Scaling the Diabetes Prevention Program and Diabetes Self-Management Education and Support Services Across a Health System

<p dir="ltr">This article describes and evaluates a multipronged strategy to expand use of the Diabetes Prevention Program (DPP) and diabetes self-management education and support (DSMES) services across a large academic health system. Strategies included streamlining referral processes, embedding diabetes educators in primary care, leveraging consistent leadership messaging, and building partnerships with community organizations. These interventions led to substantial increases in referrals, with 10.8% of 4,397 patients enrolling in DPP and 35.9% of 10,210 enrolling in DSMES. Coordinated, multilevel interventions can effectively increase engagement in these underutilized, evidence-based diabetes care programs.</p>

<p dir="ltr">This article describes and evaluates a multipronged strategy to expand use of the Diabetes Prevention Program (DPP) and diabetes self-management education and support (DSMES) services across a large academic health system. Strategies included streamlining referral processes, embedding diabetes educators in primary care, leveraging consistent leadership messaging, and building partnerships with community organizations. These interventions led to substantial increases in referrals, with 10.8% of 4,397 patients enrolling in DPP and 35.9% of 10,210 enrolling in DSMES. Coordinated, multilevel interventions can effectively increase engagement in these underutilized, evidence-based diabetes care programs.</p>

Background: In New York, Medicaid began covering diabetes self-management education and support (DSMES) services in 2009, but participation in these services remains low. This study sought to understand barriers and facilitators to referring and enrolling eligible Medicaid members to DSMES, and to yield recommendations for increasing referrals and enrollment. Methods: We conducted 14 virtual focus groups with primary care providers, endocrinologists, and certified diabetes care and education specialists (CDCESs) in New York City and the rest of the state. We used an inductive-deductive coding process to identify common themes and recommendations across participant types. Results: Participants recommended resources for addressing knowledge gaps about the benefits of DSMES and how to refer eligible Medicaid members: an online resource guide and directory of accredited services by location and insurance type; automated provider prompts; materials for exam rooms; and reimbursement guidance. Recommended strategies for disseminating resources to increase provider and patient awareness of DSMES included an advertising campaign targeting physicians and people with diabetes; academic detailing; e-mail blasts from credible sources (e.g., health department, Medicaid) ; and direct outreach (e.g., personal phone calls) to eligible Medicaid members. Conclusions: Increasing participation in DSMES hinges upon increasing provider referrals and addressing barriers to participation. CDCESs in NY reported limited capacity to provide DSMES to referred patients in a timely manner, highlighting a need to expand the workforce to meet current and future demands should referrals increase with improved awareness and buy-in. Although the strategies and recommendations identified in this study reflect the perspectives of NY providers, they may have broad applicability to other states in which Medicaid covers DSMES. Disclosure L.Arena: None. N.S.Esquivel: None. R.Austin: None. S.Millstein: None. J.Kaelin-kee: None. Funding Centers for Disease Control and Prevention (CDC NU58DP006523)

Background: Diabetes self-management education and support (DSMES) services are an integral part of quality diabetes care. However, despite strong evidence regarding its effectiveness and clear guidelines from the ADA recommending its use, <10% of eligible patients have received DSMES. In this study, we examine rates of referral to DSMES across specific subgroups at an academic medical center in Kentucky. Methods: We analyzed patterns of DSMES referrals at University of Kentucky HealthCare from 1/1/2016-12/31/20among adult patients (aged ≥ 18) with diabetes (ICD-9: 249, 250; ICD-10: E08-E13) . We restricted our sample to patients receiving primary care at UKHC with at least 365 days of follow-up and examined referral rates across the following subgroups: sex, race/ethnicity, age group, insurance type. Results: In our sample of 3,854 patients with diabetes (mean (SD) age=56.8 (13.9) ; 50% female) , 9.3% of eligible patients were referred for DSMES. Referral rates were higher in non-Hispanic Black patients (14.5%) compared to non-Hispanic Whites (9.4%) and Hispanics (9.4%; p<0.001) . Females were more likely to be referred for DSMES than males (12.3% vs. 8.7%; p<0.001) and younger patients were more likely to be referred than older patients (27.5% of patients age 18-24 vs. 5.0% of patients aged 65+; p<0.0001) . Referral rates were lower in patients with Medicare coverage (7.6%) compared to those with Medicaid (13.0%) or commercial insurance (11.6%; p<0.0001) . Conclusions: Results from our study highlight low referral rates for DSMES services in the primary care setting for patients with diabetes. Our findings also underscore disparities in key subgroups that can be targeted to improve DSMES referrals. Of particular significance are differences in DSMES referral rates across age categories. Older patients face diabetes-related challenges they may change as they age. The importance of continuing DSMES services across the lifespan should be highlighted. Disclosure G.C.Bryant: None. J.Keck: None. M.E.Lacy: None. Funding National Institutes of Health (UL1TR000117, UL1TR001998, KL2TR001996)

BackgroundAlthough evidence shows that diabetes self-management education and support (DSMES) is an effective tool to help individuals with type 2 diabetes (T2DM) improve their health outcomes, there remains a large number of individuals not attending DSMES. Understanding how frequently patients receive referrals to DSMES and the number of DSMES hours they receive is important to determine, as well as patients’ health outcomes of utilizing DSMES. This will help us understand patterns of utilization and the outcomes that occur when such a valuable resource is utilized.MethodsSecondary data analysis was conducted of patient electronic medical records at a primary healthcare federally qualified clinic and 2 area hospitals. We identified 105 adult patients with a new T2DM diagnosis with at least 2 A1c lab results 3 to 12 months apart during the study period.ResultsOnly 53.5% were referred to DSMES. Out of those who were referred, 66% received no DSMES, 17% received 1-hour assessment, 4% received partial DSMES, and 13% received 8 or more hours. Linear regression of percent change in A1c and number of DSMES hours received, revealed that receiving 1 (P = .001) or 8 or more hours of DSMES (P = .022) had a significant negative relationship with the percent difference in A1c compared to the group who received no DSMES. Patients who had an hour of assessment had a similar percent reduction in A1c to those who had partial DSMES.ConclusionReferral rates and enrollment in DSMES remain low. Those who enrolled often dropped out after the one-hour assessment session. Results suggest making the one-hour assessment session more educationally comprehensive or longer to retain patients. Improving the DSMES referral process and further investing physicians’ decisions on whether to refer or not refer patients to DSMES are key for future studies.

This systematic review and network meta-analysis compared the effects of various diabetes self-management programs: Diabetes Self-Management Education (DSME), Diabetes Self-Management Support (DSMS), and Diabetes Self-Management Education and Support (DSMES). We searched four electronic databases for eligible articles up to March 1, 2023. Only randomized controlled trials investigating the effects of DSME, DSMS, or DSMES on glycated haemoglobin (HbA1c) level, fasting blood glucose (FBG), total cholesterol (TC), systolic blood pressure (SBP), and diastolic blood pressure (DBP) in adults with type 2 diabetes were included. Cochrane Risk of Bias 2.0 tool was used to assess each study quality, and Confidence in Network Meta-Analysis was applied to evaluate the certainty of the evidence. Data were pooled with a random-effects model under a frequentist framework. A total of 108 studies encompassing 17,735 participants (mean age 57.4years) were analysed. DSMES, compared with usual care, significantly reduced HbA1c level (mean difference=-0.61%, 95% confidence interval [CI]=-0.74 to -0.49; certainty of evidence=moderate), FBG (-23.33mg/dL; -31.33 to -15.34; high), TC (-5.62mg/dL; -8.69 to -2.55; high), SBP (-3.05mmHg; -5.20 to -0.91; high), and DBP (-2.15mmHg; -3.36 to -0.95; high). Compared with DSME, DSMES showed significantly greater improvements in HbA1c levels (-0.23%; -0.40 to -0.07; high) and DBP (-1.82mmHg; -3.47 to -0.17; high). DSMES was ranked as the top treatment for improving diabetes clinical outcomes (0.82-0.97) in people with type 2 diabetes. DSMES, in people with type 2 diabetes, yields the greatest improvement in the key clinical outcomes of HbA1c, fasting blood glucose, and blood pressure levels. Healthcare providers should incorporate the DSMES approach into their daily care routines. Approximately 30% of the studies reviewed raised some concerns about their quality, underscoring the need for high-quality studies in this area.

Telehealth for diabetes self-management education and support in an underserved, free clinic population: A pilot study

Diabetes is a chronic disease that requires a person with diabetes to make a multitude of daily self-management decisions and to perform complex care activities. Diabetes self-management education and support (DSME/S) provides the foundation to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes (1–7). Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes self-management support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. (See further definitions in Table 1.) Although different members of the health care team and community can contribute to this process, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type 2 diabetes receive both DSME and DSMS in a consistent manner. The initial DSME is typically provided by a health professional, whereas ongoing support can be provided by personnel within a practice and a variety of community-based resources. DSME/S programs are designed to address the patient’s health beliefs, cultural needs, current knowledge, physical limitations, emotional concerns, family support, financial status, medical history, health literacy, numeracy, and other factors that influence each person’s ability to meet the challenges of self-management. View this table: Table 1 Key definitions It is the position of the American Diabetes Association (ADA) that all individuals with diabetes receive DSME/S at diagnosis and as needed thereafter (8). This position statement focuses on the particular needs of individuals with type 2 diabetes. The needs will be similar to those of people with other types of diabetes (type 1 diabetes, prediabetes, and gestational diabetes mellitus); however, the research and examples referred to in this article focus …

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

Diabetes is a chronic disease that requires a person with diabetes to make a multitude of daily self-management decisions and to perform complex care activities. Diabetes self-management education and support (DSME/S) provides the foundation to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes (1–7). Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes self-management support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. (See further definitions in Table 1.) Although different members of the health care team and community can contribute to this process, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type 2 diabetes receive both DSME and DSMS in a consistent manner. The initial DSME is typically provided by a health professional, whereas ongoing support can be provided by personnel within a practice and a variety of community-based resources. DSME/S programs are designed to address the patient’s health beliefs, cultural needs, current knowledge, physical limitations, emotional concerns, family support, financial status, medical history, health literacy, numeracy, and other factors that influence each person’s ability to meet the challenges of self-management. View this table: TABLE 1. Key Definitions It is the position of the American Diabetes Association (ADA) that all individuals with diabetes receive DSME/S at diagnosis and as needed thereafter (8). This position statement focuses on the particular needs of individuals with type 2 diabetes. The needs will be similar to those of people with other types of diabetes (type 1 diabetes, prediabetes, and gestational diabetes mellitus); however, the research and examples referred to in this article focus …

The world of diabetes is changing rapidly. Health care professionals, educators, and people with diabetes are advocating for more and better management options. Educators and providers must grow with the technology and tools available to better serve participants and patients. The 2017 National Standards for Diabetes Self-Management Education and Support (DSMES) (1), issued jointly this summer by the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE), help educators and providers do just that, by outlining requirements of DSMES service providers and offering best practices for those in the field. The DSMES standards are updated periodically—currently, every 5 years—by a Standards Revision Task Force convened by ADA and AADE to review and incorporate the latest research. Following are some of the major updates and highlights from the 2017 DSMES standards, including key takeaways and tools for providers of DSMES services. Previous DSMES standards referred separately to “diabetes self-management education” and “diabetes self-management support.” In the 2017 standards, the two have been combined and are now referred to jointly as “diabetes self-management education and support.” Education is not sustainable for people with diabetes if they do not have the support to continue to make choices and changes to manage their condition. Likewise, support from a diabetes care team needs to include a teaching element, so people with diabetes are up to date about tools and actions they can use for their management. Also, both education and support need to be ongoing, because diabetes is a lifelong condition; there is no “one …

The world of diabetes is changing rapidly. Health care professionals, educators, and people with diabetes are advocating for more and better management options. Educators and providers must grow with the technology and tools available to better serve participants and patients. The 2017 National Standards for Diabetes Self-Management Education and Support (DSMES) (1), issued jointly this summer by the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) and reprinted in this issue (p. 301), help educators and providers do just that, by outlining requirements of DSMES service providers and offering best practices for those in the field. The DSMES Standards are updated periodically—currently, every 5 years—by a Standards Revision Task Force convened by ADA and AADE to review and incorporate the latest research. Following are some of the major updates and highlights from the 2017 DSMES Standards, including key takeaways and tools for providers of DSMES services. Previous DSMES Standards referred separately to “diabetes self-management education” and “diabetes self-management support.” In the 2017 Standards, the two have been combined and are now referred to jointly as “diabetes self-management education and support.” Education is not sustainable for people with diabetes if they do not have the support to continue to make choices and changes to manage their condition. Likewise, support from a diabetes care team needs to include a teaching element, so people with diabetes are up to date about tools and actions they can use for their management. Also, both education and support need to be ongoing, because diabetes is a lifelong …

Diabetes self-management education and support (DSMES) provides an evidence-based approach to empower people with diabetes to navigate self-management decisions and activities, and has been shown to improve health outcomes. Despite the evidence that DSMES services are cost-effective and have a positive impact on diabetes-related outcomes, they are underutilized. To address this problem, the Centers for Disease Control and Prevention (CDC) developed a DSMES toolkit to increase access to and participation in DSMES services among people with diabetes and to promote health care provider referrals. The toolkit explains the process for securing recognition or accreditation of DSMES services. It offers resources to assist in maximizing reimbursement, eliminating barriers to participation, and linking DSMES to quality measures. The toolkit suggests improving access to DSMES through shared medical appointments, pharmacies, and telehealth. It describes the four critical times to refer persons to DSMES and provides tools to assist with making referrals. National experts from the American Diabetes Association and the American Association of Diabetes Educators, certified diabetes educators (CDE), and public health professionals informed the content of the toolkit. Participants from six state health departments; three DSMES services (pharmacy, federally qualified health center, local health department); and experts from the CDC (pharmacist CDE, nurse diabetes educator, project officer, endocrinologist) tested the toolkit and found it easy to use with relevant information that will be helpful in addressing barriers and challenges to improving access to and participation in DSMES. Expanded use of and referrals to DSMES can help ensure that people with diabetes receive the support they need to successfully manage their diabetes and prevent or delay serious and costly complications. The DSMES toolkit can assist diabetes and public health professionals in working together to address underuse of DSMES. Disclosure J. Houston: None. L.E. Edwards: None.

Population health management approaches can help target diabetes resources like Diabetes Self-Management Education and Support (DSMES) to individuals at the highest risk of complications and poor outcomes. Little is known about patient characteristics associated with DSMES receipt since widespread uptake of telemedicine for diabetes care in 2020. In this retrospective cohort study, we used electronic medical record (EMR) data to assess patterns of DSMES delivery from May 2020 to May 2022 among adults who used telemedicine for type 2 diabetes (T2D) endocrinology care in a large integrated health system. Multilevel regression models were used to evaluate the association of key patient characteristics with DSMES receipt. Of 3530 patients in the overall cohort, 401 patients (11%) received DSMES. In adjusted multivariable logistic regression, higher baseline HbA1c (odds ratios [OR] 3.10 [95% confidence interval 2.22-4.33] for HbA1c ≥9% vs <7%), insulin regimen complexity (OR 3.53 [2.59-4.80] for multiple daily injections vs no insulin), and number of noninsulin medications (OR 1.17 [1.05-1.30] per 1 additional medication) were significantly associated with receipt of DSMES, whereas rurality and area-level deprivation of patient residence were not. Diabetes Self-Management Education and Support remains underutilized in this cohort of adults using telemedicine to access endocrinology care for T2D. Factors contributing to clinical complexity increased the odds of receiving DSMES. These results support a potential population health management approach using EMR data, which could target DSMES resources to those at higher risk of poor outcomes. This risk-stratified approach may be even more effective now that more people can access DSMES via telemedicine in addition to in-person care.

By the most recent estimates, 30.3 million people in the U.S. have diabetes. An estimated 23.1 million have been diagnosed with diabetes and 7.2 million are believed to be living with undiagnosed diabetes. At the same time, 84.1 million people are at increased risk for type 2 diabetes. Thus, more than 114 million Americans are at risk for developing the devastating complications of diabetes (1). Diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes. DSMES is the ongoing process of facilitating the knowledge, skills, and ability 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 previous National Standards for Diabetes Self-Management Education and Support (Standards), DSMS and DSME were defined separately, but these Standards aim to reflect the value of ongoing support and multiple services. The Standards define timely, evidence-based, quality DSMES services that meet or exceed the Medicare diabetes self-management training (DSMT) regulations, however, these Standards do not guarantee reimbursement. These Standards provide evidence for all diabetes self-management education providers including those that do not plan to seek reimbursement for DSMES. The current Standards’ evidence clearly identifies the need to provide person-centered services that embrace the ever-increasing technological engagement platforms and systems. The hope is that payers will view these Standards as a tool for reviewing DSMES reimbursement requirements and consider change to align with the way their beneficiaries’ engagement preferences have evolved. Research confirms that less than 5% of Medicare beneficiaries utilize their DSMES benefits (2,3). Changes in reimbursement policies stand to increase DSMES access and utilization, which will result in positive impact to beneficiaries’ clinical outcomes, quality of …