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Diabetes Self-Management Education Resource 

This resource list is to assist Diabetes Prevention and Control Programs and their partners in identifying and locating resources relevant to increasing access to sustainable diabetes self-management education and support services. This resource list is not meant to be comprehensive, but rather selective so that viewers can learn efficiently about the most useful resources.



Training
Curriculum Resources
Comparisons among DSME, DSMP, and CDSMP
AADE Accreditation and ADA Recognition
Reimbursement
Success Stories
Publications
Underserved Populations
Provide Feedback on Resource


Recommend a Resource


Training 

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
    1. Introduction to DSME and Barriers to Access, Speaker:  Amparo Gonzales, MPH, RN, CDE, FAADE
    2. 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

Definition of DSME/T
Desired outcomes of DSME/T
National Standards 
DSME/T Recognition and Accreditation

Medicare Reimbursement for DSME/T
Barriers Associated with Medicare-Reimbursed DSME/T
Support for Medicaid Reimbursement for DSME/T
References


Definition of DSME/T

  • Diabetes 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 conditions.
  • This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.

Desired 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:

  • Informed decision-making
  • Self-care behaviors
  • Problem-solving and active collaboration with the health care team

Facilitating 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

Specific self-care behaviors

  • Healthy eating
  • Being active
  • Monitoring
  • Taking medication
  • Problem solving
  • Healthy coping
  • Reducing risks
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National Standards for Diabetes Education and Support

National 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 National Standards.

Five guiding principles inform the regular review and revision of the National DSME/T Standard

Five guiding principles

  1. Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term.
  2. DSME/T has evolved from primarily didactic presentations to more theoretically based empowerment models.
  3. There is no 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.
  4. Ongoing support is critical to sustain progress made by participants during the DSME program.
  5. Behavioral goal-setting 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

  • The 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.

AADE’s 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.

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 

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DSME/T Recognition and Accreditation

In 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.

Three 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.

A 2010 article (reference 3 below) in the Diabetes Educator compares the requirements, processes, and costs associated with the ADA Education Recognition Program (ERP) and the AADE Diabetes Education Accreditation Program (DEAP). See the table Overview Comparison of National Accreditation.

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Medicare Reimbursement for DSME/T

Section 4105 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 hospital setting.

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 education program.

The 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.

Outpatient diabetes self-management training is classified as initial or follow-up training.

  • When 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 training program.
  • Nine 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 training session.
  • For 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.
Medicare also 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.

Beneficiaries Eligible for Coverage

Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes.

Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria:
  • A 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 uncontrolled diabetes.
  • Documentation that the beneficiary is diabetic is maintained in the beneficiary’s medical record

Providers 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.

Quality Standards

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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Barriers Associated with Medicare-Reimbursed DSME/T

In 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.

Diabetes control 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.

Results 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.

Barriers 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.

In general, the ADA application process was perceived as expensive and laborious. Most respondents perceived Medicare reimbursement for DSME/T as inadequate.

Additional information is available from reference #4 (below).

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Support for Medicaid Reimbursement for DSME/T

It 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.

For 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.
 

References 

  1. AADE Guidelines for the Practice of Diabetes Self-Management Education and Training (DSME/T). American Association of Diabetes Educators, Chicago, Illinois. Revised November 2010. 
  2. Haas et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2012 Nov;35 (11):2393-401. 
  3. Mensing C. Comparing the processes: accreditation and recognition. Diabetes Educ. 2010 Mar-Apr;36(2):219-43. See also Overview Comparison of National Accreditation.
  4. Powell 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. 
  5. US 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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Curriculum Resources

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

Diabetes Empowerment Education Program (DEEP), developed by the University of Illinois

Diabetes Self-Management Programproduced by the Stanford Patient Research Education Center

Programa de Manejo Personal de la Diabetesproduced by the Stanford Patient Research Education Center


Professional – led training

Diabetes 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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Comparison among 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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Reimbursement

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 coinsurance.

Administration on Aging Resource

Diabetes Self-Management Training Initiative

The Administration on Aging developed a DSMT Toolkit to provide Area Agencies on Aging, community planners, and healthcare professionals with valuable information and insights that can help them operate cost-effective, accredited DSMT programs that can meet CMS requirements for Medicare reimbursement.

Diabetes Self-Management Training Initiative (has links to toolkit chapters and other resources)

DSMT Toolkit (pdf file of Toolkit)

Medicare

Medicare covers outpatient diabetes self-management education, if conditions are met. See description of coverage in the ePace prework.

Despite 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.

Medicaid

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 2013 survey of state-based Diabetes Prevention and Control Programs coordinators, 30 state Medicaid programs reimburse for DSME. 

Commercial Insurance

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).

The National 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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Success Stories

North Carolina: EXPANDING THE REACH OF DIABETES SELF-MANAGEMENT EDUCATION—Local health departments get recognition by national organization to enable reimbursement

Diabetes Conversation Map Stories—Four states used the Map curriculum to enhance and expand diabetes-self management education.


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Publications

Building 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 cost-effectiveness studies.

 

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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Underserved Populations

Indian Health Service Division of Diabetes Treatment and Prevention (DDTP).  

The IHS website has comprehensive information for the prevention and treatment of diabetes. The sites has best practices, curricula, and clinical guidelines.

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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