Busy primary care physicians have a lot on their plates. But when it comes to helping people with diabetes learn how to improve their health, they don’t have to do it all themselves. Diabetes self-management education and support (DSMES) programs, led by a diabetes educator, can provide vital assistance by helping people with diabetes maintain a healthy weight, quit smoking, begin an exercise routine and integrate other self-management behaviors into their lives. A new study adds to the growing evidence that the education and support provided by DSMES programs lead to lower A1c levels and increases in healthy behaviors.
There is no question that the need for this type of program is great: Over 30 million Americans have diabetes, which, untreated and unmanaged, can lead to multiple complications including coronary artery disease, peripheral arterial disease, stroke, diabetes-related nephropathy, neuropathy, and retinopathy. DSMES eases the primary care physician’s workload by reducing the risk of developing these complications in the future. Through lifestyle change, individuals can improve their overall quality of life and see real, improved clinical outcomes. Also, the diabetes educator’s contribution to the quality improvement work is one they can make to their organizations that, while not immediately reimbursable, provides tremendous value in helping organizations achieve their performance measures.
What are DSMES programs?
DSMES programs accredited by either the American Association of Diabetes Educators (AADE) or the American Diabetes Association (ADA) are individualized to the needs of the person with diabetes based on a thorough initial assessment led by a diabetes educator. Together, the person with diabetes and the diabetes educator create a care plan that is tailored to their lifestyle, culture, beliefs, and environment. These programs help those with diabetes learn new skills and provide information, guidance, and accountability to encourage participants to make healthy lifestyle choices and achieve and sustain their weight loss and physical activity goals. They are typically offered in a group setting so participants can share ideas, celebrate successes and work to overcome obstacles. Diabetes educators focus on the AADE7 Self-Care Behaviors that can help participants better manage their condition: healthy eating, being active, monitoring, taking medication, problem-solving, reducing risks and healthy coping.
Clinically meaningful benefits
Studies have shown these programs provide real value. The most recent study included 446 people with A1c levels greater than 8% who participated in a DSMES program at one of four Federally Qualified Health Centers (FQHC), sites which typically serve economically vulnerable populations. In the study, everyone received DSMES and half (the intervention group) also received regular phone calls to increase engagement in self-care. Participants received a call every two weeks for three months, then once a month after that through the end of the program.
After one year, people in the intervention group experienced a decrease in their A1c of 1.7 percent on average, and those in the control group benefited from a 1.4% decrease in A1c. Both numbers are statistically significant. Research has shown a 1% decrease in A1c levels leads to a 37% decrease in microvascular complications, and a 21% decrease in diabetes-related complications and death. Those in the study also reported significant improvement in satisfaction with their diabetes care.
Researchers detected other trends, including improvements in reducing BMI, total cholesterol and triglycerides, although they weren’t statistically significant.
When and how to refer
Generally, to qualify for DSMES, an individual must have documentation of a Type 1, Type 2 or gestational diabetes diagnosis and a written referral by the primary care provider. Diagnosis criteria must meet either a fasting blood glucose ≥126 mg/dl on two separate occasions, a two-hour post-glucose challenge of ≥200 mg/dl on two separate occasions, or a random glucose test of >200 mg/dl with symptoms of unmanaged diabetes. Physicians should ensure the individual understands their diagnosis, next steps and make sure they can access the program site. If they aren’t sure of their coverage status for DSMES, they should call their insurance company for details.
When referring, it is critical that people with diabetes take advantage of DSMES services at diagnosis to build a strong foundation of healthy habits and reduce the risk of serious hypoglycemic events. Additionally, Medicare and many private insurers cover 10 hours of DSMES services in the first year after diagnosis, however, if someone on Medicare doesn’t access the service in their first year, they lose it.
Several barriers currently exist to accessing DSMES programs making it a sorely underutilized tool. Aside from the mandate that all 10 hours must be used in the first year, other restrictions exist that limit who and when individuals can be referred. Currently, Medicare beneficiaries with diabetes can only be referred to a DSMES program by their treating provider. For example, if a person is admitted to the hospital with DKA, the hospitalist or ER doctor cannot write a referral for DSMES. AADE was instrumental in writing and introducing the Expanding Access to Diabetes Self-Management Training Act which will reduce barriers and improve Medicare beneficiaries’ access to DSMES. AADE is actively working with several other organizations to get this bill introduced to the 116th Congress.
Research continues to support the wealth of evidence that these services are highly valuable and can lessen the burden on primary care physicians while providing beneficial care to people with diabetes.
Karen Kemmis is president, American Association of Diabetes Educators.
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