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Behavioral Health Integration in U.S. Diabetes Care: How Close Are We to ADA Recommendations?

UMass DCOE behavioral psychologists published in Diabetes Care journal


The UMass Diabetes Center of Excellence is proud to offer behavioral psychologists as a vital part of our adult and pediatric diabetes care teams.  Despite the proven benefits of behavioral health professionals helping people living with diabetes, they are still not widely available.  The paper summarized below was authored by Samantha A. Barry, David M. HarlanNicole L. Johnson and Kristin L. MacGregor, and published in Diabetes Care, April 2018.

American Diabetes Association position statement

The Standards of Medical Care in Diabetes made by the American Diabetes Association (ADA) recommends behavioral health care in diabetes management, and provides evidence-based guidelines.  

The ADA recommends that diabetes practitioners identify and coordinate with qualified behavioral health specialists who are integrated in the diabetes care setting and knowledgeable about diabetes treatment and psychosocial aspects of diabetes. 

Current state of behavioral health care in diabetes

Despite the documented benefit, behavioral health integration is not yet being practiced as standard diabetes care in the United States.  This study administered surveys to clinic leadership at adult diabetes care centers throughout the country.  Respondents identified as clinic directors (35.1%), physician leaders (29.7%), providers (24.3%), nurse managers (5.4%) and administrative staff (5.4%).

Of the 37 institutions represented in the study sample (86.5% teaching hospitals; 70.2% following more than 2,000 individuals with diabetes per year), 100% reported that their practices included endocrinologists and most reported having nurse practitioners (NPs; 91.9%), registered dieticians (RDs; 91.9%), and/or certified diabetes educators (CDEs; 97.3%).  Only 40.5% of the practices reported having integrated a behavioral health professional, with either psychology (18.4%) and/or social work (34.2%).  Practices with a behavioral health presence reported supporting behavioral health at an average of 0.6 FTE (SD = 0.5).   Of the 22 practices reporting no behavioral health presence (absence of psychiatry, psychology and social work in the practice), only 5 of them reported having identified an external behavioral health referral source with a diabetes or chronic illness specialty.

Disappointing results

This is the first study to systematically evaluate the prevalence of behavioral health integration in U.S. diabetes practices.  The vast majority of diabetes care centers include endocrinologists, nurse practitioners, registered dieticians, and certified diabetes educators, with a minimum average of three hired professionals at 2.0 FTE across disciplines.  This is to be expected, given the longstanding recommendations for inclusion of these disciplines.   However, less than half of them employ at least one behavioral health specialist.  Given the discrepancies between ADA recommendations and the integration that appears to exist in U.S. diabetes clinics, opportunities for referrals were also evaluated.  Seventeen practices, almost half of those sampled, do not have behavioral health integrated into their clinic and have not identified an internal or external behavioral health professional with a relevant expertise accessible to their patient population.

The discrepancy between ADA recommendations and the current state of practice is especially notable given that this sample included practices that are ADA or American Association of Diabetes Educators (AADE) recognized (92%) and on the U.S. News and World Report list of top 50 practices in diabetes and endocrinology (43%), suggesting that this group of practices are among the most advanced and distinguished in the field. 

Possible barriers to behavioral health integration

Barriers to integrating behavioral health into diabetes care are not well understood.  The literature suggests a possible shortage of behavioral health providers trained to deliver lifestyle interventions tailored specifically for individuals with diabetes, and that there are several system-level barriers (principally poor reimbursement) that complicate the successful integration of psychology.  These barriers suggest it may prove difficult for diabetes practices to adhere to ADA standard of care recommendations.

Future diabetes behavioral research

Future studies should aim to better understand the specific barriers inherent to behavioral health integration.  This includes the models that exist in the field and clinical outcomes that they achieve.  Also changes that can be made at the clinic, community, legislative, and healthcare system levels, to facilitate change and make the “ideal” level of behavioral health access the norm.

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