health and medicine for nearly 5 decades. ⁷ It allows for organizing multiple expert opinions, values, and experiences from the interprofessional team into a consensus. The process applied here identified core competency domains that are inclusive of all professions who work with individuals and populations with diabetes. Experts represented nutritionists, community health workers, dental hygienists, health educators/coaches, dietitian technicians, pharmacist assistants, individual navigators, social workers, pharmacy technicians, students, care coordinators, master's level nutritionists, dietary-health technicians, DCESs, nurses, and exercise physiologists.

The competencies identified were reached through a systematic consensus-building process, expert opinion, and a focus on the vision for optimal health and QOL for PWD and related conditions. The full article with the entire methods section outlining study design, environmental scan, stakeholder consultation, surveys, and analysis can be found here .

Redefining the Diabetes Care Team

Previous ADCES competencies included 3 diabetes educator levels and 2 diabetes education associate/paraprofessional levels.^2,8,9 Driven by stakeholder input, the 2 diabetes education associate/paraprofessional levels have been merged into 1 role titled "diabetes community care coordinator" (DCCC). This title was adopted by the ADCES Board of Directors in 2021 to identify the broad skill set in the diverse workforce caring for people with diabetes in the community and was used by the research team for this study. Health care team members who hold a license or certification and who do not intend to specialize in diabetes are referred to as "health professionals." These roles are defined in Table 1 and discussed in detail in the following.

Driven by stakeholder input, the 2 diabetes education associate/paraprofessional levels have been merged into 1 role titled "diabetes community care coordinator" (DCCC).

Table 1

Health Care Team Role Definitions.

Diabetes Care Team
Diabetes community care coordinators	Health professionals	Diabetes care and education specialists
Member of the diabetes care team focused on linking individuals to resources, building relationships, and supporting people with, affected by, or at risk for diabetes and cardiometabolic conditions. a	Member of the diabetes care team who interacts with people with diabetes and related conditions but whose primary focus is not diabetes.	Experts who, as integral members of the care team, provide collaborative, comprehensive, and person-centered care and education to people with diabetes and related conditions.
This includes but is not limited to community health workers (CHWs), health educators/coaches, medical assistants (MAs), certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nutrition/dietetic technicians (NDTRs), military medics and corpsmen, pharmacy assistants/technicians, physical therapy assistants, nutritionists, dental hygienists, emergency medical technicians (EMTs), and other similar roles.	This includes but is not limited to registered nurses (RNs), registered dietitian nutritionists (RDNs), pharmacists, and other similar roles.	This includes but is not limited to those with the credential CDCES (certified diabetes care and education specialist) or BC-ADM (board certified advanced diabetes management) and similar roles specializing in diabetes.

a

Cardiometabolic conditions include obesity, prediabetes, diabetes, and the full cardiometabolic spectrum. Cardiometabolic conditions encompass microvascular damage, including but not limited to the eyes, kidneys, and nerves, and macrovascular damage to the cardiovascular system (ie, heart attack, stroke, and insufficient blood flow to the legs).

Diabetes Community Care Coordinators

The DCCC role is inclusive of a broad set of diabetes care team members focused on providing community-based, person-centered care and education and connecting individuals to health care teams and systems. DCCCs are recognized by the full care team for their understanding of local culture, environment, and social determinants of health within their community. The term was identified because it aptly describes the trusted liaisons who link individuals to diabetes-related resources, build relationships, and collaboratively work with people at any stage of readiness.

DCCCs include but are not limited to community health workers, health educators/coaches, medical assistants, certified nursing assistants, licensed practical nurses, registered nutrition/dietetic technicians, military medics and corpsmen, pharmacy assistants/technicians, physical therapy assistants, nutritionists, dental hygienists, emergency medical technicians, and those in other similar roles. As a frontline workforce, DCCCs serve as essential partners in mitigating inequalities and supporting self-care behaviors for people with, affected by, or at risk for diabetes.

Health Professionals

Health professionals not specializing in diabetes (HCPs) are key members of the diabetes care team, and they have many opportunities to enhance the care and education provided to PWD. These frontline HCPs are well positioned to use a person-centered approach that will make significant differences in the lives of people with, affected by, or at risk for diabetes. They work within a defined scope of practice that is guided by their specific professional competencies, and they have completed academic preparation in health and science.

Examples of how HCPs interact with PWD include a registered dietitian nutritionist who is creating a postoperative care plan for a person with diabetes, a pharmacist who occasionally teaches blood glucose monitoring, or a registered nurse who provides bedside care in the medical/surgical unit of a hospital.

Diabetes Care and Education Specialists

The description and competencies for this role have been addressed elsewhere. ⁷

Application and Use

The intent of these sets of competencies remains the same as described by Ryan et al ³ in 2020, as follows: "intended to guide practice regardless of discipline and encourage mastery through continuing education, individual study, and mentorship." ⁹

The intent of the competencies remains the same as described by Ryan et al ³ in 2020, as follows: "intended to guide practice regardless of discipline and encourage mastery through continuing education, individual study, and mentorship."

Although additional core competencies may be necessary for specific job roles, the competencies defined in this document pertain specifically to diabetes. The competencies are not intended to address the scope of practice, nor are they intended to override organizational policies and bylaws, protocols, state licensure, and other regulations.

Both sets of competencies for DCCCs and HCPs include a domain focused on person-centered care and education. In this approach, the beliefs, preferences, and values of the PWD are paramount. Diabetes care team members must be able to demonstrate respect for the individual and provide equitable and high-quality care for all persons they serve, incorporating individual beliefs, values, and preferences into the care they deliver. These competencies apply to all practice settings and delivery modes, including virtual interactions and competence in the use of technology to overcome barriers to self-care for PWD.

The ADCES urges DCCCs and HCPs to use these competencies to perform self-assessments and set professional development goals. The final set of 123 competencies is representative of 2 domains: (1) Clinical Management Practice and Integration and (2) Person-Centered Care and Education Across the Life Span.

DCCCs and HCPs who achieve the competencies contribute to a more proficient and empowered workforce, which can result in improved QOL and outcomes for people with, affected by, or at risk of diabetes.

Navigation of Competencies

Acquiring knowledge is a prerequisite to competency. Each competency has been carefully developed to illustrate a distinct knowledge set, skill, or ability. Note that the term "person" includes those with, affected by, or at risk for diabetes and those affected by the full spectrum of conditions including prediabetes and cardiometabolic conditions.

Table 2 outlines the competencies for DCCCs. Competencies listed under the domain of Support of Clinical Management Practice and Integration reinforce the importance of a strong foundation in the clinical management of diabetes and self-management through the ADCES7 Self-Care Behaviors™. ¹⁰ Competencies listed under the domain of Person-Centered Care and Education Across the Life Span emphasize the need to identify and incorporate an individual's needs and preferences when facilitating and delivering care and education.

Table 2

Competencies for the Diabetes Community Care Coordinator.

Domain 1: Support of Clinical Management Practice and Integration

The diabetes community care coordinator maintains the necessary knowledge and skills in diabetes to provide support in the management of diabetes and cardiometabolic conditions.

Support of Clinical Management of Diabetes and Cardiometabolic Conditions

1. Describes differences between prediabetes, type 1 and type 2 diabetes, and gestational diabetes

2. Describes the relationship between diabetes and cardiometabolic conditions 1

3. Lists risk factors for developing type 2 diabetes and related conditions

4. Reviews common acute complications of diabetes

5. Provides person-centered support and education for self-care to individuals and their caregivers

6. Identifies Social Determinants of Health and the resulting gaps in resources and support for self-care

7. Collects diabetes information, which may include glucose meter or continuous glucose monitoring (CGM) logs from health information technology sources

8. Collaborates and participates in ongoing communications with primary care providers

9. Demonstrates understanding of the relevant scope of practice of interprofessional care team, including roles and responsibilities

Support of Clinical Practice: Healthy Coping

10. Demonstrates awareness of psychosocial and emotional health within the daily self-management of diabetes

11. Provides examples of healthy coping strategies to incorporate into daily activities

12. Assists individuals with recognition of barriers and facilitators related to self-care to support positive change

13. Uses screening tools as indicated to identify concerns with healthy coping, such as diabetes distress, depression, eating disorders, and other mental health concerns

14. Assists individuals with appointments to behavioral specialists and supports ongoing participation in care

Support of Clinical Practice: Reducing Risks

15. States complications of and risk factors for diabetes

16. Explains healthy behaviors to help prevent type 2 diabetes and/or reduce risks of related complications

17. Outlines key prevention behaviors to maintain health at points of care transitions (at diagnosis, annually, and/or when not meeting treatment targets, when complicating factors develop, and when transitions in life and care occur) 11

18. Matches potential barriers to healthy behavior with steps to maintain or improve health and prevent complications

Support of Clinical Practice: Taking Medication

19. Reviews medication plan with individual and confirms understanding

20. Assists individuals with recognition of barriers and explains strategies for uninterrupted medication use

21. Identifies and communicates issues that require care team intervention

Support of Clinical Practice: Healthy Eating

22. Describes general considerations for healthy eating, such as food groups, label reading, portion sizes, and meal planning

23. Explains components of healthy eating patterns, such as including nonstarchy vegetables, minimizing added sugars and refined grains, and choosing whole foods instead of processed foods

24. Assists individuals to incorporate cultural and socioeconomic preferences into meal planning and eating patterns

25. Assists individuals with recognition of barriers and implementation of strategies for healthy eating

26. Uses knowledge of the interaction between food, activity, and medication to promote and maintain healthy eating choices

Support of Clinical Practice: Monitoring

27. Explains available tools used for monitoring, such as meters for glucose monitoring, devices for CGM, mobile applications, and point-of-care tools

28. Assists in the training needed for glucose monitoring and (when necessary) urine ketones

29. Assists individuals with recognition of barriers to effective monitoring and explores possible solutions for overcoming barriers with self-monitoring

30. Supports individuals' attempts to achieve and maintain effective self-monitoring habits

Support of Clinical Practice: Being Active

31. Understands the role and impact of physical activity and fitness in prevention and treatment of diabetes and cardiometabolic conditions

32. Encourages physical activities as recommended by the care team

33. Assists individuals to overcome barriers to routine physical activity and connects them with appropriate community resources

34. Supports individuals as they make changes in movement patterns appropriate for age and life stage and refers to health care team for modifications

Support of Clinical Practice: Problem Solving

35. Works with individuals to identify solutions to challenges with self-management

36. Demonstrates use of tools, including adaptive aids, to facilitate effective self-management

37. Assists individuals with goal setting

38. Adapts education tools to support literacy

39. Supports individuals to integrate established plan of care into daily lives

Domain 2: Person-Centered Care and Education Across the Life Span

The diabetes community care coordinator partners with team members to facilitate and advocate for care and education that promotes healthy behaviors and improves quality of life for people with diabetes and cardiometabolic conditions across the life span.

Assessment

40. Collects and reports findings from individual's assessment for self-management of health conditions

41. Provides appropriate screening tools to assess daily self-management and type 2 diabetes prevention activities to meet individual needs

42. Establishes person's interest in support networks and assists with access to those networks and community resources

43. Identifies person's preferences for use of technology to promote self-management

Care Delivery for Individual

44. Teaches evidence-based diabetes and cardiometabolic self-management topics collaboratively and within scope of practice to individuals across the life span

45. Uses the ADCES7 Self-Care Behaviors™ as a framework to teach and reinforce self-management skills 10

46. Facilitates behavior change and improved quality of life

47. Recommends appropriate services based on age, culture, health literacy and numeracy, and learning needs of individual

48. Assists individuals with evaluation of reliability of health information

49. Matches an individual's interest in technology with the most appropriate tools

50. Encourages problem-solving skills and shares techniques to overcome barriers to self-care

51. Names behavioral approaches to meet evolving needs of the individual

52. Recommends the inclusion of a support network into individual's care and provides evidence to the benefits of a support network

53. Encourages person-first language to promote positive interactions

54. Provides positive feedback to celebrate successful self-management events

Care Delivery for Population

55. Demonstrates appropriate participatory teaching methods in delivery of education

56. Participates in care coordination, including access to resources

57. Participates in education programming and services, including the National Diabetes Prevention Program, 12 diabetes self-management education and support, and chronic disease programs

Table 3 outlines competencies for HCPs whose primary focus is not diabetes. Competencies listed under Clinical Management Practice and Integration focus on the basics of clinical and self-management for diabetes and cardiometabolic conditions because HCPs have already completed academic preparation and clinical practice in their roles. Competencies listed under Person-Centered Care and Education Across the Life Span underscore the value of assessing individual needs and interests when selecting resources and delivering care and education.

Table 3

Competencies for Health Professionals (Diabetes Is Not Primary Focus).

Domain 1: Clinical Management Practice and Integration

Health professionals maintain knowledge and skills in pathophysiology, epidemiology, clinical management, and self-management to support people with diabetes and cardiometabolic conditions.

Clinical Management of Diabetes and Cardiometabolic Conditions

1. Describes the difference between prediabetes, type 1 and type 2 diabetes, and gestational diabetes

2. States the diagnostic criteria, risk factors, and progression of diabetes across the life span

3. Identifies the impact of glucose levels on the development of diabetes and cardiometabolic conditions

4. Recognizes the signs and symptoms of hypoglycemia, hyperglycemia, hyperosmolar hyperglycemic state, and diabetes-related ketoacidosis

5. Applies knowledge of the pathophysiology of diabetes and cardiometabolic conditions to provide diabetes care

6. Applies clinical practice guidelines into care and care models

7. Refers or facilitates referrals and/or treatments as appropriate

8. Assesses Social Determinants of Health and identifies the gaps in resources and support for self-care

9. Recommends and provides interventions as appropriate for community-based resources to support self-care

10. Provides person-centered care, education, and support for diabetes self-care

Clinical Practice: Healthy Coping

11. Assists individuals with identifying and prioritizing their goals as part of the shared decision-making process

12. Identifies the impact of psychosocial and emotional health within the daily self-management of diabetes

13. Assesses impact of individual's behavioral and emotional health on the plan of care

14. Assists individuals with recognition of barriers and implementation of strategies for healthy coping

15. Screens for the presence of diabetes distress, depression, eating disorders, and other mental health concerns

16. Appropriately refers individuals to behavioral specialists or community behavioral resources

17. Facilitates the development of healthy coping skills in people with diabetes and cardiometabolic conditions

Clinical Practice: Reducing Risks

18. Encourages participation in diabetes self-management education and support (DSMES), such as the National Diabetes Prevention Program (DPP), medical nutrition therapy (MNT), and other individual or group models of care

19. Provides or facilitates referrals to diabetes care and education, which may include registered dietitian nutritionists, certified diabetes care and education specialists (CDESs), and those with the credential board certified-advanced diabetes management

20. Applies knowledge of diabetes-related complications and associated risk factors for education, prevention, and management

21. Implements risk reduction strategies to minimize actual and potential risks related to common diabetes-related complications

22. Implements prevention strategies to assist individuals with diabetes and cardiometabolic conditions at care transition points (at diagnosis, annually, and/or when not meeting treatment targets, when complicating factors develop, and when transitions in life and care occur) 11

23. Assists individuals with recognition of barriers and implementation of strategies to effectively reduce the risk of diabetes and diabetes-related complications

24. Develops processes to ensure access to resources needed for self-management at the time of transition

25. Advocates for appropriate and timely adjustments in plans of care to prevent therapeutic inertia

Clinical Practice: Taking Medication

26. Explains administration technique, dosing, frequency, side effects, storage, expiration, and benefits of medication taking

27. Identifies medications ordered for diabetes and cardiometabolic conditions

28. Identifies and communicates issues that require care team intervention

29. Assists individuals with recognition of barriers and codevelops strategies for uninterrupted medication use

30. Applies knowledge of the health care system and individual's medications to facilitate uninterrupted access to medications, devices, and supplies necessary to self-manage diabetes and cardiometabolic conditions

31. Demonstrates awareness of insulin pumps

Clinical Practice: Healthy Eating

32. Facilitates referrals to National DPP, DSMES, and MNT providers, including DCESs and registered dietitian nutritionists 12

33. Applies nutrition knowledge, cultural and socioeconomic considerations, and person's preferences to assess and individualize healthy meal plans

34. Connects person with recommended online resources to support healthy behaviors to maintain healthy eating patterns

35. Describes general components of healthy eating, such as food sources of macronutrients, label reading, portion sizes, and meal planning

36. Explains relationship between food, activity, medication, and clinical outcomes, such as blood glucose, lipids, blood pressure, and weight

37. Explains components of healthy eating patterns, such as including nonstarchy vegetables, minimizing added sugars and refined grains, and choosing whole foods instead of processed foods

38. Compares and contrasts various eating patterns useful for the management of diabetes and cardiometabolic conditions

39. Assists individuals with recognition of barriers and implementation of strategies for healthy eating

Clinical Practice: Monitoring

40. Explains available tools used for monitoring, such as meters for glucose monitoring, devices for continuous glucose monitoring, mobile applications, and point of care tools

41. Supports the individual's attempts to achieve and maintain effective self-monitoring habits

42. Applies knowledge of monitoring to provide guidance on achievement of treatment goals

43. Assists individuals with recognition of barriers and implementation of strategies for effective monitoring

Clinical Practice: Being Active

44. Understands the role and impact of physical activity and fitness in prevention and treatment of diabetes and cardiometabolic conditions

45. Applies knowledge of exercise-related glucose excursions to provide recommendations for aerobic, resistance, and other physical activity

46. Assists individuals with recognition of barriers and implementation of strategies to promote physical activity

47. Selects recommendations for physical activity based on factors such as pregnancy, age, body mass index, weight management goals, and macrovascular and microvascular complications

Clinical Practice: Problem Solving

48. Employs collaborative problem-solving methods to identify and resolve gaps in the plan of care

49. Utilizes knowledge of problem solving and goal setting to develop appropriate and realistic plans of care

50. Develops person-centered plan of care consistent with available support systems and physical, developmental, and cognitive levels

51. Assists individuals with recognition of barriers and implements strategies for effective problem solving

Domain 2: Person-Centered Care and Education Across the Life Span

Health professionals partner with team members to facilitate and advocate for care and education that promotes healthy behaviors and improves quality of life for people with diabetes and cardiometabolic conditions across the life span.

Assessment

52. Assesses person's skills and knowledge level, education, health literacy/numeracy, culture, readiness to learn, preferred learning style and language, barriers to learning, financial barriers, confidence and skills with technology use, and support needs

53. Identifies appropriate community support for ongoing diabetes self-management

54. Evaluates person's interest and access to support network

55. Identifies tools that are well suited to individual preferences and plan of care to support an improved quality of life

56. Evaluates individual's physical and cognitive abilities to perform daily self-management activities and identifies tools, including adaptive aids, to facilitate effective self-management

Care Delivery for Individual

57. Provides evidence-based diabetes and cardiometabolic education to individuals across the life span

58. Uses the ADCES7 Self-Care Behaviors™ as a framework to teach, reinforce, and evaluate self-management skills 10

59. Facilitates an individualized education plan

60. Applies knowledge of technology and individual's interest in and comfort with technology to select most appropriate tools

61. Facilitates individual problem solving to overcome barriers to self-management

62. Integrates the inclusion of a support network into person's care

63. Encourages person-first language to promote positive interactions

Care Delivery for Population

64. Facilitates referrals to DSMES programs, such as the National DPP and chronic disease programs 12

65. Assists individuals in evaluating reliable information sources for diabetes and cardiometabolic conditions and identifying potential misinformation

66. Facilitates navigation of the health insurance system

Conclusion

The increase in diagnoses of diabetes, prediabetes, and cardiometabolic conditions and emerging trends in diabetes treatments, including diabetes technology, demand the need for a competent and diverse diabetes care team to address the health of the individual and population levels in the United States. It is critical for the diabetes care team to use the competencies to complete a baseline self-assessment of their individual skill set and determine their next steps for professional development.

ADCES calls on the diabetes care team, the DCCC, HCPs, and DCESs, to strive for excellence in their pursuit of optimal health and QOL for people with, affected by, or at risk for diabetes. ADCES remains dedicated to fostering a collaborative and comprehensive approach to providing person-centered care and education. The competencies for DCCCs and for HCPs who do not specialize in diabetes provide a pathway for the continued growth of the interprofessional team.

To view the full set of competencies, along with helpful resources, go to the competencies page on the ADCES website.

The increase in diagnoses of diabetes, prediabetes, and cardiometabolic conditions and emerging trends in diabetes treatments, including diabetes technology, demand the need for a competent and diverse diabetes care team to address the health of the individual and population levels in the United States