Enhancing Access to Diabetes Self-management Education in Primary Care.

BackgroundFaith-based health promotion has shown promise for supporting healthy lifestyles, but has limited evidence of reaching scale or sustainability. In one recent such effort, volunteers from a diverse range of faith organizations were trained as peer educators to implement diabetes self-management education (DSME) classes within their communities. The purpose of this study was to identify factors associated with provision of these classes within six months of peer-educator training.MethodsThis study used the Consolidated Framework for Implementation Research (CFIR) to identify patterns from interviews, observations, attendance records, and organizational background information. Two research team members thematically coded interview transcripts and observation memos to identify patterns distinguishing faith organizations that did, versus did not, conduct DSME classes within six months of peer-educator training. Bivariate statistics were also used to identify faith organizational characteristics associated with DSME class completion within this time frame.ResultsVolunteers from 24 faith organizations received peer-educator training. Of these, 15 led a DSME class within six months, graduating a total of 132 participants. Thematic analyses yielded two challenges experienced disproportionately by organizations unable to complete DSME within six months: [1] Their peer educators experienced DSME as complex, despite substantial planning efforts at simplification, and [2] the process of engaging peer educators and leadership within their organizations was often more difficult than anticipated, despite initial communication by Faith and Diabetes organizers intended to secure informed commitments by both groups. Many peer educators were overwhelmed by training content, the responsibility required to start and sustain DSME classes, and other time commitments. Other priorities competed for time in participants’ lives and on organizational calendars, and scheduling processes could be slow. In an apparent dynamic of “crowding out,” coordination was particularly difficult in larger organizations, which were less likely than smaller organizations to complete DSME classes despite their more substantial resources.ConclusionsInitial commitment from faith organizations’ leadership and volunteers may not suffice to implement even relatively short and low cost health promotion programs. Faith organizations might benefit from realistic previews about just how challenging it is to make these programs a sufficiently high organizational and individual priority.

The diabetes education program at the University of Pittsburgh Medical Center (UPMC) is the first reported program in the country to use all key elements of the Chronic Care Model in support of diabetes self-management education (see Figure 1, "the Chronic Care Model," in "Diabetes Care: The Need for Change," page 14).1 Collaboration among UPMC partners, including 19 hospitals and more than 200 primary care providers, has been instrumental to the success of this program. Not only have patients' glycosylated hemoglobin (HbAIc) levels decreased significantly, but also the costs of the program have been supported through increased reimbursement. This financial success is a result of the systems approach of the Chronic Care Model. With the support of the health system, educators were able to access services in administration, finance, billing, insurer contracting, and information technology. Tapping into these resources, educators identified gaps and problems in reimbursement. They relied on administrative support to work with the insurers, and they tracked payment through the computer and data systems. REIMBURSEMENT The key to profitability of a diabetes education program is adequate reimbursement. Medicare and other third-party payors reimburse for such programs if they meet the requirements for the American Diabetes Association (ADA) Education Recognition Program.2 Diabetes education programs pay a $1,100 ADA recognition application fee. Use of the same forms, curricula, and educational materials to assure a consistent approach to diabetes self-management education enabled the entire UPMC system (and, later, smaller facilities in western Pennsylvania that partnered with the program) to apply for ADA recognition as a group for an additional fee of only $100 per site. Support of administrators was critical to the success of the program. The administration was so impressed with the early results, including lower HbAIc levels and increased access to education, that it made diabetes a quality improvement initiative for the entire health system. This provided diabetes educators with access to many areas in the health system, including financial departments. Thus, the educators became aware of problems related to reimbursement in some of the diabetes education programs. For example, some departments weren't filing for reimbursement if they deemed it insignificant. In others, the accounting department was treating reimbursement for diabetes education as a low priority. Once these problems became apparent, administrators and educators joined with insurers. Administrators made sure to meet that staff prioritized reimbursement for diabetes education. Now diabetes education is a break-even operation and is close to becoming profitable. PRIMARY CARE OFFICES For the most part, the diabetes self-management education program at UPMC did not add new services; rather, it brought together existing services as part of an integrated health system. The exception was the addition of diabetes educators to primary care offices. Rather than travel to a hospital outpatient clinic for diabetes education, patients received their education in the more convenient, familiar setting of their physician's office. In response to this change, the program leaders received positive feedback from both patients and providers. Primary care physicians were relieved to have skilled professionals on site who could focus on the often time-consuming task of diabetes education. And they liked having direct communication with a trusted educator who saw their patients in their office. Physicians who had experienced the advantages of having diabetes educators in their office encouraged other physicians to participate in the program. The services provided by these educators were billed through the physician; by contractual agreement, a percentage goes back to the educator. This is in contrast to other situations, in which educators only have access to information regarding charges for their services. They often don't know how much revenue is actually being collected. With our systems approach, however, diabetes educators are part of the team and included in the financial operation. Moreover, they don't have to work with large systems or insurers on their own.

Implementation of a Diabetes Self-Management Education (DSME) Program as part of Discharge Counseling at a County Hospital. The CDC reports 30.3 million people in the United States have diabetes. Adults with diabetes that received Diabetes Self Management Education (DSME) have been shown to have improved outcomes and reduced healthcare expenditures. Those that did not receive DSME are four times more likely to develop complications. The 2016 American Diabetes Association (ADA) Standards of Care in Diabetes recommends that every person receive DSME at diagnosis and as needed thereafter, such as during hospital discharge. Diabetes education is most commonly provided by a Certified Diabetes Educator (CDE), most of whom are nurses or dietitians but about 8% of CDEs are pharmacists. At Zuckerberg San Francisco General Hospital and Trauma Center, there has not been a certified diabetes nurse educator (RN CDE) for the past 4 years. Pharmacists have the clinical training and counseling skills to be effective diabetes educators whether or not they are CDEs. Since August 2017, a pharmacist CDE along with the clinical pharmacy staff have been providing diabetes education along with discharge medication counseling to patients with diabetes prior to hospital discharge. Currently, national rates of newly diagnosed patients that report receiving DSME in their first year ranges from 4-7%. The Center for Disease Control (CDC) reports that 57.4% of people with diabetes report ever attending a DSME class and that 59.8% report ever attending a DSME class within California. At ZSFG, the pharmacist CDE and clinical pharmacy staff provide DSME to patients with newly diagnosed diabetes, diabetic ketoacidosis and diabetic exacerbations. From May 2017 to September 2018 quarterly DSME rates increased from 0.6% in quarter 2 of 2017 to 97.8% in quarter 3 of 2018. Thus, showing that pharmacists can be a valuable resource to improve inpatient diabetes education rates in an institutional setting. Disclosure L.I. Mulala: None.

The purpose of this integrative review was to identify effective diabetes self-management education and support for increasing adult primary care referrals, participation rates and improving health outcomes for persons with diabetes. Integrative review. A systematic literature search of PubMed/MEDLINE, Embase and CINAHL was performed by applying the PRISMA guidelines. Following Whittemore and Knafl's method, 11 papers were included for review. Integration of diabetes self-management education and support in primary care clinics and a multifaceted approach resulted in improved referral and participation rates, ameliorated glycated haemoglobin A1C and boosted patient, provider and staff satisfaction. Patient-centred multifaceted interventions can boost current diabetes self-management education referrals and participation rates and enhance health outcomes for persons with diabetes. Nurses in their role as primary care providers, diabetes educators and clinic staff are well-positioned to undertake this intervention. Further investigation is needed to explore the impact of these interventions among individuals with type 1 diabetes, gestational diabetes and those living across various global regions. Along with other healthcare providers, nurses are qualified to advocate for, and lead programmes that increase referrals for persons with diabetes to improve health outcomes. Additionally, as primary care providers, nurse practitioners are well placed to positively impact the outcomes of individuals with diabetes by referring them to diabetes self-management education. Nurses, as diabetes educators, are well positioned to implement diabetes self-management education which can improve patient outcomes. Improved referral of persons with diabetes to diabetes self-management education and increased participation have the propensity to contribute to the achievement of positive health outcomes for individuals living with Type 2 Diabetes. There is no patient or public contribution for this review.

The Impact of Diabetes Self Management Education Classes On Empowerment and A1c in Ethnic Armenian Elderly

Formal diabetes self-management education (DSME) improves glycemic control. Yet, many patients referred to DSME do not attend. This study examined differences between patients referred to DSME who attended class (PA) and those who did not (PN) to assess factors that might be associated with attendance. Methods: The study was conducted at an urban safety net hospital over two months. Phone interviews (128) were conducted with a convenience sample of patients after the scheduled DSME class (43 PA and 85 PN) to assess reason for attendance or not. Medical records supplied data on demographics, insurance status, and co-morbidities. Results: DSME overall attendance was 32% of 197. While obesity was associated with increased likelihood of attendance (OR 2.67, P < .05), overall disease burden was not. Attendance did not differ by age, sex, diabetes duration, insurance status, or A1c. PA and PN reported similar reasons for planning to attend (general knowledge, 36%; “told to”, 32%; dietary information, 24%). Primary reasons for not attending were time conflicts (31%), poor health (24%), lack of perceived need (24%), and transportation (22%). Excluding those PN who denied perceived need for DSME, 64% of PN wanted to reschedule. Thus, lack of attendance may be related more to barriers than lack of interest. PN wanting knowledge were more likely (OR 6.7 p< 0.001) to want to reschedule and those just “told to” go (OR 0.24 p< 0.05) or felt no need (OR 0.15 p< 0.05) were less likely to reschedule. Conclusions: Addressing both external and internal factors should improve DSME attendance. Flexible/negotiated scheduling, greater variety of class times/locations, ease of rescheduling, and access to alternative transportation options may address external barriers. To address perception of a lack of need for DSME, additional strategies such as clear communication of DSME benefits by clinical providers are needed to enhance attendance. Disclosure R. Wolf: None. C.S. Barnes: None. J. Caudle: None. S.G. Krishnapura: None. J.L. Dupont: None. R.J. Crawford: None. P.L. Dickerson: None. D.C. Ziemer: None.

Purpose: Chinese Americans (CAs) with diabetes and limited English proficiency often struggle to adhere to standard diabetes diets focused on food measurement/restriction. Chinese medicine principles commonly inform food choices among CAs but are rarely acknowledged in nutritional interventions. We developed and tested feasibility of a theoretically informed integrative nutritional counseling (INC) program that combines Chinese medicine principles with biomedical nutrition standards.Methods: We randomized diabetes self-management education (DSME) classes to include either: (1) usual nutrition curriculum based on American Diabetes Association (ADA) recommendations delivered by a diabetes educator (control) or (2) INC curriculum based on a combination of ADA recommendations and Chinese medicine principles delivered by a diabetes educator and a licensed acupuncturist (intervention). All DSME enrollees were invited to participate in research entailing data collection at three time points: baseline, after the DSME nutrition class, and at 6-month follow-up. Using validated measures, we collected dietary self-efficacy, diabetes distress, diet satisfaction, and dietary adherence. We also measured weight and glycemic control.Results: Study participants were 18 Cantonese-speaking patients with diabetes who were predominantly female and older, with low levels of income and acculturation. Intervention and control groups were similar at baseline. INC performed similarly to usual DSME with 100% of participants reporting the INC booklet helped their learning. Dietary adherence significantly improved in participants who received the INC curriculum.Conclusion: INC is feasible to implement as part of DSME classes and shows promise as a complementary culturally sensitive addition to usual diabetes nutrition education for CA patients.

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

Diabetes Self-Management Education (DSME) is recommended for patients with a new diagnosis or without prior diabetes education. However, not all Military Treatment Facilities (MTFs) have capacity to provide this resource to patients, which creates a disparity in healthcare. The Diabetes Center of Excellence (DCOE) has an ADA-recognized DSME program and potential to fill this gap through DSME via telemedicine. The Military Interagency Satellite Training (MIST) system, which utilizes satellite technology to broadcast one-way video and two-way audio to distance learners, is available at all MTFs. To test the concept, DSME was broadcast to Randolph Air Force Base (RAFB) from October 2016-October 2017. During this time, 181 patients enrolled in DSME classes; 127 were DCOE patients and 54 were from RAFB. Among data collected were pre/post patient knowledge tests and the validated 17-item Diabetes-related Distress Scale (DDS-17). Knowledge significantly increased from baseline to Class 4. Few patients completed all 4 classes and 6 month follow-up (n=16). Patients had an increase in all DDS-17 domains at the completion of Class 4; however, by 6 months, distress returned to baseline levels. Patient satisfaction surveys were completed at DCOE (n=429) and RAFB (n=227) at each encounter and provider satisfaction surveys were collected from RAFB facilitators. Patients at RAFB reported higher satisfaction (99.1%) than DCOE patients (97.2%). In fact, most measures of satisfaction were higher in RAFB patients than DCOE patients. Moreover, facilitators expressed high satisfaction with DSME via MIST and all facilitators were willing to conduct more classes in this format. Initiation of the DSME Telehealth program presented challenges, especially in technology-related issues and documentation at 6 months. The pilot program allowed the DCOE to gain valuable feedback from our remote site. Technology issues have largely been resolved enabling us to provide an even better experience to our new sites in 2018. Disclosure N. Watson: None. D.G. Acuna: None. J.L. Wardian: None. E.C. Cobb: None. D. Beavers: None. T.J. Sauerwein: Speaker's Bureau; Self; Merck & Co., Inc., AstraZeneca.

The purpose of this study was to examine patients' diabetes risk factors, comorbid conditions, and patient participation in and primary care practitioner (PCP) referrals to a rural diabetes self-management education (DSME) program. A total of 295 patients in a rural community were identified by their PCP as having type 2 diabetes (T2D). Using patient information that was collected and entered into a diabetes data management system, patients' risk factors, comorbid conditions, and patient participation in and PCP referral patterns to a DSME program were examined. Of the 295 patients with T2D, 162 (65%) reported that they had never received any DSME services. Despite educator efforts to improve patient participation and PCP awareness of local DSME services, 123 (76%) of the 162 patients never received a subsequent referral for DSME. Those patients who did receive a referral had a higher number of risk factors and comorbid conditions than those who did not receive a referral. Eighty-three percent of the patients who received a PCP referral attended the DSME program. The findings reaffirm concerns that DSME patient participation and PCP referral practices are poor. Advocacy efforts should force policies and procedures that will make DSME a mandatory service and universally accessible. Unless referral practices are attended to, it is doubtful that the United States will reach the Healthy People 2010 objective for diabetes education.

Veterans with prediabetes are referred to a Diabetes Self‐Management Education (DSME) to provide them with the skills, knowledge, and ability to adopt lifestyle behaviors that will prevent the onset of diabetes.PurposeTo evaluate the impact of goal setting and behavior changes on body weight (BW; kg), hemoglobin A1C (A1C; %), and systolic blood pressure (SBP; mmHg) in Veterans with prediabetes.MethodsSecondary data analysis was conducted on de‐identified data collected on Veterans with prediabetes who attended DSME at Louis Stokes Cleveland Department of Veterans Affairs Medical Center. BW, SBP, and A1C were assessed pre‐ and post‐DSME and then compared as follows: 1) Behavior Changes: Veterans who followed the American Association of Diabetes Educators 7 (AADE7; n=16) self‐care behaviors vs. those who did not (C; n=40); 2) Goal Setting (Diet and Exercise): Veterans were grouped and compared according to goals of diet only (Diet, n=51), exercise only (Ex; n=34), diet and exercise (Diet+Ex; n=27), or control (i.e., no goals set; n=9); and 3) Goal Setting (Objective vs. Subjective): Veterans with objective (n=57; i.e., goals measured by changes in biomarkers) vs. subjective (n=27; i.e., goals measured by changes in lifestyle behaviors) goals. The changes in BW, A1C, and SBP were evaluated utilizing two‐way analysis of variance (Group × Time). Dunnett's Test was used to evaluate if goal setting groups (Diet, Ex, and Diet+Ex) differed from control.ResultsThe change in BW, A1C, and SBP were similar between AADE7 (change in BW=−1.3±4.9kg, A1C=−0.2±0.4%, and SBP=3±18mmHg) and C groups (change in BW=−1.9±7.8kg, A1C=−0.0±0.4%, and SBP=2±17mmHg; p>0.05). Goal setting choices for diet and exercise were not associated with changes in BW (Diet=−0.8±3.8kg, Ex=−1.1±3.7kg, Diet+Ex=−1.7±5.7kg, and control=−5.5±22.1kg; p>0.05) and A1C (Diet=−0.2±0.3%; Ex=0.0±0.3%; Diet+Ex=0.0±0.4%; and control=−0.1±0.2%; p>0.05). Lastly, the changes between the subjective group (change in A1C= −0.1±0.4%; BW= −2.2±20.3kg; SBP=2±32mmHg) and the objective group (change in A1C= −0.1±0.4%; BW= −2.2±7.4kg; SBP=1±17mmHg) were also similar (p>0.05).ConclusionBehavior changes and goal setting choices were not associated changes in BW, A1C, or SBP in Veterans with prediabetes participating in DSME program. The incorporation of self‐monitoring devices (e.g., fitness trackers and continuous glucose monitors). which provide immediate feedback, may aid Veteran with prediabetes in making recommended lifestyle changes to prevent the onset of diabetes.

Despite evidence that DSME is a critical component of diabetes (DM) care, participation remains low. Innovative methods to improve attendance need to be explored. The purpose of this study was to evaluate the impact of a primary care (PC)-based DSME delivery model on DSME referrals and participation. Using a non-randomized design, diabetes educators (DEs) and PC practices were assigned to the intervention group (IG; 3 DEs, 6 practices) or control (CG; 2 DEs, 6 practices). IG practices applied patient-centered medical home elements to DSME delivery and had direct access to a DE. The CG employed traditional DSME delivery (PC patients referred to hospital-based DE). To examine DSME referrals and participation, medical record data were extracted for patients with DM, 18-75y, presenting to PC practices over 18 months (n=4,894; 59% IG, mean age 58.7y, 50.8% male) and compared between study groups. IG practices referred a higher percentage of patients to DSME compared to CG (18.4% v 13.4%; p<0.0001). Of those referred, IG patients were more likely to attend DSME than CG (34.9% v 26.1%; p=0.02). This equated to a total of 6.8% IG and 3.5% CG patients participating in DSME. Adjusted multiple logistic regression modeling found that IG practices were 1.8 times more likely to refer patients to DSME than CG (Confidence Level 1.4-2.2). Other factors that predicted referrals were female (Odds Ratio=1.3, CL 1.1-1.6), obesity (OR=1.6, CL 1.3-2), and higher A1c (OR=1.4, CL 1.3-1.4). Older patients were less likely to be referred (OR=0.98, CL 0.975-0.999). Similar adjusted regression modeling found that IG patients were 1.7 times more likely to participate in DSME than CG (CL 1.1-2.6); lower A1c also predicted DSME attendance (OR=0.9, CL 0.8-0.999). This study demonstrates the positive influence of a PC-based intervention on DSME referral and participation. However, modest improvements in DSME rates, even with targeted efforts to address barriers, raise questions as to what is truly needed to drive meaningful change. Disclosure J. Krall: None. J. Kanter: None. K. Ruppert: None. V.C. Arena: None. F.X. Solano: None. L.M. Siminerio: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Objective. The purpose of this study was to evaluate glycemic control as measured by A1C during a 2-year period after patients received diabetes self-management education (DSME).Methods. Patients who completed DSME in 2009 and received medical follow-up with A1C measurements for at least 2 years after DSME were included in the evaluation. Primary endpoints were changes in A1C from before to immediately after, 1 year after, and 2 years after DSME. Secondary outcomes included the effects of the following factors on change in A1C: sex, duration of diabetes, uncontrolled diabetes (A1C ≥ 9%), health insurance coverage, and self-reported education level.Results. Forty-three patients were included in the evaluation. Mean A1C before DSME was 10.2 ± 3.7%. Mean A1C after DSME was 7.8 ± 2.2% (P < 0.0001), a 23.5% reduction. Mean A1C at 1 and 2 years after DSME was 7.8 ± 2.1% for each year and remained unchanged from just after DSME to 1 and 2 years after DSME (P > 0.05). Patients with a duration of diabetes of < 1 year had a significantly greater reduction in mean A1C than those with a duration of diabetes ≥ 1 year (28.7 and 20.2%, respectively, P = 0.001).Conclusion. DSME improved glycemic control to a substantial degree, and the effect was sustained for up to 2 years. Although the reduction in A1C was significant for all patients receiving DSME, there was a significantly greater reduction for patients who had a duration of diabetes of < 1 year than for those with a duration of diabetes > 1 year.

PurposeThis study investigated the sociodemographic factors associated with participation in diabetes self-management education (DSME) among community-dwelling adults with diabetes.Materials and MethodsData from 23400 people aged ≥30 years who were diagnosed with diabetes from the nationwide 2016 Korea Community Health Survey were analyzed. The relationship between sociodemographic factors and participation in DSME was examined by logistic regression analysis. The study sample was classified according to the type of institution providing DSME: hospitals/medical clinics (HMCs) and/or public health institutions (PHIs).ResultsOf the total sample population with diabetes, 27.2% had attended DSME programs, including 21.9% at HMCs, 4.0% at PHIs, and 1.3% at both types of institutions. As age increased and educational level and monthly household income decreased, the odds ratios (ORs) of participation in DSME decreased in a fully adjusted model. Respondents living in rural areas had lower ORs for attending DSME compared to those living in urban areas [OR, 0.85; 95% confidence interval (CI), 0.80–0.91]. Service/sales workers and mechanical/manual workers had lower ORs for attending DSME (OR, 0.84; 95% CI, 0.71–0.99; and OR, 0.81; 95% CI, 0.69–0.94, respectively) compared to professional/managerial workers. However, in the subgroup of participants receiving education at PHIs, the likelihood of participation in DSME increased as age increased, and respondents living in rural areas had higher ORs compared to those living in urban areas (OR, 1.73; 95% CI, 1.51–1.98).ConclusionCustomized DSME programs targeting socioeconomically vulnerable groups, including residential region and reimbursement of DSME by public insurance, are needed to resolve the inequalities in participation in DSME.

The purpose of this study is to explore issues related to access to diabetes self-management education (DSME), including supply and demand, educator outreach and expansion efforts, patient and physician barriers to access, and acceptability of alternative DSME delivery strategies. Telephone focus groups were conducted with 17 diabetes educators, 18 primary care physicians who treat adults with diabetes, and 14 adults with type 1 or type 2 diabetes (8 in a group for those who had received diabetes education and 6 in a group for those who had not). DSME programs develop new services to attract additional patients but do little outreach, and budget struggles are common. Some physicians establish good relationships with DSME programs, but others are critical of the available programs and experience conflicts over the role of educators vis-à-vis that of the physician. Physicians do not refer all patients to DSME and are perceived by educators and patients as not providing enough encouragement to attend DSME. Patients generally have positive experiences with DSME but do not discuss these experiences with their physicians. Patients are receptive to alternative strategies for DSME delivery (community settings, electronic media), but physicians are concerned about meeting standards, and educators want to make sure that they are available to support alternative education strategies. Future advocacy efforts should seek implementation of policies to guarantee that all people with diabetes can receive the DSME they need.