good afternoon and good morning to viewers on the west coast Alaska and Hawaii Welcome to our webinar enhancing access protecting tomorrow for people with diabetes the role of community health workers this webinar is part of our efforts to recognize the international diabetes Federation 2022 where Diabetes Day theme us access to care education to protect tomorrow where diabetes day will be celebrated on November 14th my name is Betsy Rodriguez and I will be your moderator today I am a senior Public Health advisor in the health education and promotion team in the division of diabetes translation at the Center for Disease Control and prevention before we begin I would like to go over some information about the webinar at this time we are required to share our disclosure statement CDC our planners content experts or their spouses and partners wish to disclose they have no financial interest or other relationship with the manufacturers of commercial products suppliers Commercial Services or commercial supporters planner has reviewed content to ensure there is no bias the content presented will not include any discussion of the own label use of a products or products under investigational service CDC did not accept commercial support for this continued education activity there are no fees charged for CDC continuing education activities the findings and conclusion of these presentations are those of the authors and not necessarily represent the views of CDC the program has been approved for cneu c-e-c-h-n-c-p-h credit to receive the credit please complete the evaluation and take the past test available at www. cdc. gov tceo online a password for this activity is required so take note the password is diabetes stuff please note if you have never registered to Cee online you will have to create a new account and returning users should Loan in with their existing username and password this webinars is being recorded and an email will be sent once once the recording is available the recording will also be approved for continuing education credit these slides and scripts of the webinar will be available with a recording during the webinar if you have questions for our speakers please type them in the Q a bit of box below if you want to direct your question to a particular speaker please feel free to know that in your question we will do our best to answer our questions during the Q a portion of this webinar if you have a questions about obtaining continuing educational credits where to access these webinar once it's over or other technical questions please use the chat box feature I will now like to invite DrChristopher Holliday director of the division of Vegas translation at CDC to give the opening remarks thank you Betsy and good afternoon everyone it is my pleasure to be here with you today I'd like to begin by thanking this Paulina duker and the association of Diabetes Care and education Specialists for collaborating with us on this webinar thank you also the cdc's Betsy Rodriguez for moderating the international diabetes federation's theme for this year's World diabetes day is education to protect tomorrow calling attention to the need for better access to Quality diabetes self-management education and support services keeping with that theme today's webinar not only highlights the importance of access to quality dsmes services for people with diabetes and their families but also brings awareness to the role that community health workers play in increasing that access as we know people with diabetes require quality care and support to manage their condition and avoid or delay complications however millions of people with diabetes around the world do not have access to this care and support increasing access to life-changing and sometimes life-saving support doesn't just mean improving Therapeutics it means meeting people where they are in the places where they live work learn play and pray and addressing the conditions of these physical and social environments those social and structural determinants of Health are often enduring barriers to Optimal Health and well-being causing inequities and inequalities for many communities and addressing them is a public health priority they are part of the healthy people 2030 goals and one of the four top priorities of cdc's national Center for chronic disease prevention and health promotion now cdc's division of diabetes translation is also committed to reducing the health inequities that exist among populations that are disproportionately impacted by diabetes and at risk for type 2 diabetes one way that we've been addressing Health inequity for some time now is by enhancing the engagement of community health workers the American Diabetes association's 2022 standards of medical care and diabetes includes recommendations based on strong evidence that clinicians should that clinicians should address food insecurity housing insecurity and homelessness Financial barriers and social Community Support to inform treatment decisions and referrals these guidelines also recommend the provision of diabetes self-management education and support services to patients from lay health coaches Navigators or community health workers when available the community Prevention Services Task Force recommends interventions engaging community health workers for both type 2 diabetes prevention and management the findings listed in the community guide show that this intervention approach is effective in terms of health outcomes Health Equity as well as cost we continue to support community health workers roles in medical and Social Services by by maintaining the CDC Community Health worker resources webpage and facilitating ongoing work between states and community health workers for chronic disease prevention and management CDC is also supporting states that are building the infrastructure to sustain community health workers as a Workforce the forthcoming evaluation of these programs and the translation of aggregate outcomes from States and from Partners will provide meaningful models and information to programs using this Workforce we can only sincerely put patients at the center of care when we appropriately understand and address the circumstances affecting their ability to manage well their diabetes community health workers hold a key that can help unlock and open our awareness to all aspects of patient experience and serve as that conduit for education to protect tomorrow thank you for your efforts and all that you do to improve the lives of people with diabetes and your partnership in realizing a vision of a world free of the devastation of diabetes I'll now turn it back to Betsy thank you DrHolliday the update for to analyze lies in access to diverse self-management educational support Esme services and identify opportunities to enhance and expand access we're also going to be talking about the unique role that community health workers can play to deliver culturally sensitive dsmes Services as part of team-based care models in both clinical and community-based settings and lastly we want we would like to explore tools and resources to support capacity building of organizations and individuals providers in implementing best practices for effectively engaging community health workers to reduce diabetes-related Health disparities it is my pleasure to introduce today presenter Paulina duker is a 32 years veteran Healthcare professional her background is in nursing with broad practice experiences that includes Critical Care clinical program development outcome management home care and Hospital performance Improvement she is gradually trained in public health with an mph from John Hopkins Bloomberg School of Public Health her clinical specialty and subject matter expertise is in Diabetes Care and education she have co-authored publication on standard of cares in diabetes including the National Standard for diabetes of management education and support Paulina has worked in church internationally as part of a global diabetes team developing diabetes content to support people with diabetes in such areas as the Middle East India and China she currently serves as the vice president of practice and learning at the association of Diabetes Care education and a specialists she's passionate about self-management education as a scalable intervention from chronic disease and the potential it has to bring in the Health Equity Gap Paulina enjoys traveling and spending time with her family she considered her best work to be raising her two daughters and I have the honor to consider her my true friend Paulina thank you thank you Betsy for that very kind introduction it is my honor to be here today to join the CDC to kick off uh diabetes Awareness Month uh I am very honored also to share some thoughts on diabetes self-management education and support and how to scale this intervention through leveraging community health workers before we get started I'm going to invite you to work with me on answering this question if you are a community health worker Community Healthcare work and you're online with us today or if you work with community health workers I want you to go to mentee.
com and put in the in that platform what the title of your community health workers are so the different roles and different titles that are assigned to the Community Health worker category of workers but I can see the responses popping up now and as we can see there are Myriad of titles that we use for this category of workers and part of the Diabetes Care team thank you the purpose of that exercise was really to point out that there are multiple titles that we use in our various work practice settings to categorize this group of workers at the association for Diabetes Care and education Specialists we undertook this exercise of looking at all of these different titles that exist out there on this group of workers and what we came to the conclusion we came to was a adopting a title diabetes Community Care coordinators because we think that these are the group of workers that actually Connect Health Care Systems with the communities in which people with diabetes live and play and work and pray there are a variety of names that we use for this group of workers and we we have acknowledged that and part of that acknowledgment was really to create competencies to Define clearly the work that this group of people do and also to create the competencies and the resources to support them so having done that let's look at why this group of workers are so important the slide that you're looking at right now shows the rapid acceleration of diabetes uh medications the development of new diabetes medications from 1920 to 1950 and probably 60s into the 60s there were four classes of diabetes medications those insulin so final ureas metformin metformin actually came on the market and went off the market so there were few drug classes and then came the 70s and right in the 80s when we have seen an explosion of diabetes medications you can see we are up to 12 13 classes of medications now and as we have learned more about the way diabetes manifests in people with diabetes so all of the systems that are impacted by diabetes have led to all of these developments these are medications but we also have devices we have other technological devices and we have seen again rapid advances in all of these to support people with diabetes despite all of these advances what we know is that people with diabetes are not doing better hemoglobin A1c which is the classic clinical measure to to really see how people with diabetes are doing how well they're doing those measures are not improving over time in fact they're slightly going down so people with diabetes are not doing better despite all of those advances in Technologies and medications that we have seen and why is that so one of the reasons we know is that there's a disproportionate Workforce diabetes Workforce we have 8 500 endocrinologists that's one for every 4 300 people with diabetes 11. 3 percent of the U. S population have diabetes and so that's what that one in four thousand proportion comes from if we look at certified diabetes skin education Specialists there are 20 000 of them not quite but almost twenty thousand certified diabetes skin education Specialists that works out to be about one that certified diabetes skin education specialist for about 1800 people with diabetes of course we have primary care physicians where most people with diabetes are receiving care we have none Specialists nurses dietitians and pharmacists who also participate in the care of people with diabetes we have community health workers or diabetes care diabetes Community Care coordinators peer supporters who all participate but just for comparison we have about 7.
2 percent of the U. S population that have heart disease and we have about 33 000 cardiologists we have about 5. 2 percent of the population with cancer and for that we have about 22 000 oncologists that is not to say that we want to shift resources anywhere there are not enough Physicians period but if you look at the proportions you can see that that of endocrinologists to a number of people with diabetes is acutely um limiting what else do we know we also know that we have a benefit Medicare pays for diabetes scan education diabetes self-management education and support as a service but only very few people are accessing this service 1997 is when the balanced budget act allowed for payments of diabetes self-management education and support services but not much has changed since 1997.
five percent of people with on Medicare are accessing this benefit and for people with Commercial Insurance the numbers aren't any better percentage is only slightly better than the Medicare population 6. 8 percent that tells us something the design of this service is not serving people with diabetes what else do we know the people who are at increased risk for experiencing poorer Health outcomes these are the same people who have been persistently underserved the outcomes they have poor health outcomes because of the inadequate service they receive and who are these people you can see here who has diabetes if you break it down by ethnicity people of black non-hispanic ethnic background have a higher rate of diabetes than the rest as you can see not only do they have the highest rates of diagnosed diabetes they also have higher rates of undiagnosed diabetes compared to White non-hispanic there's it's almost double the number of the percentage of undiagnosed uh black non-hispanic people with diabetes that just predisposes them to higher risk and poorer outcomes and here's why community health workers come into the picture what we know is that diabetes self-management education works it took us a while to get to that but we now know that when people receive diabetes self-management education and support they do better that a1cs improve and it's those who receive it whether they do it in group settings or in one-on-one settings it's the support that helps them the dose it is dose related the more education and support they receive the better their outcomes seem to be and how can community health workers help us here community health workers often share the same characteristics that as these communities that we've talked about those who are at higher risk of experiencing poor diabetes outcomes community health workers are those who they serve these same communities that by delivering culturally appropriate care through their lived experiences these community health workers tend to be part of these communities their lived experiences the languages they share the religion where they pray the foods they eat all of these characteristics help them be ideal supporters for these people who are at highest risk for diabetes in supporting them let's talk about the burden of diabetes treatment so what you see in pink this looks like a very busy slide but I'm going to summarize it for you what this means to the person with diabetes in pink what you're looking at is the burden that chronic disease puts on the person with the chronic disease so people with diabetes are forced to perform tasks medical tasks if you will inject insulin monitor their blood glucose put insulin pumps on themselves families are affected by the same but these tasks and the Health Care Systems they have to operate in they have to schedule appointments to see their doctors they have to get referrals to see diabetes self-management to access diabetes self-management education services all of these tasks increase the burden of diabetes treatment what you see in blue is the structures surrounding people with diabetes like I said they may have to travel to a health system they have to work and they have to balance between work and attending Healthcare appointments structures such as uh insurance they may have insurance that allows them to have some medication and not others or buy one blood glucose meter and not the other all of these impose additional burdens on the person with diabetes similar to other chronic diseases and then in green what you see are the social impacts this is why they experience not so great outcomes these things get in the way of work and Life Family Life and social life they may not be able to attend all the functions they want to they may not be able to eat healthily as we or helpfully as we expect them to so if you put all of these things together the simple messages people with diabetes need support this this uh taxonomy of the burden of treatment was research done in multiple countries about 30 countries and all of these things showed up the same across the world that chronic disease management puts burdens on the people who have chronic diseases and the simple answer is that they need support people with diabetes are on their own most of the time for the more than 8 700 hours in the year they spend most of this time on their own in the U. S where we have fairly Good Health Care Systems folks with diabetes may be able to spend 15 hours that's about an average of an hour a month with a healthcare professional that's not enough but more importantly they have to do this work on their own which is why we have to provide this service this self-management education and support to equip them to be able to better do this there's spending less than one percent of their time with Healthcare professionals and the goal is to really build their skills up and give them the support they need so they can break through the structures and get to the services they need even more important maybe take the services to them The Chronic care model instructs us of this people do better when there's a linkage between the communities they live in and the Health System state rely on for care what we as Healthcare professionals have to do is to design care delivery so that it meets people's needs right where they are and give them what they need we can rely on community health workers to help us achieve this goal of Bridging the community and the Healthcare System sometimes we they come to us where we are in the Healthcare System but they have to go back to their communities what if we could design the delivery of the care so that we actually take it to them so they don't have to miss work so they don't have to take buses to get to us and taxis and and and just basically give up life so they can take care of their diabetes patient-centeredness is key to this meeting them where they are understanding exactly what it is they need and building in them the informed patient that they need to be to be able to interact with Healthcare systems for the best outcomes possible for them again Community Healthcare care workers can help do all of that bring the services into the communities they share the some of the characteristics with these community members the language the food and evidence also shows that community health workers help improve diabetes outcomes again this study was a global study and what some of the things that improve some of the factors that get better when people with diabetes interact with community health workers is their symptom management their food intake they improve on what they eat blood glucose levels get better blood pressures get better their bmis get better and this is evidence across the world so what are the four critical times at diagnosis we have plenty of opportunities to serve people with diabetes to bring services to them and to support them with what they need there's a lot of information to be consumed at that time and it is ideal to deploy community health workers to support people with diabetes at this very critical time annually so if the people with diabetes are doing fine at least every year we should be checking in on them or if they're not doing so well when we see that their treatment targets are not being met that is a good time to also intervene and support them if needed when complicating factors of care when they start seeing kidney complications so eye complications and and some of the other complications that's also a good time to intervene and support them and then when transitions in life occurs when they change Insurance when they are admitted to a hospital when they're discharged back home from the hospital for younger people when they attend college these pivotal times can be very optimal for working with community health workers and others in the healthcare profession to support people with diabetes we talked about being newly diagnosed and the amount of information that people need at this time and why it is an optimal opportunity to support them so at the start of the new new diagnosis what happens is there's a lot of information we try when we are interacting with them to give them as much as possible but people with diabetes have to go into their communities have to go back into their homes and interact with their families too incorporate the information they get into their lives that is the time when we need to follow up with them to ensure that the information they get becomes useful they get to put it in practice they get to have more questions that we can then answer for them and help them address annually so why annually well for one thing diabetes information changes rapidly a lot is changing and new diagnosis I'm sorry new medications new devices are all coming to market and sometimes people with diabetes simply need new information and more information to help them self-manage remember the goal is to make them independent self-managers of their diabetes and so checking in with them annually is ideal of course there are times when we need to do it more frequently than annually that means they're not we're seeing that their targets are not being met and we need to check in with them there may be changes in their medications and nutrition there may be changes in the lifestyle they may change jobs in which case what they did before doesn't work anymore we have to help them find resources in the community that can support these changes and again diabetes community health workers can be the ideal support system during these times when complicating factors occur people with diabetes do everything they can but we know from the burden of treatment that sometimes they're not able to keep up with the work that they have to do to self-manage and complications do happen there are physical limitations as people age their emotional stressors there's just the diabetes as a stressor itself diabetes distress situations like pregnancies changes like that need extra support to help people transition smoothly and do the best they can to live with their diabetes and again what an ideal opportunity to deploy community health workers to support people with diabetes and then finally transitions in kale we talked about situations like changing the living situations maybe they really move out of a family situation to now live by themselves that may require arranging for more support um co-workers may be stepping in to help managing hypoglycemia or hypoglycemic events discharging a patient from hospital to home a lot of times when patients are in hospital the treatment changes and so we need to send them home on sometimes possibly something different than what they came to the hospital with great opportunity to help have community health workers follow up with them through phone calls through apps through going physically into the community to places close to them that are more easy or easier for them to access care there's a new clinical team and they have to learn the the how to work with these new teams changes in medication intensifying insulin regimens these are all times transitions that may require extra support insurance coverage changes for those of us who know this it can throw you off the insurance your previous Insurance May cover your medication and your blood glucose and your testing strips and then come January you have no insurance which you have no control over as a person living with diabetes and you find that you're thrown into changes that may truly impact your diabetes care community health workers can help navigate the systems figure out the best way to close the gap quickly so the care doesn't deteriorate too far age related changes and self-management limitations all of these changes can require additional support and again community health workers app in ideal positions to help us do that we have to build these expectations when we're working with patients we have to make them confident that and understand that the support is there we currently we have systems that require referrals and different scheduling appointments and patients traveling to places that sometimes are difficult to access how about if we design the system so we can take the care to them how about adding in the support that they need maybe follow-up phone calls maybe partnering with social systems in their communities churches grocery stores pharmacies fitness centers how about just knowing those resources that are available in their community so when they need support we're ready to help them with those lists of resources and more important than anything is to create a system where community health care workers can document this care this is what helped folks other Healthcare Professionals in the on the team on The Diabetes Care team need access to to know where these services are to know what community health workers are helping people with diabetes Implement and access in their own communities so they can actually bridge the gap this is how we improve care over all for people with diabetes documenting that care so people all of the team the entire Diabetes Care team can have access to information and the strategies that are being implemented by community health workers is key to elevating care for people with diabetes ultimately we want to improve outcomes prevent or delay complications and preserve tomorrow and this is how we do it by building it into our systems and Care delivery but aade7 self-care behaviors these are the seven self-care behaviors that we know if you work with people with diabetes on when you focus on these areas they tend to do better problem solving helping them figure out if I have a low blood sugar what do I do if I run out of medication what do I do what is my backup plan that's problem solving reducing risks helping them access care to prevent complications can they see an ophthalmologist and where does that Ophthalmology Services sit in the system that can help them access it as easily as possible um Dental Care other things to help the monitor so they can delay or prevent the complications of diabetes monitoring is key you're monitoring they're monitoring their blood glucose levels so people with diabetes and other cardio metabolic conditions they're monitoring their blood pressure they're monitoring their blood fat levels different things that they have to monitor to know that they're doing well with their diabetes how to communicate that back to their caregivers their Health Care Professionals community health workers can use these seven self self-care behaviors and even the self-monitoring guidelines and and numbers that people are working on uh communicating with people with diabetes based on what they're monitoring can help guide where care needs to proceed to healthy coping healthy eating being active helping them find resources in the community where they can do all of this taking medications if checking in with people with diabetes making sure that they are taking their medications as prescribed and if not why not communicating that back to prescribers and letting them know maybe they're not taking their medications and possibly why so that we don't wait too long until we until the Health Care System actually discovers that people with diabetes are falling off and and developing poor outcomes so in summary there are opportunities for for us to interact with people with diabetes we have to position diabetes self-management and education services as a key way to help people with diabetes improve outcomes and integrating community health care workers to help us do this to access the education to improve clinical management and ultimately to preserve tomorrow for people with diabetes community health workers can help activate the patient meaning give them information they need to better interact with the broader Health Care System they can connect patients with the Community Resources they can help people with diabetes navigate the health systems so how to access additional care if needed to get a head start on what may be complications developing or outcomes going sour so they can access care as soon as possible to reverse these trends they can be key to improving systems quality so a lot of our Healthcare Systems we are constantly looking for best ways to improve outcomes and connecting services to the community Through community healthcare workers help us learn what it is in the community that we need to know to really do a better job of improving quality for people with diabetes and at the association we have lots of resources we have competency list more important than more important than knowing that we can deploy community health workers is to really working with them we have resources on training uh we so that you can build resources to support community health workers to actually deliver on this big dream that we have you can reach me at the association at that email you see on the slide or at our website we have plenty of resources that you can access and we are always ready to partner with you to help you help the people with diabetes that you take care of thank you questions thank you falina we will now begin our q a session please type your questions in the Q a box and we will do our best to answer all of them in fact Paulina I have here very interesting question and I would like to start with the first one allow me here I have been copy and pasting these questions there's an interesting one that says here we need a short version of bsmes people don't like to stick for 12 months long education package that I could not agree with you more you do not have to stick with 12 months that's what person-centered care is all about that's what connecting uh people with diabetes with a community health care worker for example is all about when you're with that patient that's what what you're assessing is what is most critical for that patient it doesn't have to be a curriculum it doesn't have to be a list of topics it is only what that patient in that moment needs and and they will tell you you can ask them those are the competencies that we help all people all Healthcare professionals develop asking the right questions so you can get to What that particular patient in front of you needs and address that particular need no we do not need 12 hours or 10 hours we only have to address what each individual patient needs at the time in the moment that's how they get to build confidence improve them their self-care and then they begin to build on it and get confident they can in fact do more to self-manage however there is a dichotomy here Paulina because for reimbursement purposes for example in Medicare have to be 10 classes of 10 hours or I don't even recall anymore that I know the 10 is somewhere somehow in the story but yes it should be patient-centered and and as diabetes Educators we have the aav7 behaviors that should guide that conversation so services are provider taking the patient at the center so in other words patient-centered individualized approach that's the way it should go because at the end what we're looking here is to join the people where they are in their Journey while living with diabetes right can you expand on that please yes I can expand on that so yes Medicare we have to live with the reimbursement systems that we have so I I would agree with you Medicare pays for 10 hours of diabetes self-management education and support services annually when you're newly diagnosed that is the amount that you're entitled to because that is the prescribed reimbursement amount we take that 10 hours and we use it for the patient in front of us what we know is that if the patient is not ready so there are seven self-care behaviors we focus on that ideally you will talk to the patient and find out how they're doing in all those areas but ultimately what you end up finding is that the patient may need more help in one area than the other and that's what you focus on um because Medicare pays for 10 hours we're going to use those 10 hours to meet the direct need of that patient in that time and that means we may not get to talking to them about complications we may need to we talk about survival skills they need to learn how to monitor their blood glucose they need to have basics of how to eat properly to prevent glucose excursions we focus on those things that will help them Thrive first if we use all of those 10 hours and we haven't gotten to the rest that's what that patient needs it is more important to build confidence in the patients help them gain skill that they can use in an area and then you have the opportunity to build on it Medicare comes back and gives another two hours a year so over the course of time people with diabetes will get to learn all of the areas that will help them but it's important for us to focus on their needs in the moment if we're going to build the confidence that they need to self-manage and to build skill over time we cannot overwhelm them with everything if we try to deliver all of those areas they end up with nothing because they don't in fact become skillful in any area the better way is to assess figure out what they need provide that service help them build the skill and then build on it as additional time becomes available that we can use thank you thank you I have a comment here that I would like to read because I think that really touches my heart this person said I just wanted to say thank you for using people with diabetes instead of diabetics I am a community health worker and a person with diabetes I struggle with feeling guilt and having diabetic thinking I did something to myself as diabetic insinuates we don't refer to people with cancer as concentrix I really appreciate your efforts in this area it's a good lesson for all chws as well as to keep in mind can you expand on that comment we have a language a language model practice doctor right yes we do have the language document that we it is part of the skills we all have to build over time I don't even know if I can say that word anymore because it's always people with diabetes for me now we understand that and these are the skills that we strive to equip people with why is it important because that's what's important to the people with diabetes we can relate to them and they can relate to us if we have a common language that is respectful and supportive of them managing their chronic diseases thank you here is another question it says how beneficial are here health fair screening in recognizing early sign of pre-diabetic stage to initiate preventing plants our health fair screen of Rush you know there are different schools of thought on Healthcare screenings what I will say is this if you were going to perform Healthcare screenings in any settings because sometimes that's all that people have access to then you should have a backup plan on what you're going to do if you in fact discover that they have hyperglycemia and you have to refer them if you screen and you don't have the supporting services to send them to that screening is really not helpful in fact it may cause anxiety and restlessness in a person who Now does not know where to go to access the services they need screening should always be paired with follow-up services that is one thing to know otherwise it doesn't help to really screen we screen to help people to from early diagnosis so we can pick people up before it's too late but if you pick early diagnosis if you pick an early sign of diabetes or pre-diabetes and you don't have the service to refer them to to say here's how we can follow up with you this is the support available to you here's where you can go learn more information or get that support that you're going to need then it is not helpful to do the screening here's another question here that says how are some patients put on pills right away and others on insulin should they change their diet and exercise first before getting an insulin yes great question so we know from the pathophysiology and how diabetes manifests that everyone shows up at the time of diagnosis differently so they show up and their blood sugars are so high so high that the pill is not going to take effect in time to really help them they are already at risk they may have type 2 diabetes but you don't know that what you do know is that their blood sugars are way too high and so some clinicians physicians primary care practitioners will start insulin because you need to decrease that glucose toxicity because at every moment that glucoses are high there are systems in the body that are compromised there are eyes there are kidneys there are other things that are getting affected so what determines the treatment is what how the patient presents at the time of diagnosis how high their blood sugars are the other important things like have they lost weight things like that will indicate where you start from but the ideal situation is to be with the Healthcare System to have them monitored over time so we can make changes in treatments as needed over time thank you Paulina this is another very interesting question right away here it says diabetes is the number one blinding IDC among working age adults up to 26 percent of people with diabetes have some level of vision impairment so why it is so hard to find accessible materials and why do so many programs not include information for people with diabetes with vision loss self-management skill have to be adopted for vision loss this is a serious Gap in care and education I can only agree that there's a gap in care I think you know there are so many challenges with managing people with diabetes but I will agree that there's a limitation there we we don't have enough um support systems for people with vision challenges there are some um but they're not enough and thank you for bringing that up because we all have to do better um for people with diabetes who have Vision challenges well I I have I have news to share about this Paulina you might not even know this but I have been working um to develop a dsmes toolkit for people with low literacy issues and non-english speaking populations uh that is about to be clear and now we're moving into working areas for Low Vision people and Rural communities so for the person who raised these questions stay tuned because that it says in the movie coming soon coming soon we need them we need all the resources we can use to support people with diabetes there is another question here are there any tips to engage with community health workers when the smes services are delivered virtually are there any any it says are there any tips to engage with community health workers when the SNES services are delivered virtually ah okay so tips when dsmas is delivered virtually by e so I think that in terms of virtual dsmas delivery it is really seeing as much as possible you want to see as much as you can see first you want to ask the right questions so in the virtual setting you may miss some physical things that you can see when you're in person and so the the idea is to ask the right questions um what is it that is is really difficult for you what what one thing about your diabetes is getting in your way right now ask specific questions about what is happening now because you may miss something in the virtual environment that you will see if you were in person um affect the way they look depression and things like that may be difficult to pick up in the virtual environment so ask questions and spend time listening to what they're telling you indeed there there are also um another resource that we're working um and this one is for community health workers on diabetes prevention it's called a virtual toolkit it has been in the in the environment for quite a long time and now has been updated and in that particular one in this new version that is going to be launch we are going to be including tips on how to virtually engage communities for for prevention but I would like to say that the tips that we are included in that resource will also be very helpful to engage community health workers while providing virtual services and so I think you may want to consider exploring also engaging community health workers in those um what I'm calling virtual trainings for a lack of a better word on how to describe it because yet one of the legacies that we have Paulina from the pandemic is that beautiful mean has become kind of the way to to go so we have been learning as we do and I think that there are a lot of opportunities to engage community health workers in the virtual space so there's the one thing I would say about those virtual environments is the ability for the person with diabetes to access care immediately so in the moment if they have a question and they know that they have a community health worker that they can reach out to it is excellent to have that yeah I will agree there is another question here it says what are the salaries so low for all the viewers that community health workers have to provide I wish I had a good answer for this um all I can say is if if I had my brothers it would be very different and we continue to advocate for these services in tandem with diabetes self-management at all diabetes self-management education services I wait for the day when this question will not come up ever again well I have news too there is a group that is working on sustainability and financing mechanisms for community health workers I cannot say more but there are a group of people who have trust interested in working in this area so stay tuned unfortunately Molina we don't have time for any more questions I try to answer some of them in the Q a section um um so now let's go now that we are wrapping off we have one more question for you please we will go back to mentee.
