More than 80 diabetes educators have been trained to provide virtual diabetes self-management training through the Virtual Medical Center (VMC) created by the Department of Veterans Affairs. The avatars of the staff responsible for training these educators are shown within the simulated environment of the VMC. (Photo courtesy U.S. Department of Veteran Affairs)
CLEVELAND — When Mary Julius was diagnosed with Type 1 diabetes in 1974, the world was a very different place. There were only approximately 4.5 million Americans who had been diagnosed with diabetes. That’s compared to the 26 million diagnosed today. The research was not as robust, medications were less effective, and the monitoring was a long way from swiping your phone across a monitoring device.
“I had the choice between Bunsen burner with tablets or these great, novel urine test strips,” Julius said.
She went with the strips. But her diabetes still limited her career possibilities.
“I had thought about nursing,” she said. “But my father told me, ‘Mary, you can never enlist. And being a nurse you can’t work night shifts and swing shifts and weekends—not when you’re on insulin.’”
So, inspired by her disease, she became a dietician, getting a dual degree in nutrition and chemistry. In 2001, she began working as a research dietician at the Cleveland VAMC. There she took part in several landmark studies into Type 2 diabetes, including the ACCORD study, which examined glycemic control and lipid control and how they impact health outcomes.
In 2013, Julius took a position as the VA Northeast Ohio Healthcare System’s diabetes self-management education coordinator. In that role, she ensures that the system meets the quality standards required to be recognized as a credentialed diabetes self-management program. Those include having a full curriculum, having a qualified instructional team, monitoring clinical outcomes and monitoring behavioral outcomes.
Because much of diabetes management has to do with a patient’s day-to-day living, educating them about healthy choices and creating a sustainable, diabetes-friendly lifestyle is key.
While VA/DoD guidelines strongly recommend that all individuals diagnosed with diabetes be offered self-management education, only 4% of veterans have access to that kind of training. Which is why in 2019, VA and DoD received a Joint Incentive Fund award that tasked the departments with creating a diabetes self-management education and support program that would be recognized for the entire United States and available to all 1.6 million veterans living with diabetes.
The eventual result of that collaboration was the VA Virtual Medical Center (VMC)—the first avatar-to-avatar national diabetes self-management education and support (DMES) program recognized by the American Diabetes Association.
In the VMC, patients can interact, find information, take classes and interact with healthcare providers and each other. Much like at the Ohio VA, Julius is tasked with monitoring the program and ensuring that it meets the mark for recognition as a legitimate DMES program.
Currently, three VA facilities (Cleveland, Phoenix and Indianapolis) have adopted the virtual training and are offering it to their patients, and DoD is offering it to newly-diagnosed servicemembers. And nine VA facilities are in the process of adopting the program, plus six locations on the DoD side.
“Ninety-percent of care for an individual with diabetes is self-care,” Julius explained. “The class series really helps them to achieve that knowledge: understanding diabetes; the nuts and bolts of the disease; why is high blood sugar bad; why is low blood sugar bad. There are also tremendous questions about monitoring A1C and kidney function. They want to learn healthy coping. What kind of skills do I need to cope with this twist or turn in my life?”
Caregivers and family members are encouraged to take part.
“One woman—she had significant social anxiety—and she and her daughter attended an entire series of classes together,” Julius explained. “She felt very very comfortable interacting as an avatar. … They spent a lot of time looking at recipes and watching the healthy teaching kitchen YouTube, and then using those recipes at home.”
However, while patients have enjoyed that virtual world, it’s unlikely that it will replace in-person interactions.
“We’ve done some qualitative research and asked veterans, as well as staff members. In that particular environment, one of the things I thought we would find in interviewing patients would be that they preferred that self-learning, that independent learning,” Julius said. “It was just the opposite. They actually wanted more time with the staff. They wanted the staff to be more accessible and more available.”
Equally surprising is, how easily older veterans have taken to the virtual nature of the program.
“People in that 60-plus or minus age group really enjoy being an avatar and having that avatar-to-avatar interaction,” Julius said. “They like the fact that there’s no travel. It’s also an efficient use of their time. They can come to a class and meet with peers before or after. Patients found the VMC very motivating, and they enjoyed immersing themselves in that virtual environment.”
