Recommend a Resource
ePace: Sustainable Diabetes Self-Management Education, September 11, 2012
ePace is an online training
produced by the Diabetes Training and Technical Assistance Center (DTTAC) at
Emory University with support from the Division of Diabetes Translation at
CDC. Materials and video of presentations from the September 2012
training can be found on the ePace website.
The following materials are available on the ePace website.
- Training pre-work, which outlines many basics of DSME from the definition to outlining the National Standards (pre-work is also provided below)
- Two speaker presentations
- Introduction to DSME and Barriers
to Access, Speaker: Amparo
Gonzales, MPH, RN, CDE, FAADE
- 9 Multi-faceted strategies to
Improve DSMT Program, Speaker:
Mary Ann Hodorowicz, RD, LDN, MBA, CDE
- Speaker Question and Answer
- All session handouts and slides
ePace: Expanding Access and Promoting Reimbursement Pre-Work
self-management education and training (DSME/T) is a collaborative process through which
people with diabetes gain the knowledge and skills needed to modify their
behavior and successfully self-manage the disease and its related
- This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.
outcomes of DSME/T
The overall objectives of DSME are to
support the following in order
to improve clinical outcomes, health status, and quality of life:
and active collaboration with the health care team
positive self-care behaviors directed at successful diabetes self-management
was formally adopted as a desired outcome of DSME/T in 2002.
Seven specific self-care behaviors developed
by the American Association of Diabetes Educators, known collectively as the
AADE7™, have been defined to guide the process of DSME/T and help patients
achieve behavior change.
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- Being active
- Taking medication
- Problem solving
- Healthy coping
- Reducing risks
Standards for Diabetes Education and Support
Standards for Diabetes Education and Support were
designed to define quality diabetes self-management. The Standards are reviewed
and revised approximately every 5 years by key organizations and federal
agencies within the diabetes education community. Organizations seeking Medicare reimbursement for DSME/T must meet the
guiding principles inform
the regular review and revision of the National DSME/T Standard
Five guiding principles
is effective for improving clinical outcomes and quality of life, at least in
evolved from primarily didactic presentations to more theoretically based
one "best” education program or approach; however, programs incorporating
behavioral and psychosocial strategies demonstrate improved outcomes. Studies
show that culturally and age-appropriate programs improve outcomes and that
group education is effective.
is critical to sustain progress made by participants during the DSME program.
is an effective strategy to support self-management behaviors.
The 10 Standards of DSME/T
The 10 Standards can be found in the article, National Standards for Diabetes Self-Management Education and Support.
Practice Guidelines Overview
Practice Guidelines support the delivery of DSME/T within the framework of the
AADE7 Self-Care Behaviors and The National Standards for Diabetes
Self-Management Education and Support.
- The AADE Guidelines for the Practice of Diabetes Self-Management Education and Training (DSME/T) describe the implementation of The Scope of Practice, Standards of Practice and Standards of Professional Performance for Diabetes Educators.
competencies for diabetes educators are clustered into five main domains.
- A companion to the Guidelines for the Practice of Diabetes Education are the Competencies for Diabetes Educators. The five domain competencies are specific skills needed across the continuum of care for the various levels of practice, from novice to clinical expert.
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Domain I: Pathophysiology, Epidemiology, and Clinical Guidelines of Diabetes
Domain II: Culturally Competent Supportive Care Across the Lifespan
Domain III: Teaching and Learning Skills
Domain IV: Self-Management Education
Domain V: Program and Business Management
Recognition and Accreditation
1997, the federal Balanced Budget Act passed, permitting the U.S. Health Care
Finance Administration (HCFA)— now called the Centers for Medicare and Medicaid
Services (CMS)— to provide expanded coverage for DSME/T.
organizations were originally authorized by CMS to determine whether diabetes
education programs meet required standards.
These 3 organizations were deemed "certifying bodies” and include the
American Diabetes Association (ADA) which was authorized in 2001, the Indian
Health Service (IHS) authorized in 2002, and the American Association of
Diabetes Educators (AADE) authorized in 2009.
(The IHS discontinued this work in 2010; more information on this
transition is on the IHS website.)
Each certifying body has a formal application
process and requires supporting documentation. Both AADE and ADA require a fee
with applications. The certifying bodies also require annual reports and
renewals and have a process for auditing existing programs to ensure continued
compliance with certification criteria.
Both organizations have volunteer auditors who are trained reviewers and
conduct random program audits. Both also
offer multi-site recognition/accreditation.
Each certifying body uses a yes-or-no checklist for standards being met
or not met. Although their terminology differs, the programs’ content and
concepts are all based on the National Standards for Diabetes Self-Management Education and Support.
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Reimbursement for DSME/T
of the Balanced Budget Act of 1997 expanded Medicare coverage of diabetes
outpatient self-management training services when these services are furnished
by a certified provider who meets quality standards. Previously, Medicare reimbursement was
provided only if the educational services were administered in an outpatient
Diabetes outpatient self-management services may be covered by Medicare
only if the physician or qualified non-physician practitioner (the "certified
provider”) who is managing the beneficiary’s diabetic condition certifies that
such services are needed by sending an original referral form to the diabetes
order must be part of a comprehensive plan of care and describe the training
that the provider is ordering and/or any special concerns such as the need for
general training, or insulin-dependence.
self-management training is classified as initial or follow-up training.
a beneficiary has not yet received initial training, they are eligible to
receive 10 hours of initial training within a continuous 12-month period. The
12-month period does not need to be on a calendar-year basis.
- The 10
hours of initial training may be provided in any combination of half-hour
increments within the 12-month period and less than 10 hours of initial
training may be used in the 12-month period if, for example, the beneficiary
does not attend all of the sessions or the physician does not order the full
hours of the initial training must be
provided in a group setting consisting of 2 to 20 individuals who need not all
be Medicare beneficiaries unless the provider certifies that a special
condition exists that makes it impossible for the beneficiary to attend a group
all beneficiaries, one hour of initial training may be provided on an
individual basis for the purpose of conducting an individual assessment and
providing specialized training.
covers 2 hours of follow-up training each year starting with the calendar year
following the year in which the beneficiary completes the initial training. The
2-hours of training may be given in any combination of half-hour increments
within each calendar year on either an individual or group basis.
Part B covers 10 hours of initial training for a beneficiary who has been
diagnosed with diabetes.
is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed
using the following criteria:
fasting blood sugar greater than or equal to 126 mg/dL on
two different occasions;
- A 2
hour post-glucose challenge greater than or equal to 200 mg/dL on 2
different occasions; or
- A random glucose test over 200 mg/dL for a person with symptoms of
that the beneficiary is diabetic is maintained in the beneficiary’s medical
Eligible to Bill for DSME/T
All certified providers that bill Medicare for other individual items or
services on a fee for service basis and that meet quality standards can receive
reimbursement for diabetes training.
The outpatient DSME/T program must be
accredited as meeting approved quality standards. CMS accepts recognition by
the ADA or accreditation by the AADE as meeting the National Standards for
Diabetes Self-Management Training Programs.
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Associated with Medicare-Reimbursed DSME/T
2005, a study was conducted to explore barriers practitioners face in providing
diabetes education services to Medicare beneficiaries, with a special focus on
barriers practitioners in rural areas may face. Two methods were used to
explore this issue.
program coordinators (DCPCs) in each of the 50 states and the District of
Columbia were surveyed to understand problems with obtaining ADA recognition
for Medicare reimbursement, differences in obtaining ADA recognition by rural
and urban facilities, and facility-level barriers to providing diabetes
education to Medicare patients. Second, information about perceived barriers to
providing diabetes education in all areas and in rural areas was collected
through a survey of ADA-recognized diabetes education facilities.
indicated that most DCPCs believed it was more difficult for rural providers to
obtain ADA recognition than for urban providers; the largest barriers were
costs and reporting requirements. The top barriers for rural providers
mentioned by DCPCs were the shortage of designated specialists, fewer
resources, and high application fees for ADA recognition.
identified by ADA-recognized programs included staffing/institutional support,
amount of Medicare reimbursement, lack of hours covered, and transportation.
Respondents from ADA-recognized programs providing care in urban areas were
more likely to perceive barriers to providing diabetes education in rural areas
than were rural providers.
general, the ADA application process was perceived as expensive and laborious.
Most respondents perceived Medicare reimbursement for DSME/T as inadequate.
information is available from reference #4 (below).
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for Medicaid Reimbursement for DSME/T
has been documented that people with diabetes who are members of racial/ethnic
minority populations, enrolled in public insurance programs such as Medicaid,
or living in low-income communities are more likely to experience multiple
hospitalizations and have higher hospital costs than their counterparts.
example, the number of multiple hospitalizations is 80 percent higher for
pediatric patients and 55 percent higher for nonelderly adults enrolled in
Medicaid than for their privately insured counterparts. Yet, many state
Medicaid programs do not include DSME/T as a covered service for their
beneficiaries. For this reason, several
state DPCPs are working with state diabetes coalitions and other partner
organizations to demonstrate the need for Medicaid reimbursement for DSME/T.
Guidelines for the Practice of Diabetes Self-Management Education and Training
(DSME/T). American Association of Diabetes Educators, Chicago, Illinois.
Revised November 2010.
- Haas et al. National Standards for Diabetes Self-Management Education and Support. Diabetes
Care. 2012 Nov;35 (11):2393-401.
- Mensing C.
Comparing the processes: accreditation and recognition. Diabetes Educ. 2010
Mar-Apr;36(2):219-43. See also Overview Comparison of National Accreditation.
MP, Glover SH, Probst JC, Laditka SB.
Barriers associated with the delivery of Medicare-reimbursed diabetes
self-management education. Diabetes Educ. 2005 Nov-Dec;31(6):890-9.
Department of Health and Human Services. Expanded coverage for diabetes
outpatient self-management (final rule). Program memorandum B-01-40. 2001.
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Many curricula exist for diabetes
self-management education. To be effective, the curriculum must meet the National
Standards for Diabetes Self-Management Education and Support. Many curriculum are
available online; some are available for no cost. Curricula have been developed for specific
audiences. Below is not a comprehensive
list, but rather a sample of types of curriculum that are available.
Lay health worker – led training
Empowerment Education Program (DEEP), developed by the University of Illinois
Diabetes Self-Management Program, produced by the Stanford Patient Research Education Center
Programa de Manejo Personal de la
Diabetes, produced by the Stanford Patient Research Education Center
Professional – led training
Education Curriculum: Guiding Patients, published by the American Association of Diabetes Educators
Life with Diabetes, 4th Edition, published by the American Diabetes Association
NC Self-Management Education Curriculum, published by the NC Diabetes Prevention and Control Program.
U.S. Diabetes Conversation Map Program, published by Healthy Interactions, Inc.
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DSME, CDSMP, and DSMP
Prepared by the Vermont DPCP, this document uses
a table to outline features and to distinguish similarities and differences among Diabetes Self-Management Education, Chronic Disease Self-Management
Program, and Diabetes Self-Management Program.
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AADE Accredited and ADA Recognized Programs
American Diabetes Association
recognition and American Association of Diabetes Educators accreditation
ensures that a program is comprehensive and meets the National Standards for
DSME. It is also a requirement for Medicare reimbursement.
To find out how these organizations
compare, review the Overview Comparison of National Accreditation.
AADE accredited programs
ADA recognized programs
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To ensure access to DSME/T, health insurance coverage is
necessary. Below is information about health insurance coverage based on
Medicare, Medicaid, and commercial insurance. Even with health insurance
coverage, barriers related to cost still exist such as copayments and
Medicare covers outpatient diabetes
self-management education, if conditions are met. See description of coverage
in the ePace prework.
coverage, Medicare beneficiaries’ use of DSME/T services remains low; only about 1 percent of beneficiaries with diabetes received DSME/T services in 2004-5 per a review by the American Association of Diabetes Educators. The
Administration on Aging is working to expand access to DSME/T. One model uses
Area Agency on Aging as delivery sites for DSMT.
See also ePace prework. The National Council of State Legislatures tracks diabetes coverage and has some information for Medicaid related to
diabetes education. State by state tables outline State Insurance and Medicaid
Requirements and Programs. Per NCLS:
"Medicaid covers the health
care needs for qualified low-income people and those who have few resources.
There are special expanded eligibility terms for pregnant women.
Medicaid is jointly funded by the federal and state governments; covered
populations and benefits vary among states. As a condition for receipt of
federal funding, states must provide certain services, such as in- and
out-patient care, doctor visits and long-term care. While services such
as prescription drugs are optional under federal law all states and territories
have chosen to include them. Other details of benefits such as prescribed
insulin, disposable needles, syringes, monitors and blood glucose strips are
determined by each state's Medicaid policy and are listed by state.”
According to a 2010 survey of state-based Diabetes
Prevention and Control Programs at least seven states had Mandates for DSME/T (Michigan, Minnesota, New
York, South Dakota, Utah, Vermont, and Washington).
Most states (46) have commercial
health insurance mandates in place to cover diabetes self-management
education. View the National Council
of State Legislatures website.
Coverage of Community Health Workers and Peer Leaders for DSME
DSME has show to be effective using
community health workers and trained peer leaders. The Stanford Patient Education
Research Center offers evidence-based programs using peer leaders for people
with chronic diseases and specifically for people with diabetes. The Diabetes Self-Management Program is offered in both English and Spanish (Programa de Manejo Personal de la Diabetes).
Council on Aging offers webinars on business planning and reimbursement for
services. The webinar by Tim McNeil titled, Diabetes Self Management Training:
How it Benefits Seniors and Steps to Reimbursement, focuses on DSMT
reimbursement can be found on the NCOA's sustainability web page.
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EXPANDING THE REACH OF DIABETES SELF-MANAGEMENT EDUCATION—Local health
departments get recognition by national organization to enable reimbursement
Conversation Map Stories—Four states used the Map curriculum to enhance
and expand diabetes-self management education.
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the Case for Diabetes Self-Management: A Handbook for Program Managers (2008). This handbook outlines how to calculate a
return on investment for a DSME program. It addresses the rational for
developing a business case (both financial and nonfinancial) and provides and
excel sheet for calculating return on investment, and have an overview of
Publications from Diabetes Preventions and Control Programs
Invited Commentary by April
Reese in the NC Medical Journal. Ms. Reese discusses approaches to reduce
diabetes costs in NC. Diabetes self-management is a required benefit of
Medicare, Medicaid, and private insurance in NC.
Benefit Cost Analysis.
Diabetes Education Recognition Program, North Carolina Diabetes Prevention and
Control Program. This document outlines how the State derived their final
conclusion that their Diabetes Education Recognition Programs offers a +21
percent return on investment.
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Indian Health Service Division of Diabetes Treatment and
The IHS website has comprehensive information for the
prevention and treatment of diabetes. The sites has best practices, curricula, and
Diabetes Self-Management Education (DSME): Establishing a Community-Based DSME Program for Adults with Type 2 Diabetes to Improve Glycemic Control—An Action Guide (updated 2009). Developed by the Partnership for Prevention in Washington, DC, this is a step-by-step guide for a Program Coordinator who wishes to start a community-based DSME program. Roles for public health are outlined in the guide.
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