Strengthening Patient Connections Diabetes Self-Management Education and Support Services

Welcome to Strengthening Patient Connections to Diabetes Self-Management Education and Support or DSMES Services, a training for nurse practitioners. The purpose of this training is to provide information on DSMES services so that nurse practitioners or NPs can enhance their role in helping people with diabetes strengthen their self-care management skills and more effectively refer them to appropriate DSMES services online or in their local area. At the end of this training, you will be able to identify two benefits of accessing DSMES services for a person with diabetes. Recognize the four key times that you can refer people with diabetes to DSMES services as a primary care provider. Explain how you can become qualified to offer DSMES services to patients directly and list one strategy for increasing awareness of DSMES services among people with diabetes. My name is Susan Van Busch. I'm a professor-in-residence at the University of Nevada Las Vegas School of Nursing. In the spirit of being more accessible to the audience for this training, I would describe myself as a woman wearing glasses with long dark blonde hair, a blue jacket, and a black shirt, and I'm sitting in front of books for my background. As a nurse for over 31 years and an advanced practice family nurse practitioner for more than 21, I'm excited to welcome you to this on-demand training especially designed for nurse practitioners on strengthening patient connections to diabetes self-management education and support or what we call DSMES services. Working with people with diabetes has long been an area of passion for me rooted in my 15 years of endocrinology practice and I can think of no more important topic for us to talk about than how we can enhance our existing efforts to help our patients access the additional care and support they need to better manage their diabetes. It is my hope that you find this training to be a refresher on the ins and outs of locating and referring these covered services as well as an opportunity to learn something new such as how you can pursue offering DSMES services yourself or within your practice. More importantly, this training was developed with input from nurse practitioners like you and me and we hope this means that it resonates with you and the already amazing work you do every day for your patients. So thank you and let's get started. Over a series of four topics, this training will present information and resources tailored specifically for nurse practitioners. Part one, DSMES services helping my patients and me. Part two, connecting people with diabetes to DSMES services. Part three, helping patients find support when DSMES services aren't available. Part four, building momentum for and increasing access to DSMES services. As you complete each part of this training, take a few minutes to reflect on what you learned and plan your next steps. Here are some questions to consider. What is one new thing I learned about DSMES services? How can I change my referral practices based on the four key times to refer patients to DSMES services? What is one way I can find a local or virtual program offering DSMES services? You may find it helpful to take notes on your answers to the questions and any ideas for next steps on the companion planning worksheet. Part one, DSMES services helping my patients and me. DSMES services make up an evidence-based diabetes management service model that is defined as the ongoing process of facilitating the knowledge, skills, and abilities necessary for diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training. In other words, DSMES services help people set and track goals, learn to manage diabetes using knowledge, skills, and tools, build confidence and emotional strength, practice how to fit diabetes care into all of their daily routines, and find support from their family, friends, community, and health care team. As nurse practitioners, I know that DSMES services provide benefits to both my patients, to me as a provider, and the overall health care team. Patients can have more self-confidence in managing their diabetes and have healthier lifestyle behaviors, such as better nutrition, increased physical activity, and improved coping and stress management skills. They are more likely to use primary care and preventive services. When it comes to medication management, they can have better adherence to recommended medication usages, and all of these changes can lead to fewer or less severe diabetes-related complications, including hospitalizations. For health care providers and health care organizations, DSMES services can increase the quality of health care services and decrease the cost of delivering those services. They can help us better meet the standards and goals related to quality and health care reform. But for me, the value of DSMES services really lies in how I can offer my patients education, support, and more information for them to be in control of their own health. People with diabetes generally visit their primary care provider two to four times a year, with an average appointment time of 15 to 20 minutes. In that time, they can be addressing four or more health concerns. This means that on average, a person with diabetes spends less than one percent of their time with their health care professionals. Access to DSMES services that promote and encourage regular self-care behaviors is essential for the person with diabetes to achieve their healthiest life with their diabetes. The national standards provide guidance and evidence-based quality practice for all DSMES services that meet or exceed quality standards for the Centers for Medicare and Medicaid Services, or CMS. They are reviewed and revised every five years by a cross-disciplinary task force. The standards can be applied to all care delivery models, including solo practice, community-based, large practice, and virtual care delivery. The standards serve as a guide for all care team members, as well as insurance providers, to help make sure that people with diabetes receive quality, evidence-based, and current DSMES services. Inclusion of DSMES services is required in many current care models, including accountable care organizations, patient-centered medical homes, population health programs, and value-based payment models. The standards can help providers and organizations make sure they are incorporating DSMES services correctly. Accreditation and recognition processes help ensure that DSMES offers quality education. This also makes the services eligible for reimbursement from Medicare, many private health plans, and some state Medicaid agencies. CMS has authorized both the American Diabetes Association, or ADA, and the Association of Diabetes Care and Education Specialists, ADCES, to grant accreditation and recognition, respectively, to DSMES service providers. Both organizations rely on the latest addition of the standards to evaluate DSMES services. Participating in DSMES is linked to positive changes in health behaviors and improved diabetes-related outcomes. This includes healthier lifestyle behaviors, such as better nutrition, increased physical activity, and use of primary care and preventive services, improved hemoglobin A1c levels, improved management of blood pressure and cholesterol levels, higher rates of medication adherence, fewer or less severe diabetes-related complications, enhanced self-confidence to manage diabetes, and decreased health care costs, including fewer hospitalizations and readmissions. DSMES services can increase the quality of health care services while lowering the cost. Health care organizations and payers are more likely to invest in interventions when they see a likely financial return on investment. DSMES can increase use of primary care and preventive services and lower use of acute inpatient hospital services. Research shows that when primary care providers and diabetes care and education specialists, or DCESs, collaborate, positive clinical quality and cost savings result. For example, DSMES services can help support health care providers, people with diabetes, and community members in addressing diabetes-related needs, support health care organizations and providers in adhering to standards and goals for health care reform, including meeting the National Committee for Quality Assurance Standards for a patient-centered medical home or an accountable care organization, increase the quality of health care services, and decrease the cost of delivering those services, and increase indirect revenue, such as from lab tests, related to the DSMES service. Demonstrating how DSMES services can help address quality measures is one way to show the value of that service. Example quality measures include patient caregiver experience, care coordination and patient safety, preventive health and screening, at-risk populations. There are also DSMES services outcomes recommended in the national standards that are tracked, monitored, and reported, including knowledge, behavior change, clinical change, quality of life, and satisfaction. Both ADA and ADCES offer resources and training related to connecting DSMES services to value-based care and quality improvement efforts. In Part 1, we focused on how DSMES services help people with diabetes manage their diabetes in ways that fit their lifestyle. DSMES services are guided by national standards and are accredited or recognized by ADA and ADCES. Accreditation and recognition processes help ensure that DSMES offers quality education. This also makes the services eligible for reimbursement from Medicare, many private health plans, and some state Medicaid agencies. There are documented benefits to patients participating in DSMES services such as lower A1C levels, higher medication adherence, and reduced hospitalizations. There is also value to nurse practitioners and all healthcare providers, including more support for people with diabetes across clinical and community-based settings, increased quality of services, and decreased cost of service delivery. Congratulations! You have completed Part 1. Now is a great time to take a few minutes to reflect on what you learned and plan your next steps. Part 2, Connecting People with Diabetes to DSMES Services. Though the benefits of DSMES services for people with diabetes are well known, only a small percentage participate. While certain challenges that affect enrollment in DSMES services are harder to address, such as cost, insurance coverage, physical access, or location, there are opportunities to improve awareness of these services among people with diabetes. You can play an important role in ensuring they understand the full breadth of the services offered, that they may even be able to access them online, and that the services can be tailored to help them manage their diabetes in ways that fit their life. DSMES services are delivered in a depending on the individual or organization providing them. Participants may attend by themselves or in a group or class-like setting. And while the traditional in-person approach still exists, strong evidence supports DSMES delivery through virtual, telehealth, telephone, text messaging, and web-based mobile phone apps. So who provides DSMES services? The DSMES team may include one or more health care professionals. The evidence recommends that the inclusion of nurses, dieticians, pharmacists, or others with special certifications that demonstrate mastery of diabetes knowledge and training, such as certified diabetes care and education specialists, can support all DSMES services, including clinical assessment. Each DSMES team also needs to have someone serving in the role of quality coordinator. This person monitors the implementation of DSMES services and tracking and reporting of outcomes. The 2022 DSMES national standards change to the term diabetes care and education specialist, DCES, formerly diabetes educator. This change in title is designed to more accurately reflect the diverse skills and specialization and conveys the broad clinical management skill set and the expanded role of technology. ADCS has a video about DCSs you can share with people with diabetes. Whether you're newly diagnosed with diabetes or have had it for years, a diabetes care and education specialist is someone you can turn to for answers. Diabetes care and education specialists are health care professionals who get to know you. From eating decisions to reducing risks, they're your partner in diabetes management. They'll help you find coping strategies to ease the burden and support you in making changes that benefit your overall health. A diabetes care and education specialist will work with you to learn how to use devices like meters, insulin pens, pumps, continuous glucose monitors, and more. They'll use the information from your devices and lifestyle to identify patterns and problem areas and collaborate with you to come up with workable solutions. Together, you'll develop a plan that fits your lifestyle and respects your habits, interests, and beliefs, and they can direct you to resources to set you up for success. Medicare and most insurance policies will cover diabetes self-management education and support. Research shows diabetes self-management education and support can help lower your blood sugar, reducing the risk of complications, and improving your overall health. Ask your provider to refer you to a diabetes care and education specialist or visit our website to locate a diabetes education program near you. DSMES services are designed for the whole patient, whether newly diagnosed or living with diabetes for years. The services support the patient where they are in their health care journey. Person-centered DSMES is a recurring process over the lifespan of people with diabetes. Each person's DSMES plan will be unique and based on their concerns, needs, and priorities. These are collaboratively determined as part of a DSMES assessment. The DSMES team monitors and communicates the outcomes of the diabetes care team, the referring provider, or other qualified health care professionals. As described in the standards, DSMES services, while designed to be tailored to the person with diabetes, need to be framed in a curriculum. The curriculum will help ensure that evidence-based content is shared and that there is consistency across the team in teaching concepts, methods, and strategies. While there is not one universal curriculum, both the ADA and ADCS offer teaching resources for DSMES services that are often rooted in the evidence-based framework of the ADCES-7 self-care behaviors. Healthy coping, taking medication, healthy eating, being active, monitoring, problem solving, reducing risks. Through application of patient-centered approaches, such as motivational interviewing, the DCES and team can determine which areas of the ADCES-7 to focus on during DSMES sessions. Now let's watch a video that you could share with your patients about the ADCES-7. If you have diabetes, pre-diabetes, or another chronic health condition, you know how challenging it can be to manage. By focusing on these seven behaviors with your health care team, you can live your healthiest life. Healthy coping means taking care of your whole self. Chronic health conditions affect you physically and emotionally. A diabetes care and education specialist will help you discover healthy ways to cope, such as finding the supports you need, helping you celebrate successes, reducing diabetes-related stress. If you have diabetes or other chronic conditions, healthy eating can help you feel your best. If you have pre-diabetes, it can also prevent or delay type 2 diabetes. Partner with your care team to find what works for you. Start with one focus, such as knowing the foods that raise blood sugar, managing portion sizes, searching for healthy choices when eating out, setting realistic, achievable goals. Being active supports your overall well-being in many ways. Do activities you enjoy, working up to 30 minutes, five days a week. Monitoring is an important aspect of self-care. It helps you know if you are meeting recommended treatment goals to keep you healthy. Monitoring provides vital information for you and your care team to know if you need to adjust your food, activity, or medications. Taking medications as prescribed helps lower health risks posed by your chronic health condition. Keep a list of all your current medications and bring them to each appointment. Tell your care team if you're taking vitamins and supplements. Share your medication beliefs and concerns with your care team. Your health changes over time, so you may need new ways to manage it. Using problem-solving techniques can help. Your health care team can help you identify the problem, find solutions, and take action. Having a chronic health condition puts you at higher risk for developing other health problems. To reduce risks, know when to reach out to your care team. Be prepared for sick days and other changes in your daily routine. Get enough sleep and get regular checkups, health screenings, and vaccines. If you have diabetes, pre-diabetes, or other chronic conditions, a diabetes care and education specialist can help. They get to know you and work with you to manage these seven self-care behaviors, taking into account your lifestyle, culture, and beliefs. Ask your health care provider for a referral to a diabetes care and education specialist. Now that we've talked about what DSMES services include, who delivers them, and how they are delivered, let's focus on eligibility. In order for someone to qualify to participate in DSMES services, they need to have a diagnosis of type 1, type 2, or gestational diabetes. The diagnostic criteria are presented here as well. A referral is also required from a physician, NP, physician's assistant, or other qualified primary care provider. There are many documentation requirements for referrals, and depending on the place of service, such as a federally qualified health center, rural health center, or hospital, extra or different documentation may be required. DSMES services are covered by Medicare and many other insurers for enrolled recipients if the treating physician or qualified practitioner documents the need for DSMES in a referral or order. Medicare covers up to 10 hours of diabetes education for people diagnosed in the past year. After the first year, coverage may change. Changes in health status or the ability to meet treatment goals can be used to document ongoing need or repeat referrals, and both ADA and ADCS provide resources and support related to reimbursement for DSMES services. To help facilitate participation in DSMES services, NPs and all primary care providers can make referrals to their patients at four key times. To facilitate participation in diabetes self-management education and support services, nurse practitioners can refer their patients at four key times. At diagnosis, annually, or when treatment goals aren't met, when complicating factors develop, or when transitions in life or care occur. At diagnosis, all newly diagnosed people with diabetes can benefit from an introduction to DSMES services. Annually, or when treatment goals aren't met, this is a great time to refer for new techniques, technology, and updated information. When complicating factors develop, for example, changes in health conditions such as kidney disease and stroke, planning a pregnancy or becoming pregnant, cognitive, visual, or physical impairment, emotional issues like diabetes, distress, anxiety, and depression, changes in access to basic needs like shelter, food, and money. When transitions in life or care occur, this can include changes in a living situation or changes in health care or insurance or age-related changes. Since a referral is required for DSMES services, we need to remember that while we can make a referral at any time, there are four key times to refer. And for this referral to be more effective and meaningful to the patient, it helps if we are familiar with the programs we are referring to and to have personal contacts we can make on our patient's behalf or have success stories to share from our past patients who have participated. Research shows that patients count on the voice and experience of their trusted health care providers, us, to help them make decisions about their care and treatment. NPs and all primary care providers play a critical role in facilitating access to DSMES services. Referring patients to DSMES improves health outcomes and can help you meet follow-up care guidelines. Steps in the referral process include find programs in your area and make a connection to a DCES program coordinator through ADA or ADCES or consult with the DSMES specialist in your state health department to find out about available programs in your state. Determine if referral options for the program are paper or electronic-based. Ask for posters, handouts, or other things that you could display, handout, or share electronically with your patients. Perhaps invite a DCES or program coordinator to come to your health center to share information or to make a video introduction you could share. And if your patient attends a DSMES session, follow up on how it went. Patients often respond more positively to DSMES when their primary care provider is engaged. In part two, we discussed how DSMES services are delivered in a range of ways depending on the individual or organization providing them. Participants may attend by themselves or in a group, face-to-face, in person, or online. DCESs, typically nurses, dieticians, pharmacists, and other clinicians with training and expertise in diabetes self-management, deliver DSMES services as part of multidisciplinary teams. The four key times to make a referral to DSMES services are at diagnosis, annually and or when treatment targets aren't being met, when complicating factors such as new comorbidities arise, and when there are transitions in life or care such as aging or changing living arrangements. Visit the ADA and ADCES websites to find local or virtual accredited or recognized programs or contact your DSMES state specialist through your health department or the National Association of Chronic Disease Directors. Congratulations, you have completed part two. Now is a great time to take a few minutes to reflect on what you learned and plan your next steps. Part three, helping patients find support when DSMES services aren't available. What happens when you can't locate in-person DSMES services in your area? In part three, we will look at some other options for helping your patients with diabetes access additional resources. While 56% of counties across the United States have accredited or recognized DSMES services, 62% of rural counties don't. When you can't locate an individual or organization offering DSMES services in person, you can explore virtual, live, or self-paced options or telehealth delivery. Telehealth DSMES services can also be helpful when there are time or transportation constraints. Referrals from health care providers for DSMES via telehealth helps patients receive the critical care they need. Through DSMES, DCESs can connect with patients and help reduce their stress. They can provide answers to patients' critical questions to help them better manage blood glucose, blood pressure, cholesterol, and more. Patients can take advantage of the many benefits of telehealth services regardless of circumstances. Telehealth options include video conferencing, telephone, and texting. These alternatives provide the same life-saving benefits as in-person visits with added convenience for participants. For DSMES services to be billable to Medicare, telehealth services must include real-time audio and visual communication. Other insurers may reimburse for email, telephone, or online communication without a visual component. CDC's DSMES toolkit offers success stories of DSMES participants who use telehealth. As an NP, you're already doing so much to help your patients with diabetes and you're not alone. Making connections in your community to free and low-cost healthy eating, stress management, and physical activity resources and events for your patients. This can include cooking classes, grocery store tours, food prescription programs, walking groups, and more. In-person and virtual diabetes support groups can also be a great resource for your patients. Visit the ADA's website to find local events and groups in your area as well as online activities. Other ideas for expanding your support for your patients with diabetes include connecting with community health workers, health educators, peer educators, and others in programs supporting individuals and families in your area and using the list of free resources from the CDC, ADA, and ADCES accompanying this training to promote diabetes self-management knowledge and skills. In addition, you can add to your education and counseling resources by accessing the visual library and plain language glossary in the CDC's DSMES health literacy tool. When it comes to shortages of accredited or recognized services in your area, perhaps the answer lies close to home. If your organization is already seeing a large number of people with diabetes and providing programming and services for them, consider applying to become an accredited or recognized program. You can also work to obtain the CDCES credential or support someone on your team in achieving it. And finally, you can find plenty of support and resources in this toolkit from the CDC or from your DSMES state specialist. You can find this individual through their state health department or by contacting the National Association of Chronic Disease Directors. So what does accreditation or recognition look like? While detailed information and technical assistance can be found through both organizations, it comes down to applying to ADA or ADCES through their online systems, providing required documentation of your diabetes services, and getting approved and participating in an online orientation. Once accredited or recognized, you will get access to ongoing support to help you enhance service delivery and potentially increase reimbursement. In Part 3, we discussed what to consider when you can't locate in-person DSMES services in your area. Telehealth services can provide the same lifesaving benefits as in-person visits with added convenience for participants. For the telehealth services to be billable to Medicare, they must include real-time audio and visual communication. Other insurers may reimburse for email, phone, or online communication without visuals. Some DSMES content is also available in online self-paced learning or hybrid learning modules. When DSMES is unavailable in-person or online in your area, there are resources in your community that can help you further your care, and this can include cooking classes, food prescription programs, and walking groups. And finally, you as a nurse practitioner can pursue accreditation or recognition for diabetes services you're already providing. Congratulations, you have completed Part 3. Now is a great time to take a few minutes to reflect on what you learned and plan your next steps. Part 4, Building Momentum for and Increasing Access to DSMES Services. The amount of time a primary care provider is low compared to all the hours they spend in self-management. Primary care providers, in general, don't have enough time to devote to chronic disease management in their day. According to a 2022 study, a primary care provider would need almost eight hours a day to provide chronic disease management care alone. This is where DSMES services can help, but how do you encourage your patients to participate? We know that our time with patients goes by quickly, and we're already trying to cover so much in a quick 15-minute visit. So how do we talk about DSMES services? Well, when I talk to my patients, I like to get a sense of what their knowledge level is about their disease state, how they manage on a day-to-day basis, and what kinds of interests they have in learning more. I want to know their daily routine, their support system, and most importantly, how they see themselves in managing their diabetes. In understanding who they are, what they know, and where they would like to go, I can provide direction, encouragement, set goals, and make referrals for education and training to support their needs. So how can you talk about DSMES services to your patients? It starts with prioritizing the four key times to refer, but knowing that you can refer at any time. It's also important to start the dialogue as part of the natural flow of care. For example, if a patient is talking about needing more support at home or wanting to learn about new diabetes-related technology, that is a great time to start talking about DSMES. Patients have busy lives and are surrounded by lots of information and suggestions online and from family and friends. They count on you, their health care provider, more than any other source of information to help them manage a serious chronic condition like diabetes. DSMES services can be the regular support and guide for people with diabetes, but without the voice of their primary care provider encouraging them to participate, most people won't pursue these services. There are resources available to help programs and providers talk about DSMES services in more plain language ways that were developed with insight from people with diabetes. CDC's Division of Diabetes Translation, in collaboration with national partners, including the American Association of Nurse Practitioners, or AANP, set out to create the DSMES Promotion Playbook with clear and compelling materials and messages that would resonate with people with diabetes and referring health care providers. The DSMES Promotion Playbook is designed to help programs and providers promote DSMES services with one voice. This approach can help more people with diabetes participate in DSMES services and learn where to go for help, know how to take better care of themselves, and reduce how much treatment they need, including hospitalizations. The playbook was developed with insight from people with diabetes, DCESs, referring health care providers, including NPs, state health departments, and accredited and recognized programs delivering DSMES services. Here are examples of the playbook materials. Programs that provide DSMES services can add their local program name and contact information to the playbook materials. Photos can also be changed to feature local program photos or others that are available from the playbook photo gallery. In this section, we talked about how DSMES services can be the regular support and guide for people with diabetes, but without the voice of their primary care provider encouraging them to participate, most people won't pursue these services. It's important in talking with people with diabetes to prioritize the four key times to refer, but know that you can refer your patients to DSMES services at any time. Fit the referral into the natural flow of the visit. If a patient is talking about needing more support at home or wanting to learn about new diabetes-related technology, that is a great time to talk about DSMES. CDC's DSMES Promotion Playbook can help programs and providers talk to patients about DSMES services in more understandable ways. Congratulations, you have completed Part 4. Now is a great time to take a few minutes to reflect on what you learned and plan your next steps. We hope that this training and companion toolkit materials are just the beginning of your steps to energize or re-energize your efforts to increase referrals to in-person or online DSMES services in your area. Or maybe you realized that you're already providing similar diabetes care and you want to pursue getting your program accredited or recognized so that you can increase access for your patients in your community. Regardless of your next steps, and especially if you aren't sure what the next steps are to take, know that the CDC and its partners at the American Association of Nurse Practitioners, American Diabetes Association, and Association of Diabetes Care and Education Specialists are here to help with resources and guidance. Your DSMES state specialist is also a good person to connect with. Learn more about this by contacting your state health department or the National Association of Chronic Disease Directors. As a nurse practitioner and clinician, I encourage you to learn more about DSMES services in your community. In addition, please look at the toolkit developed and designed for you and your patients so you may have the knowledge, tools to teach, refer, and improve outcomes for your patients with diabetes.