July/August 2019

Education: Self-Management Training and Diabetes — A Rich Resource For Patients And Providers
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 12 No. 4 P. 6

Patients and providers alike may soon have improved access to a key resource for supporting individuals with diabetes. Legislators in the US Senate recently reintroduced the Expanding Access to Diabetes Self-Management Training Act, which aims to increase the number of patients taking advantage of the services of diabetes educators.

Medicare has covered diabetes self-management education and support (DSMES) for more than 15 years, and the American Diabetes Association (ADA) recommends DSMES as an important part of care for people with diabetes. However, participation in DSMES programs historically has been low. Among individuals newly diagnosed with diabetes, less than 7% of those with private insurance1 and only 5% of those covered by Medicare participate.2

The new legislation aims to increase participation by removing several barriers to access. Among other provisions, the bill would eliminate patient cost-sharing for those on Medicare, expand the scope of providers who can refer for DSMES, and loosen restrictions regarding location for covered programs.

According to Kellie Rodriguez, RN, MSN, MBA, CDE, director of the Global Diabetes Program for Parkland Health & Hospital System in Dallas, DSMES services are a major asset for time-strapped providers who simply can’t offer patients in-depth education and support on how to manage a complex condition such as diabetes. “Chronic diseases [such as diabetes] don’t really fit the acute care model of 15- to 20-minute visits,” Rodriguez says. Given the overwhelm that most providers face, “partnering with a diabetes educator is a really rich resource.”

The Need for DSMES
While providers typically give patients information about diabetes when they first make a diabetes diagnosis, patients with diabetes often don’t know how to apply that information when they leave. “There’s a difference between information and education,” says Rodriguez, who’s a member of the board of directors for the American Association of Diabetes Educators (AADE).

DSMES services focus on assessing patients’ needs and providing them with the knowledge and skills to make everyday life decisions, Rodriguez says. In DSMES, “it’s not just learning how to use a meter to check your blood glucose level; it’s about how you use that meter, what you do with the numbers, how you make decisions based on that information, and how you make positive lifestyle changes based on that information,” Rodriguez says. “If you just read a pamphlet or a brochure about the meter, it’s just going to tell you how to use it, but it’s not going to teach you the key intricacies of monitoring.”

Although DSMES is of value for all patients with diabetes, it may be of particular value for older patients, according to Gretchen Youssef, MS, RD, current ADA president for health care and education. This is because older adults often have cognitive deficits and might need a simplified diabetes plan. “The diabetes educator can work closely with the primary care provider to help with medication adherence strategies, simplifying medication regimens, avoidance of hypoglycemia, meal planning for the geriatric patient, foot care, etc,” Youssef says.

Providers sometimes fear that if they refer patients out for DSMES, they’ll lose the patient to another clinic or health system. But while Rodriguez understands the concern, she says providers need not worry. From her point of view, diabetes educators are working on the same team with patients’ providers, and she says her view is widely shared among other educators. “We do not want to take your patients,” she says. “We want to work with you. We want to support your goals and objectives with your patients.”

Myriad Benefits: Hemoglobin A1c Management
According to current estimates, nearly 50% of people with diabetes do not maintain A1c levels at the recommended target of <7%.3 A large body of research, however, suggests that DSMES results in significant improvement in hemoglobin A1c (HbA1c).

One systematic review published in 2015 examined 132 studies on the impact of DSMES in individuals with type 2 diabetes. The programs included in the review varied considerably (there were differences in the program components, duration, intensity, and methods of communication and delivery, among other factors). However, the authors concluded that DSMES resulted in a reduction of ≥0.4% in HbA1c as long as the contact time was 11 hours or more (little benefit was seen in programs with contact time of 10 hours or less). The benefits were especially significant in ethnic minorities, in people older than 65 years, and those with an HbA1c greater than 7%.4

A second systematic review, this one from 2016, found similar results. Again, there was significant variety among the 118 different interventions included in the review in terms of the content, intensity, duration, and other parameters. Despite the variation, in 61.9% of the included interventions, patients who engaged in DSMES had clinically relevant improvements in A1c compared with those who did not engage. The overall mean reduction in A1c for patients who received DSMES was 0.74, compared with just 0.17 for patients in the control group. Once again, the benefits were greater in programs with contact time of 10 hours or more, and were also greater for patients with higher glycemic values.3

Beyond simply improving A1c, DSMES has other benefits as well. It reduces emergency department visits,5 hospital admissions and readmissions,6-8 and estimated lifetime health care spending.9 DSMES also has positive effects on other clinical, psychosocial, and behavioral aspects of diabetes. For example, participation has been found to reduce the risk of diabetes complications,10 improve quality of life,11-15 and decrease depression associated with diabetes.16,17

What’s Covered?
DSMES services focus on several major categories of processes and outcomes, including the following:

• biomedical (including HbA1c levels, cardiovascular risk factors, weight management, and hypoglycemia);

• behavioral (including medication use, self­monitoring of blood glucose, foot self-care, dietary management, and physical activity);

• psychosocial (including knowledge, health beliefs, self­management skills, coping skills, anxiety and depression, and distress related to diabetes); and

• all-cause mortality.18

Closely related to DSMES is medical nutrition therapy, a complementary service that’s often prescribed at the same time as DSMES. Facilitated by licensed diabetes educators or nationally registered health care professionals from multiple disciplines, DSMES provides overall guidance related to all aspects of diabetes. By contrast, medical nutrition therapy is facilitated by registered dietitians and focuses intensively on nutrition therapy in particular. Recent research suggests that the two services in combination result in improvements in multiple outcomes for patients with diabetes, including weight, body mass index, HbA1c, and triglycerides.19 Youssef recommends both to make sure that patients receive comprehensive education on all aspects of diabetes management.

Most DSMES services are general and cover all types of diabetes, Youssef says, but some are more specialized. For example, one program may see a large number of people with type 1 diabetes and may focus extensively on managing insulin pumps, while other programs may see mainly patients with type 2 diabetes and may not spend as much time on insulin pump management.

All DSMES services accredited through the ADA and the AADE must adhere to a common set of national standards.20 These standards require that all DSMES programs use an evidence-based curriculum, but the details and formats of the programs may vary—some programs are one-on-one, some are group-based, and some are a combination of individual and group based. While many programs meet face-to-face, some are offered virtually. And while some programs cover all core content in a single day, others are broken up into multiple sessions.

When to Make a Referral
Medicare covers DSMES for patients who meet one of the following criteria for diabetes diagnosis:

• fasting blood glucose of 126 mg/dL on two separate occasions;

• two-hour postglucose challenge of ≥200 mg/dL on two separate occasions; or

• random glucose test of >200 mg/dL with symptoms of unmanaged diabetes.

The ADA, AADE, and Academy of Dietetics and Nutrition have identified the following four critical points at which a referral to DSMES is important:21

• when an individual first receives a diabetes diagnosis;

• annually for ongoing assessment of education, nutrition, and emotional needs;

• when new complicating factors arise (such as a change in health status with respect to either physical, mental, or emotional health); and

• at the point of a care transition (such as a change in the care team, the patient’s living conditions, or the patient’s insurance).

Medicare covers up to 10 hours of DSMES with an initial referral; once started, this benefit must be used within one year. Each subsequent year, Medicare covers an additional two hours of diabetes self-management training, though providers must make a new referral each year. Additional hours may be available based on provider-determined need and referral. Most private insurance plans follow Medicare, although patients should be encouraged to check with their insurance providers to verify their benefits.

Making a Referral: What Providers Need to Know
In an ideal world, referrals wouldn’t be required for DSMES, Rodriguez says, but in today’s health care environment, they’re a necessity. Referral forms typically address several different questions, including type of diabetes diagnosis, reason for education referral, type of education required, and whether the patient has any special needs or complications. “These are mandated referral elements, really, not because we want to make it difficult, but because that’s what’s needed for reimbursement and possible audit purposes.” Rodriguez says.

Providers should make sure to refer to a program accredited through either the ADA or the AADE, Rodriguez says, given these programs have demonstrated adherence to established quality standards.

The Expanding Access to Diabetes Self-Management Training Act is pushing to increase the number of providers who are able to make a referral, but currently, only the provider who is managing a patient’s diabetes can refer. “Hospitalized patients are unable to be referred by hospitalists even if the patient was hospitalized for diabetes,” Youssef says. “If the patients are identified as needing DSMES, they then need to go to their diabetes providers to obtain the referrals.”

— Jamie Santa Cruz is a health and medical writer in the greater Denver area.

Resources
To find an accredited diabetes education program, visit www.diabeteseducator.org/living-with-diabetes/find-an-education-program.

To print a sample referral form, visit www.diabeteseducator.org/practice/provider-resources/make-a-referral.

References
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2. Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. Use of Medicare’s diabetes self-management training benefit. Health Educ Behav. 2015;42(4):530-538.

3. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-943.

4. Pillay J, Armstrong MJ, Butalia S, et al. Behavioral programs for type 2 diabetes mellitus: a systematic review and network meta­analysis. Ann Intern Med. 2015;163(11):848-860.

5. Magee M, Bowling A, Copeland J, Fokar A, Pasquale P, Youssef G. The ABCs of diabetes: diabetes self-management education program for African Americans affects A1C, lipid-lowering agent prescriptions, and emergency department visits. Diabetes Educ. 2011;37(1):95-103.

6. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36(10):2960-2967.

7. Duncan I, Ahmed T, Li QE, et al. Assessing the value of the diabetes educator. Diabetes Educ. 2011;37(5):638-657.

8. Robbins JM, Thatcher GE, Webb DA, Valdmanis VG. Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study. Diabetes Care. 2008;31(4):655-660.

9. Brown HS 3rd, Wilson KJ, Pagán JA, et al. Cost-effectiveness analysis of a community health worker intervention for low-income Hispanic adults with diabetes. Prev Chronic Dis. 2012;9:E140.

10. The Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.

11. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with diabetes mellitus. Cochrane Database Syst Rev. 2005;(2):CD003417.

12. Cooke D, Bond R, Lawton J, et al. Structured type 1 diabetes education delivered within routine care: impact on glycemic control and diabetes-specific quality of life. Diabetes Care. 2013;36(2):270-272.

13. Cochran J, Conn VS. Meta-analysis of quality of life outcomes following diabetes self-management training. Diabetes Educ. 2008;34(5):815-823.

14. Trento M, Passera P, Borgo E, et al. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care. 2004;27(3):670-675.

15. Toobert DJ, Glasgow RE, Strycker LA, et al. Biologic and quality-of-life outcomes from the Mediterranean Lifestyle Program: a randomized clinical trial. Diabetes Care. 2003;26(8):2288-2293.

16. Hermanns N, Schmitt A, Gahr A, et al. The effect of a diabetes-specific cognitive behavioral treatment program (DIAMOS) for patients with diabetes and subclinical depression: results of a randomized controlled trial. Diabetes Care. 2015;38(4):551-560.

17. de Groot M, Doyle T, Kushnick M, et al. Can lifestyle interventions do more than reduce diabetes risk? Treating depression in adults with type 2 diabetes with exercise and cognitive behavioral therapy. Curr Diab Rep. 2012;12(2):157-166.

18. Chatterjee S, Davies MJ, Heller S, Speight J, Snoek FJ, Khunti K. Diabetes structured self-management education programmes: a narrative review and current innovations. Lancet Diabetes Endocrinol. 2018;6(2):130-142.

19. Marincic PZ, Salazar MV, Hardin A, et al. Diabetes self-management education and medical nutrition therapy: a multisite study documenting the efficacy of registered dietitian nutritionist interventions in the management of glycemic control and diabetic dyslipidemia through retrospective chart review. J Acad Nutr Diet. 2019;119(3):449-463.

20. Beck J, Greenwood DA, Blanton L, et al. 2017 National standards for diabetes self-management education and support. Diabetes Educ. 2017;43(5):449-464.

21. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Clin Diabetes. 2016;34(2):70-80.