An Evidence-Based, Underutilized Intervention KPCA Annual Fall Conference November 9, 2017 Kim Coy DeCoste RN, MSN, CDE, MLDE Kentucky Department for Public Health Kentucky Diabetes Prevention and Control Program (KDPCP)

Objectives Upon completion of this session, learners will be able to: Describe the evidence around quality diabetes self-management education (DSME) and its relationship to improved diabetes outcomes. Identify resources for referral for DSME or for incorporating DSME into your practice. 2

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Diabetes in Kentucky Adults 449,324 with diagnosed diabetes 1.1 Million with Prediabetes* 275,368 Kentucky adults (9.6%) report a diagnosis of prediabetes (KY BRFSS, 2016) *National Health Interview Survey estimates applied to KY 4

Diabetes in Adults by County 106 of Kentucky’s 120 counties had rates of diagnosed diabetes at 11.2% or above ─ ranking these counties among the top in the nation! (2013 CDC Diabetes Atlas) http://www.cdc.gov/diabetes/atlas/countydata/atlas.html 5

Diabetes Prevalence by Area Development District 6 Diabetes Prevalence by Area Development District 2015 KY Behavioral Risk Factor Surveillance Survey 6

Clinical and Self-Care Measures Kentucky Department for Public Health and CDC, BRFSS Survey, 2011, 2012, 2013, 2015 7

DSMES is an integral part of standard diabetes care. “… Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications …” ADA. Standards of Medical Care. Diabetes Care (2017)

What is DSMES? “Diabetes self-management education and support is the ongoing process of facilitating the knowledge, skills, and ability necessary for prediabetes and 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. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by evidence-based standards. 9

What is DSMES? (continued) Support (whether behavioral, educational, psychosocial, or clinical) helps implement informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status and quality of life.” Beck et. al, Diabetes Care and The Diabetes Educator, July 2017 10

What is DSMES? (continued) Healthy eating Being active Monitoring Taking medication Problem solving Healthy coping Reducing risks DSMES focuses on seven self-care behaviors

National Standards for DSMES 2017 –The Standards define timely, evidence-based quality DSMES services that meet or exceed the Medicare DSMT regulations. Evidence supports person- centered services. The current standards are designed to reflect the value of ongoing support and multiple services.

National Standards for DSMES Internal Structure Stakeholder Input Evaluation of Population Served Quality Coordinator Overseeing DSMES Services DSMES Team

DSMES Team At least one team member facilitating DSMES will be a RN, RD, or Pharmacist with training and experience pertinent to DSMES or another health professional holding a certification as a diabetes educator (CDE) or Board Certified Advanced Diabetes Manager (BC-ADM). Licensed Diabetes Educator In 2011, KY became the first state to pass legislation relating to licensure of diabetes educators. Licensed diabetes educators are health professionals, registered nurses, registered dietitians, pharmacists, licensed clinical social workers and other CDE eligible health professionals. Diabetes Paraprofessional Must directly report to the qualified DSMES team member.

National Standards for DSMES Curriculum Individualization Ongoing Support Participant Progress Quality Improvement

Evidence-Based Curriculum Core Content Areas Diabetes pathophysiology and treatment options Healthy eating Being active Monitoring and using patient- generated health data Taking medication Problem solving Healthy coping –with psychosocial issues and concerns Reducing risks –preventing, detecting and treating acute and chronic complications

National Standards for DSMES Curriculum Individualization Ongoing Support Participant Progress Quality Improvement

DSMES Improves Outcomes Immediate Intermediate Post-intermediate Long-Term Behavior Change Clinical Indicators Improved Health Status Learning Outcomes Continuum

DSMES Improves Outcomes More likely to receive guideline driven care More likely to take medications as prescribed More likely to use primary care and preventive services or follow- up on treatment recommendations More healthful eating patterns and regular activity Increased self-efficacy and empowerment Healthy coping Improved quality of life Improved A1C - 1% reduction translates to: 21% reduction in diabetes-related death 14% reduction in MI 37% reduction in microvascular complications Reduced hospital admissions and readmissions Reduced healthcare costs

If DSMES were a pill would you prescribe it? AADE, Joint Position Statement Toolkit; https://www.diabeteseducator.org/practice/educator-tools/joint-position-statement-toolkit 20

Four critical times for DSMES At diagnosis. Annually for assessment of education, nutrition and emotional needs. When new complicating factors influence self- management. When transitions in care occur. Powers, et. al, 2015

DSMES makes the biggest impact when: Both group and individual education are involved Provided by a team rather than an individual More than 10 hours is attended The DSMES is individualized to the participant Is focused on behavior and engages the participant rather than didactic

Licensed Diabetes Educators/Provision of DSMES can Support the Work You Do Increase your practice efficiency By assuming time-consuming patient training and counseling to reinforce your treatment recommendations Quality and payment Improve Clinical Quality Measures Achieve pay-for-performance/quality improvement goals Be better positioned for MACRA and ongoing healthcare reform Help track and monitor your patient’s progress

Call to Action Refer to an accredited or recognized DSMES program----at all critical times When someone is diagnosed Yearly check ins When a new challenge is presented, such as financial or emotional distress, or medication issues When there are changes in a person’s healthcare: physician, insurance, moving to a new location, or experiencing age-related issues Utilize the Kentucky Diabetes Resource Directory https://prd.chfs.ky.gov/KYDiabetesResources/

Kentucky Diabetes Resource Directory

Call to Action Utilize “Change Package for Clinical Practice Teams” Make DSMES referral part of standing orders Establish mechanism for comparing outcomes in patients who have had DSME compared to those who have not Use clinical decision supports/prompts in EHR system Encourage staff to observe a quality DSMES program Become an accredited or recognized DSMES provider Provide ongoing diabetes self-management support

References & Resources Garfield, Downer, Rosenberg, Greenwald, Reconsidering Cost-Sharing for Diabetes Self-Management Education: Recommendation for Policy Reform, Center for Health Law & Policy Innovation, Harvard Law School (2015). Powers et. al, 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 Care 2015; 38:1-11/DOI: 10: 10.2337/dc15-0730 Duncan et.al., Assessing the Value of the Diabetes Educator, 37, The Diabetes Educator, no. 5, 638-657. Sept./Oct. 2011. Li R, S. , et. al; Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2014 Nov 21;63(46):1045-9 Norris et. al, Self-Management Education for Adults With Type 2 Diabetes .A meta-analysis of the effect on glycemic control; Diabetes Care 2002 Jul; 25(7): 1159-1171. https://doi.org/10.2337/diacare.25.7.1159 Beck, et. al , 2017 National Standards for Diabetes Self-Management Education and Support, The Diabetes Educator, July 28, 2017 http://journals.sagepub.com/eprint/gv4N52NSqErrKxBfPJIJ/full ADA Standards of Medical Care in Diabetetes-2017 Jan; 40 (Supplement 1). Kentucky Board of Licensed Diabetes Educators: http://bde.ky.gov/Pages/default.aspx American Association of Diabetes Educators—https://www.diabeteseducator.org Kentucky Diabetes Network-- http://www.kydiabetes.net/ American Diabetes Association—http://www.diabetes.org/ Kentucky Diabetes Prevention and Control Program-- http://chfs.ky.gov/dph/info/dpqi/cd/diabetes.htm

Kim Coy DeCoste RN, MSN, CDE, MLDE, FAADE kim.decoste@ky.gov