January/February 2018

New National Standards Improve Diabetes Self-Management
By Judith C. Thalheimer, RD, LDN
Today's Geriatric Medicine
Vol. 11 No. 1 P. 14

Quality education and support services greatly improve diabetes prevention and management. Updated guidelines published by the American Diabetes Association provide a blueprint for success.

An estimated 30.3 million people in the United States have diabetes, 7.2 million of these are believed to be living with undiagnosed diabetes, and an additional 84.1 million people are at risk for developing this disease and its potentially devastating complications. Education and support can help patients living with diabetes and caregivers develop the skills needed to address high blood sugar and its consequences, and also can help individuals with prediabetes make lifestyle changes that delay or even prevent progression to diabetes. Every five years the American Diabetes Association (ADA) assembles a panel of experts to review and update standards for diabetes education and support services. "The 2017 National Standards for Diabetes Self-Management Education and Support provide guidelines for timely evidence-based quality services for all who currently provide—or plan to provide—diabetes education," says Melinda Maryniuk, MEd, RD, CDE, director of clinical education programs for Joslin Diabetes Center and a member of the 2017 Standards Revision Task Force.

High-quality services to facilitate diabetes self-management have been shown to improve clinical outcomes and quality of life while reducing hospitalizations and health care costs. In fact, studies show that diabetes self-management education and support (DSMES) services improve hemoglobin A1c (a measurement of long-term blood sugar control) as much as many medications, with no side effects. Unfortunately, the majority of people with or at risk of diabetes do not currently receive DSMES services.

Lack of access is a key obstacle to care, which is why the standards advise DSMES service providers to cultivate external contacts and conduct ongoing data collection and evaluation. Seeking regular input from participants, community stakeholders, referring practitioners, and community-based groups that support DSMES (eg, health clubs) can help providers understand the target community and develop options and tools that align with the needs of that community. The standards encourage providers to understand specific barriers to service—such as insurance shortfalls, perceived lack of need, cultural or educational hurdles, or scheduling issues—and consider creative solutions, such as the use of technology to expand reach and engagement.

Key Point #1: Individualization
Understanding specific barriers to care and gathering assessment data on participants is a first step in individualizing care. While curriculum must be based on up-to-date evidence-based information, the guidelines emphasize it should be flexible enough to be tailored to an individual patient's needs. It's recommended that education and support sessions include practical problem-solving approaches, address behavior change, and suggest strategies to sustain self-management efforts, always taking into account the real life day-to-day challenges facing that particular patient.

DSMES should address eight core content areas put forth in a joint statement of the ADA, American Association of Diabetes Educators (AADE), and the Academy of Nutrition and Dietetics in 2015 and supported by the 2017 standards. These include the following:

• diabetes pathophysiology and treatment options;

• healthful eating;

• physical activity;

• medication usage;

• monitoring and using patient-generated health data;

• preventing, detecting, and treating acute and chronic complications;

• healthful coping with psychosocial issues and concerns; and

• problem solving.

"Each of these content areas must be assessed to determine which will have to be addressed with a given patient," Maryniuk says. "Patients may need education in a variety of areas." A number of tools exist to assist providers in assessment of needs (see Assessment Tools, below).

Key Point #2: Ongoing Services
Along with individualization, the 2017 standards stress ongoing care as vital to successful DSMES. In the past, diabetes self-management education and diabetes self-management support were discussed separately. By combining these to create DSMES, and by changing terminology from "programs" to "services," the 2017 standards assert the fact that neither short-term education programs nor sporadic support sessions provide the kind of care necessary to maximize diabetes self-management and, therefore, patient health and quality of life. While education services are typically offered at the time of diagnosis, improvements from these initial contacts have been shown to diminish after six months.1 "Diabetes education does not end after an initial set of classes," Maryniuk says. "There should be ongoing assessments of behaviors and continuous support. Physicians need to annually review and assess whether additional education is needed. Four critical time points have been identified for providing DSMES services: at diagnosis, annually, when complicating factors arise, and when transitions in care occur."

Ongoing support not only refreshes and updates the participants' knowledge but also helps them sustain the skills and behavior changes needed to manage their condition. As with education services, the standards again emphasize individualization in support services. Participants should select from the following the resource or activity that best suits their needs: group meetings (in the community or online), medication management, continuing education, resources that support behavior change goal-setting, physical activity programs, weight-loss support, smoking cessation, and psychosocial support, all of which are areas where attention could possibly be beneficial. These services can be provided by diabetes educators, disease management programs, trained peers, diabetes paraprofessionals, or community-based programs. Learning what services are available in the community will help clinicians refer patients appropriately (see Resources, below).

The 2017 standards take into account recent advances in technology and emerging data on the effectiveness of its use. "Based on a growing body of evidence, these standards put more emphasis on the role of technology in diabetes education," Maryniuk says. Wearable devices such as continuous glucose monitors provide valuable information that can inform education and treatment decisions. Online learning, e-health tools, text, e-mail, and mobile applications have all been identified as effective tools for providing support. Peer support using social networking sites has been shown to improve glucose management, and online diabetes communities, which are available around the clock, can help participants learn from others living with the condition.

Provision of DSMES Services
"To ensure the best outcome for patients with prediabetes or diabetes—whether newly diagnosed or less than ideally managed—clinicians should refer patients to qualified DSMES services," Maryniuk says. "They could also consider starting their own services. It's easier than one might think, and doesn't even require a certified diabetes educator (CDE)—just a nurse, dietitian, or pharmacist who has taken some additional training in diabetes."

In DSMES programs as in all businesses, successful organizations tend to have clear and shared missions and goals, defined relationships, and lines of communication. The provision of high-quality services is so essential to the success of DSMES services that the standards now refer to the 'program coordinator' as the 'quality coordinator.' In addition to ensuring implementation of the standards and overseeing provision of DSMES services, this individual typically collects and evaluates data to identify gaps and opportunities for improvement and provides feedback to team members. An interprofessional team is recommended as an effective approach to diabetes care, education, and support. There is room for properly supervised paraprofessionals such as community health workers and peer educators, but the curriculum should be created by a nurse, dietitian, or pharmacist with specialized clinical knowledge in diabetes and behavior change principles or by another health care provider holding a CDE or board certified in advanced diabetes management credential. Needless to say, all team members should participate in appropriate continuing education.

"In order for a diabetes education service to be eligible for Medicare reimbursement, application must be made for either 'recognition' status through the ADA or 'accreditation' status through AADE," Maryniuk says (see Resources, below). "This demonstrates that a diabetes education service meets the minimum quality standards set forth by the DSMES standards. While they do not guarantee reimbursement, the standards meet or exceed the regulations set forth by Medicare for what defines a quality diabetes educations service." There are no specifications for what types of providers are eligible to offer services. "Application for recognition or accreditation can be completed by a wide range of providers," Maryniuk says, "from solo practice physician offices to group practices, hospital systems, community pharmacies, population health programs, and technology platforms ... wherever diabetes education can take place."

DSMES relies on behavior change goal-setting strategies to help participants meet their personal targets. The DSMES team guides the participant in choosing SMART goals (specific, measurable, achievable, realistic, and time bound). All DSMES service providers should make provisions to track participant progress toward these goals and measure the impact and effectiveness of interventions. Clinical markers, knowledge, behavior, quality of life, cost savings, and satisfaction are all measurable outcomes that demonstrate the benefits of services.

Whether DSMES services are provided through an approved in-house program or through referral, seeking to understand and meet the needs of individual patients, and addressing needs as they change over time are core concepts of the 2017 standards. Adhering to these guidelines will help ensure quality flexible ongoing services that have the power to greatly improve the lives of the millions of Americans working to prevent or manage diabetes. As Maryniuk says, "DSMES is an ongoing lifelong process."

— Judith C. Thalheimer, RD, LDN, is a registered dietitian and principal of JTRD Nutrition Education Services, LLC outside Philadelphia.

Reference
1. 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.

ASSESSMENT TOOLS
The following forms are recommended to help providers gather some of the information necessary to support the participant in designing an effective personalized diabetes self-management education and support plan:

• Starting The Conversation: an eight-item simplified food frequency instrument designed for use in primary care and health promotion settings.

• Self-Care Inventory-Revised: a survey that measures what people with diabetes do vs what they are advised to do in their diabetes treatment plan.

• Summary of Diabetes Self-Care Activities: an 11-item or expanded 25-item measure of diabetes self-care behaviors.

• Three-Item Screen: a tool to measure health literacy. It asks how often someone needs help reading hospital materials, how confident they are filling out forms, and how often they have difficulty understanding their medical conditions.

• Diabetes Self-Efficacy Scale: an eight-item self-report scale designed to assess confidence in performing diabetes self-care activities.

• The Diabetes Distress Scale: a two-question initial screening tool to assess diabetes-specific distress (followed by the full 17-item scales when indicated).

• The WHO (Five) Well-Being Index: a reliable measure of emotional functioning and screen for depression that is validated in many languages and has been used extensively in research and clinical care.

• Problem Areas in Diabetes Scale: a 20-item measure of diabetes-specific distress identifying emotional distress and burden associated with diabetes.

— Source: Beck J, Greenwood Da, Blanton L, Et Al. 2017 National Standards for Diabetes Self-Management Education And Support. Diabetes Care. 2017;40(10):1409-1419.

RESOURCES

Referrals
The American Association of Diabetes Educators (AADE) website offers the following:

• information on diabetes self-management education and support (DSMES) services;

• a tab for finding local approved service providers; and

• a link to an appropriate referral form.

From the homepage, choose the Practice tab, and click on Provider Resources.

Accreditation
In order to seek reimbursement for DSMES, services must be approved through one of the following two programs:

• the American Diabetes Association Education Recognition Program at diabetes.org/erp; or

• the AADE Diabetes Education Accreditation Program at www.diabeteseducator.org/deap.

2017 NATIONAL STANDARDS FOR DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT
The updated national standards provide detailed information on the following 10 standards all diabetes self-management education and support (DSMES) providers should seek to meet in order to ensure provision of quality effective services.

Standard 1: Internal Structure
The provider(s) of DSMES services will define and document a mission statement and goals. The DSMES services are incorporated within the organization, whether large, small, or independently operated.

Standard 2: Stakeholder Input
The provider(s) of DSMES services will seek ongoing input from valued stakeholders and experts to promote quality and enhance participant utilization.

Standard 3: Evaluation of Population Served
The provider(s) of DSMES services will evaluate the communities they serve to determine the resources, design, and delivery methods that will align with the population's need for DSMES services.

Standard 4: Quality Coordinator Overseeing DSMES Services
A quality coordinator will be designated to ensure implementation of the standards and oversee the DSMES services. The quality coordinator is responsible for all components of DSMES, including evidence-based practice, service design, evaluation, and continuous quality improvement.

Standard 5: DSMES Team
At least one of the team members responsible for facilitating DSMES services will be a registered nurse, registered dietitian nutritionist, or pharmacist with training and experience pertinent to DSMES or be another health care professional holding certification as a diabetes educator or board certification in advanced diabetes management. Other health care workers or diabetes paraprofessionals may contribute to DSMES services with appropriate training in DSMES and with supervision and support by at least one of the team members listed above.

Standard 6: Curriculum
A curriculum reflecting current evidence and practice guidelines with criteria for evaluating outcomes will serve as the framework for the provision of DSMES. The needs of the individual participant will determine which elements of the curriculum are required.

Standard 7: Individualization
The DSMES needs will be identified and led by the participant with assessment and support by one or more DSMES team members. Together the participant and DSMES team member(s) will develop an individualized DSMES plan.

Standard 8: Ongoing Support
The participant will be made aware of options and resources available for ongoing support of their initial education and will select the option(s) that will best maintain their self-management needs.

Standard 9: Participant Progress
The provider(s) of DSMES services will monitor and communicate whether participants are achieving their personal diabetes self-management goals and other outcome(s) to evaluate the effectiveness of the educational intervention(s) using appropriate measurement techniques.

Standard 10: Quality Improvement
The DSMES services quality coordinator will measure the impact and effectiveness of the DSMES services and identify areas for improvement by conducting a systematic evaluation of process and outcome data.

— Source: Beck J, Greenwood DA, Blanton L, et al. 2017 National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2017;40(10):1409-1419.