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Diabetes Self-Management Education and Support Model Policy

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Rationale

 The purpose of this policy is to provide recommendations for referring patients with diabetes to the Diabetes Self-Management Education and Support (DSMES) program. 

DSMES is a program facilitated by a healthcare professional, during which the patient learns the skills and gains the ability to successfully self-manage their diabetes on a daily basis, as well as implement and sustain diabetes self-care behaviors. DSMES significantly contributes to long-term positive health outcomes and clinical improvement.2 Additionally, improved diabetes self-management is shown to decrease the incidence of emergency room visits and hospital stays, which result in cost savings.6 

This policy outlines the process [Healthcare facility] has in place to ensure patients are referred to DSMES at these four critical times: 

  1. At diagnosis
  2. Annually for health maintenance and prevention of complications
  3. When new complicating factors influence self-management
  4. When transitions in care occur

 Diabetes is a chronic disease that is a growing health threat and is the seventh leading cause of death in the United States and in South Dakota. In the last 20 years, the number of adults diagnosed with diabetes has more than tripled as the American population has aged and become more overweight or obese.3 Diabetes is a costly disease both in terms of money and quality of life. Patients with diabetes accrue approximately 2.3 times the medical expenses of patients without diabetes.1 Diabetes accounts for an additional $163 million in indirect costs due to lost productivity.1 Complications that affect quality of life for patients with diabetes include heat disease, stroke, amputation, kidney disease, and more. 1 

Through DSMES programs, participants are expected to learn how to make lifestyle changes to lower their Hemoglobin A1c levels. Lower A1c levels are associated with improved outcomes for diabetes patients, including “reduced onset or progression of microvascular complications.”4 Specifically, a 1% reduction in mean A1c levels has been found to be associated with risk reductions of: 21% for deaths related to diabetes, 14% for myocardial infarction, and 37% for microvascular complications.4 Research shows an association with diabetes education (and disease management) with decreased costs, cost savings, cost effectiveness or positive return on investment. Analysis of two studies observed cost-savings associated with patients who had participated in DSMES. These cost-savings were largely attributable to decreased inpatient costs.4 

Why are provider referrals important? 

Having diabetes requires one to make daily self-management decisions and perform complex care activities. DSMES provides the foundation to help people with diabetes navigate these decisions and activities, as well as being shown to improve health outcomes. 

While research has proven engagement in DSMES can improve A1c by as much as 0.6% (as much as many medications) or more, this evidence-based program is still greatly underutilized, with less than 5% of Medicare beneficiaries accessing the program, thus underscoring the importance of provider-driven referrals.2 

Policy Guidelines

  1. [Healthcare facility] is committed to providing its healthcare professionals with evidence-based information and resources that aid patients in the successful self-management of diabetes. 
  2. [Healthcare facility] is committed to providing patients with diabetes the recommended education they need to be most successful in self-managing their diabetes. 
  3. [Healthcare facility] encourages all healthcare professionals who see patients with diabetes to refer their patients to DSMES during each of the four critical points: 
    • At diagnosis
    • Annually for health maintenance and prevention of complications
    • When new complicating factors influence self-management
    • When transitions in care occur
  4. [Healthcare facility] will assure that the program to which the referral is made will be a formally recognized DSMES program that follows the National Standards for Diabetes Self-Management Education and Support. 
  5. [Healthcare facility] reaffirms its commitment to educate healthcare professionals, patients with diabetes, and the patient’s family members about the importance of successful diabetes self-management and the availability of DSMES, during points of contact which may include discharge and/or visit summaries. 
  6. [Healthcare facility] requires that all healthcare professionals are educated about the DSMES, its eligibility criteria, recommended referral criteria, and positive patient outcomes [insert frequency, e.g. on an annual basis]. 
  7. [Healthcare facility] integrates assessment of participation in diabetes education at each point of patient contact thus making referral to DSMES a standard of practice when seeing patients with diabetes.
  8. [Healthcare facility] has information about available DSMES programs within the service area and will provide information to the patient when discussing the program. 
  9. [Healthcare facility] will schedule the first appointment for DSMES before the patient leaves the building. 
  10. [Healthcare facility] will follow up with referred patients to assure they have attended DSMES and answer any questions. 
  11. [Healthcare facility] will incorporate DSMES in the organization’s models of care such as Accountable Care Organizations, Patient-Centered Medical Homes, population health programs, and value-based payment models.2 
  12. [Healthcare facility] will employ a self-determined tracking tool to determine the number of patients referred to DSMES within a given timeframe and the A1c level of each referred patient at baseline and at conclusion of participation in DSMES. 

Implement

Implementation will be in a timely manner, offered to all in need and be guided by established guidelines ex. ADA, DSMES. The referral process will be systematic, consistent and written to address workflow, patient identification, individual needs, community resources, notification of navigators, case managers and others who engage with the patients and family to assure appropriate referrals. Engagement with the provider will occur at the time of identification of need. The guidelines will individualize the patient needs at critical times in the disease process including new diagnosis, annually, transitions of care, and new complicating factors. 

Elements of the referral process should include patient registries, patient portal use, and IT/vendor involvement to utilize information from those patient registries. Team members should have available for their use, information including lists of CDEs, educational center and contacts, ADA – DSME sites, and any other educational offerings by. 

Promotion of innovative methods to engage or educate patients are encouraged. Below are best practice suggestions for implementation of this policy. 

  1. Notify patient of appointment with DSMES through the patient portal. 
  2. Keep a registry of who needs DSMES based on core time identified. 
  3. Provide an annual reminder of education for each diabetic patient. 
  4. Support the program with decreased or waived out of pocket expenses. 
  5. Develop a newsletter that is distributed to patients with diabetes or prediabetes. 
  6. Provide written reminders of classes/cost/location and instructors to patients. 
  7. Allow staff to become DSMES certified and provide assistance with cost of education/time off. 
  8. Advertise classes/location/contact information in the community. 
  9. Post flyers and posters at primary care clinics outlining opportunities, when to attend classes, locations, educators. 
  10. Utilize EHS referral at the time of primary care visit.

Enforcement

The above policy language is a guide for your clinic or hospital. Implementing a policy that will fit your facility and benefit your patients is the overall goal and policy compliance should be considered for this purpose. A quality improvement committee should ensure this policy remains a priority. [Healthcare facility] will track quality measures in regard to patients who are and are not referred to DSMES. 

Quality Measures

There are several quality measures that focus on long-term health outcomes, including the Uniform Data System (UDS) and National Quality Strategy (NQF). Both focus on Hemoglobin A1c control and the fact that there will be fewer long-term complications such as amputations, blindness, and end-organ damage, if there is less poorly-controlled diabetes. The measures look at the percentage of patients 18-75 years of age with diabetes who had Hemoglobin A1c > 9.0%. Likewise, the Healthy People 2020 Goal is 16.2% of patients with Hemoglobin A1c >9.0%. 

Merit-based Incentive Payment System 

Improvement activities are a new performance category and clinicians are rewarded for care focused on care coordination, beneficiary engagement, and patient safety. Two improvement activities that might benefit from Diabetes Self-Management Education and Support (DSMES) include: 

  • Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes. 
  • Use group visits for common chronic conditions (e.g., diabetes).5 

Final Statement

By implementing this model policy in its entirety or choosing to tailor this policy to your healthcare facility’s needs, you are taking an important step to improve diabetes self-management for your patients. 

Definition of Terms

Diabetes Self-Management Education and Support (DSMES): the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage diabetes on an ongoing basis. 

Hemoglobin A1c: test that indicates the average level of blood sugar over the past 2 to 3 months. People with diabetes need to have this test done regularly to see whether their blood sugar levels have been staying within a target range. 

Sigmoidoscopy: A procedure where the doctor puts a short, thin, flexible, lighted tube into the rectum. The doctor checks for polyps or cancer inside the rectum and lower third of the colon. 

Mammography: X-ray of the breast used to look for signs of breast cancer.

Summary

Policy Contact

Contact [Healthcare facility staff] with questions or concerns about the policy. 

Effective Date

The policy is effective [date]. 

Policy Monitoring and Review

The [Healthcare facility] will evaluate and revise this policy on an [annual] basis. 

Review Date

The policy will be reviewed [annually]. 

Resources

DSME support in Diabetes- Diabetes Self-management Education and Support in Type 2 Diabetes: https://www.diabeteseducator.org/docs/default-source/practice/practice-resources/position-statements/dsme_joint_position_statement_2015.pdf?sfvrsn=0. 

References

  1. American Diabetes Association. (n.d.) The Burden of Diabetes in South Dakota. Retrieved from http://main.diabetes.org/dorg/PDFs/Advocacy/burden-of-diabetes/south-dakota.pdf. 
  2. Beck, J. et. al. (October 2017). 2017 National standards for diabetes self-management education and support. The Diabetes Educator, 43, 5). 
  3. Centers for Disease Control and Prevention. (June 2017). About Diabetes. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html. 
  4. Center for Health Law and Policy Innovation of Harvard Law School. (n.d.) Reconsidering Cost-Sharing for Diabetes Self-Management Education: Recommendation for Policy Reform. Retrieved from https://www.diabeteseducator.org/docs/default-source/advocacy/reconsidering-cost-sharing-for-dsme-chlpi-paths-6-11-2015-(final-draf.pdf?sfvrsn=2. 
  5. Centers for Medicare and Medicaid Services. (n.d.) Quality Measures. Retrieved from https://qpp.cms.gov/mips/quality-measures. 
  6. Georgia Department of Public Health. (July 2015). Return on Investment of Diabetes Prevention Programs (DPP) and Diabetes Self-Management Programs (DSME/T). Retrieved from https://dph.georgia.gov/sites/dph.georgia.gov/files/DPP-DSME%20ROI%20Factsheet%20July%202015%20Final.pdf.