1. 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)

2. 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

3. 3

4. 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

5. 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) 5

6. Diabetes Prevalence by Area Development District6
Diabetes Prevalence by
Area Development District
2015 KY Behavioral Risk Factor Surveillance Survey 6

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

8. 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)

9. 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

10. 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

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

12. 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.

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

14. 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.

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

16. 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

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

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

19. 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

20. If DSMES were a pill would you prescribe it?
AADE, Joint Position Statement Toolkit; 20

21. 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

22. 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

23. 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

24. 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

25. Kentucky Diabetes Resource Directory

26. 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

27. 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: /dc
Duncan et.al., Assessing the Value of the Diabetes Educator, 37, The Diabetes Educator, no. 5,
Sept./Oct
Li R, S. , et. al; Centers for Disease Control and Prevention (CDC).
MMWR Morb Mortal Wkly Rep 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):
Beck, et. al , 2017 National Standards for Diabetes Self-Management Education and Support, The Diabetes Educator, July 28,
ADA Standards of Medical Care in Diabetetes-2017 Jan; 40 (Supplement 1).
Kentucky Board of Licensed Diabetes Educators:
American Association of Diabetes Educators—
Kentucky Diabetes Network--
American Diabetes Association—
Kentucky Diabetes Prevention and Control Program--

28. Kim Coy DeCoste RN, MSN, CDE, MLDE, FAADE