Diabetes Self-Management Education and Support: Component of Standard Diabetes Care 1, 2 “… Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications …” 1 Using this slide set This 10-slide set can be used as an overarching review of the benefits of diabetes self-management education and support (DSMES) and the 4 critical times to assess, provide, adjust, and refer for DSMES. It can take from 10-20 minutes to present. Consider adding case studies to the presentation that highlight each of the 4 times. Discussing each case helps the audience start applying the information. This could add another 10-20 minutes. The slide set can be shared widely with anyone doing such presentations. Main point of this slide DSMES is a component of standard diabetes care. Referrals to a DSMES program are recommended for quality diabetes care. Talking points Updated annually, the American Diabetes Association’s Standards of Medical Care in Diabetes provides clinicians and others with the components of diabetes care, general treatment goals and tools to evaluate the quality of care. It is published every January as a supplement to Diabetes Care. ADA provides complimentary access. The introduction to the 2017 Standards of Care begins: “Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications. Significant evidence exists that supports a range or intervention to improve diabetes outcomes…” This presentation will provide an overarching review of the benefits of DSMES and the 4 critical times to assess, provide, adjust, and refer for DSMES. The goal is to increase the number of persons with diabetes who benefit from DSMES. Resources ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017) 1. ADA. Standards of Medical Care. Diabetes Care (2017) 2. Powers MA et al. Joint Position Statement on DSMES. Diabetes Care, TDE, JAND (2015)

Presentation Goal and Objectives Increase the number of persons with diabetes who benefit from diabetes self-management education and support (medical nutrition therapy and emotional health support) Objectives Describe ADA Standards of Care related to diabetes education List benefits of diabetes self-management education and support Describe the 4 critical times to assess, provide, adjust and refer for diabetes self-management education and support Understand the role of the health system in promoting quality diabetes care Main point of this slide This slide lists the goal and objectives for this presentation.

Definitions Diabetes Self-management Education (DSME): Ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes Self-management Support (DSMS): Activities that assist in implementing and sustaining the behaviors needed to manage diabetes. Diabetes Self-management Education and Support (DSMES): The combination of education (DSME) and support (DSMS). With the inclusion of “support” in the most recent update in the National Standards for DSMES, this is now the preferred terminology. Diabetes Self-management Training: Term used by the Centers for Medicare and Medicaid Services for DSMES. Preferred tem for legislative activity and reimbursement/billing issues. Medical Nutrition Therapy (MNT): Application of nutrition care process; includes individualized nutrition assessment, nutrition diagnosis, intervention and monitoring and evaluation; if not included in DSME program, refer to registered dietitian. Lifestyle Management: Includes DSMES, DSME, DSMS, MNT, physical activity, smoking cessation counseling, psychosocial care. Main point of this slide Provides definitions of DSME, DSMS, the combination term of DSMES, MNT, and Lifestyle Management Talking points Although different members of the healthcare team and community contribute to DSMES, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that persons with type 2 diabetes receive both DSME and DSMS in a consistent manner. Note: The reference “DSMES” combines these two interventions. Additional points that can be made DSME is typically provided by a health professional, whereas ongoing support (DSMS) may be provided by personnel within a practice and with a variety of community-based resources. DSMES 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. Some DSMES programs include MNT services delivered by a registered dietitian, whereas other programs provide basic nutrition guidance and rely on referrals for MNT. All members of the healthcare team should be versed in the basic principles of diabetes nutrition therapy so that they can facilitate basic meal planning, clarify misconceptions and/or provide reinforcement of the nutrition plan developed collaboratively by the registered dietitian and the patient. If expertise and time are not available in the DSMES program, ensure that a referral to a registered dietitian is made. [see Table 5 in position statement]. Resources Haas L and Maryniuk MD et al. Nat Standards for Diabetes Self-Management Education and Support. Diabetes Care (2012) Powers et al. Joint Position Statement on DSME. Diabetes Care, TDE, JAND (2015) ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017) 1. Haas L and Maryniuk MD et al. Nat Std for DSMES Diabetes Care (2012) 2. Powers MA et al. Joint Position Statement on DSMES. Diabetes Care, TDE, JAND (2015) 3. ADA. Standards of Care. Diabetes Care (2017) 3

Lifestyle Management is Integral Component of Diabetes Care Main points of this slide Pharmacological therapy is only one component of diabetes care. Lifestyle management is an integral component of diabetes care. DSMES is often used to provide and support lifestyle management. The table is a comparison of medications utilized in diabetes management. It compares medications by drug class using a 5-point scorecard to provide an objective comparison. Talking points The American Diabetes Association’s Standards of Care provide guidance on initiating and advancing diabetes medications. This slide shows the algorithm of recommendations. The recommendations are based on an objective comparison of each drug class using a 5-point scorecard. Each class is rated on: efficacy, hypoglycemia risk, weight, side effects, and cost. Pharmacological therapy is only one component of diabetes care. Lifestyle management is an integral component of diabetes care as noted in this algorithm. DSMES is often used to provide and support lifestyle management. Note there is no comparison of DSMES using a similar scorecard. Resources American Diabetes Association: diabetes.org ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017)   ADA. Standards of Medical Care. Diabetes Care (2017)

Recognizing the many benefits of DSMES If DSMES was a pill, would you prescribe it? 1 Main points of this slide The 5-point rating system used to compare diabetes medications was then applied to DSMES. The ratings scorecard for DSMES is impressive and confirms the benefits and value of DSMES. The scorecard challenges providers to rethink the inclusion of non-pharmacologic therapy in their treatment plans and make referrals to a DSMES program. It can be used as a decision-aid in discussion with patients. Talking points A 2016 paper in Diabetes Care by Maggie Powers, PhD, RD, CDE, raised the question “If DSME was a pill, would you prescribe it?” Diabetes medications have been rated on five criteria – efficacy, hypoglycemia risk, weight changes, side effects, and cost. Dr. Powers applied this rating system to DSMES to provide an objective comparison to metformin. Metformin was selected as it is a commonly used first line, low cost medication therapy. The scorecard challenges providers to rethink the inclusion of non-pharmacologic therapy in their treatment plans and make referrals to DSMES programs. For the DSME ratings, research focusing on medical nutrition therapy (MNT) alone and MNT with DSME was included. Referrals to DSME and MNT are recommended for all patients with diabetes. The scorecard can be used as a decision-aid in discussion with patients. [Presenter – You can review each criteria with the following information or research provided in the paper or briefly compare and go to the last bullet point and summary statement.] Efficacy was rated high for DSME as research shows DSME lowers A1c by 1 or more percentage points. Metformin has the same rating. Hypoglycemia risk was rated low; a rating of low was selected as hypoglycemia may occur as better control is achieved and further adjustments are made. Metformin was rated low hypo risk. Weight: A number of studies show that weight loss is achievable and sustainable through lifestyle intervention, even when insulin is being initiated. Improvement in glycemic control also occur with weight maintenance. Weight change was rated as neutral or loss with DSMES. Metformin had the same rating. Side effects: There have been no reported side effects with DSMES. However, there are potential side effects with metformin, most notably related to GI disturbances. Although rare, lactic acidosis is also noted. Cost: The rating for DSMES is low to cost savings. Medicare reimburses for recognized and accredited DSMES programs and many private insurers follow suit. Research shows that longer term cost savings are realized through decreased hospitalizations, emergency room visits, and better control. Metformin is rated low because of its generic status resulting in low out of pocket cost. Psychosocial benefits: This criteria is added to the scorecard to acknowledge the many benefits realized through DSMES: Increases or improves quality of life, self-efficacy, empowerment, healthy coping, knowledge, self-care behaviors, adherence to a food plan, healthier food choices, increased physical activity, and use of glucose monitoring data. Reduces blood pressure and lipids, problems managing diabetes, the incidence of acute complications, and the risk of long-term complications. In summary, the ratings scorecard for DSMES is impressive and confirms the benefits and value of DSME. The scorecard challenges providers to rethink the inclusion of non-pharmacologic therapy in their treatment plans. It can be used as a decision-aid in discussion with patients.   Resources Powers M. 2016 Health Care & Education Presidential Address: If DSME Were a Pill, Would You Prescribe It? Diabetes Care (2016) Inzucchi S et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care (2015) ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017)   1. Powers MA. Diabetes Care (2016)

Sorry State of DSMES Utilization Medicare provides reimbursement for: DSMT - first year 10 hours and 2 hours each subsequent year MNT – first year 3 hours and 2+ hours each subsequent year Referrals are required; easy to make Main points of this slide Due to their beneficial impact on overall diabetes care and health outcomes, DSMES and MNT are covered benefits through Medicare and many private insurers. DSMES and MNT are greatly underutilized Medicare benefits. Talking points Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity and medications and more. DSMES facilitates the adoption of these skills by providing knowledge and skill training, as well as helping that individual identify barriers, facilitate problem solving and develop coping skills to achieve effective self-management and behaviour change. While there is robust data demonstrating that the vast majority of people with either Medicare or private insurance coverage do not receive DSMES in the year they are diagnosed. Medicare provides coverage for 10 hours of DSMES in the first year of using the benefit. Medicare provides coverage for 3 hours of MNT in the first year and 2 or more hours in subsequent years. The data from Strawbridge et al. shows that those participating in the year in which they are diagnosed engaged in only 1.5 hours. Only 30% participated for a half hour. Resources Li et al. Diabetes Self-Management Education and Training Among Privately Insured Persons with Newly Diagnosed Diabetes – United States, 2011-2012. MMWR (2014) Strawbridge et al. Use of Medicare’s Diabetes Self-Management Training Benefit. Health Education & Behavior (2015) Medicare: Only 5% with newly diagnosed diabetes used DSMT benefit1 Only 1.7% of those with diabetes had a claim for DSMT claim in 20122 Private Insurance: 6.8% with newly diagnosed T2D received DSMES within 12 months of diagnosis3 Strawbridge et al. Health Edu Behav. (2015) http://www.healthindicators.gov Li et al. MMWR Morb Mortal Wkly Rep. (2014)

Diabetes Self-Management Education and Support Maximizing the Benefits The DSMES Position Statement describes when, what and how to best provide DSMES. Ensure nutrition, education and emotional health needs are met. There are 4 critical times to assess, adjust, provide and refer for DSMES. Main points of this slide The Joint Position Statement on DSMES describes when, what and how to best provide diabetes education. In addition to education, the nutrition and emotional health needs of each individual must be recognized and addressed. There are 4 critical times to assess, adjust, provide and refer to meet these needs. An algorithm is included in the position statement that is a visual depiction of the concepts discussed in the statement. Talking points Representatives from four organizations – the American Diabetes Association, the American Association of Diabetes Educators, the Academy of Nutrition and Dietetics, and the National Diabetes Education Program – collaborated and developed a position on when to identify and refer individuals with type 2 diabetes to DSMES. Multiple stakeholders and organizations provided input throughout the process. In addition to education, the nutrition and emotional health needs of each individual must be addressed. In fact, at the top of the Algorithm of Care it states -- The ADA Standards of Care in Diabetes recommend that all patients be assessed and refer for nutrition, education and emotional health. The position statement defines when DSMES should be provided for type 2 diabetes, what is included at each of the time points for quality diabetes care, and how best to provide DSMES in a patient-centered manner. The four critical times to assess, provide, adjust and refer for DSMES are: Upon diagnosis Annual assessment of education, nutrition, emotional issues When new complicating factors influence self-management When transitions in care occur The Joint Position Statement includes an algorithm, part of which is shown on this slide. Key successes to DSMES, nutrition, education and emotional health are included to show the comprehensive scope of self-management. The DSMES program should ensure these needs are addressed. Some referral forms for DSMES also include a referral checkbox for medical nutrition therapy (MNT) to make access easy. The algorithm is a visual depiction of the concepts discussed in the Joint Position Statement. You are encouraged to reproduce the algorithm as a stand-alone document and distribute widely. The Joint Position Statement and its algorithm can be used as a guide as to when and how to refer for DSMES. Resources American Diabetes Association American Association of Diabetes Educators Academy of Nutrition and Dietetics National Diabetes Education Program ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017) Joint Position Statement Algorithm of Care Find a DSMES Program Find a Dietitian Powers MA et al. DSMES Position Statement (2015) Diabetes Care, The Diabetes Educator, Journal of Academy of Nutrition and Dietetics

Diabetes Self-Management Education and Support Maximizing the Benefits When to refer At diagnosis Annually When complicating factors occur When transitions in care occur Main points of this slide Orients the audience to the two parts of the DSMES algorithm and describes how they complement each other. Provides specific details of focus areas for both the provider and educator during the 4 critical times Both parts include checklists that can be used by and with patients and the healthcare team to identify if (when) one needs DSMES and if so what is included Talking points There are two parts to the DSME algorithm. [Presenter – You can review each part of the algorithm with the following information or review/discuss specifics from the position statement. You are not expected to read the algorithm. This orients the audience to the two parts of the algorithm.] The first, shown on the left, is the Algorithm of Care. This is the ‘when’ to assess, adjust, provide and refer to DSMES. This portion of the algorithm summarizes and provides a checklist for determining if it is ‘time’ for DSMES to be assessed, adjusted and provided. If yes, this typically means a referral to DSMES. Although four distinct time-related opportunities are listed, it is important to recognize that type 2 diabetes is a chronic condition and situations can arise at any time that require additional attention to self-management needs. Whereas patient’s needs are continuous, these four critical times that require assessment and, if needed, intensified re-education and self-management planning and support. This breakdown helps to illustrate the chronicity of the disease state. The second part is shown on the right and is the ‘what’ of DSMES. This is the Algorithm Action Steps. This section summarizes action steps and provides a checklist for identifying what topic/information/support is needed at each of the 4 critical times. The top portion is for the primary care provider/endocrinologist/clinical care team and the lower portion for the DSMES team. This provides guidance on areas of focus during the 4 critical times. This helps outline what type of assessment and focus to help structure the visit. In addition it gives the provider a better sense of the focus areas that can be expected from the DSMES referral. Resources American Diabetes Association American Association of Diabetes Educators Academy of Nutrition and Dietetics National Diabetes Education Program ADA Standards of Medicare Care in Diabetes. Diabetes Care (2017) Joint Position Statement Algorithm of Care Find a DSMES Program Find a Dietitian  What - focus and actions by Primary care providers/ endocrinologists/ clinical care team Diabetes self-management education educators / program Powers MA et al. DSME/S Position Statement (2015) Diabetes Care, The Diabetes Educator, Journal of Academy of Nutrition and Dietetics

Evidence for Greatest Impact of DSMES 1, 2 Engaging adults with type 2 diabetes in DSMES results in statistically significant and clinically meaningful improvements in A1c. The greatest improvements are achieved when DSMES: Involves both group and individual education Is provided by a team vs a single individual Participants attend more than 10 hours Is tailored to the individual participant Is focused on behaviors and engages the participant rather than didactic interventions Main points of this slide There is increasing evidence on what encompasses effective DSMES. How DSMES is delivered makes a difference in the outcomes. Talking points Evidence from two recent systematic reviews highlight the impact DSMES has on A1c levels. Key findings are highlighted on this slide. Engaging adults with type 2 diabetes in DSMES results in statistically significant and clinically meaningful improvement in A1c. The greatest improvements are achieved when DSMES: Is provided by a team vs a single individual. Participants attend more than 10 hours. Is tailored to the individual participant. Is focused on behaviors and engages the participant rather than didactic interventions. [Presenter – Consider describing how your education is delivered and how you make it patient-centered.] Resources Chrvala et al. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Education and Counseling (2015) AHRQ’s Behavioral Programs for Diabetes Mellitus: Executive Summary Chrvala et al. Pt Ed & Counseling (2015) AHRQ add reference

Summary – Maximize the Benefits of DSMES There are many evidence-based benefits of DSMES. Of note are the many psychosocial benefits and behavioral improvements DSMES is grossly under utilized The DSMES position statement: Describes the 4 critical times to assess, adjust, provide and refer for education Provides clear expectations of the focus areas of DSMES at each of the 4 critical times The checklists in the algorithms provide objective criteria for discussing self-management needs with a patient Health systems should mobilize to ensure all patients have easy access to DSMES, including nutrition, physical, and emotional health needs Consider automatic referrals for DSMT and MNT; opt-out versus opt-in Main points of this slide This slide summarizes the key messages of the presentation. Talking points DSMES is a necessary component of standard diabetes care yet it is grossly underutilized. The Joint Position Statement and algorithm provides the evidence and strategies for the provision of education and support services to all adults living with type 2 diabetes. It is imperative that the healthcare community responsible for delivering quality care mobilizes efforts to address the barriers and explores resources for DSMES in order to meet the needs of adults living with and managing type 2 diabetes. Despite the evidence and support of the leader organizations in recognizing the importance of DSMES as necessary for optimum management of diabetes, there is still a gap in the knowledge by those with diabetes and healthcare providers on what DSMES entails, how and when to access it, and the expectations for those who participate in the process. The general purpose of the statement is to improve patient care, provide healthcare teams with information to better understand the diabetes education and support process and expectations, and how they integrate DSMES into routine care. The Joint Position Statement and algorithm of care and action steps provide guidance for primary care providers and other healthcare providers on how to include DSMES into the management of those with type 2 diabetes. The checklists in the algorithms provide objective criteria for discussing self-management needs with a patient. It takes the ‘guess work” out of when and how to refer. It also sets expectations of what should occur by referring for DSMES. The position statement is evidence-based thus refocusing from “Do my patients need DSMES?” to “How do I ensure my patients receive and participate in DSMES?” In summary: There are many evidence-based benefits of DSMES. Of note are the many psychosocial benefits and behavioral improvements DSMES is grossly under utilized The position statement: Describes the 4 critical times to assess, adjust, provide and refer for DSMES. Provides clear expectations of the focus areas of DSMES at each of the 4 critical times. The algorithm checklist provide objective criteria for discussion self-management needs with a patient Health systems should mobilize to ensure all patients have easy access to DSMES, including nutrition, physical, and emotional health needs Health systems can consider improving easy access by recommending an automatic referral to DSMES and MNT at the 4 critical times. Currently a provider must remember to write a referral and opt-into DSMES and MNT. An opt-out system would support easy access. Resources Joint Position Statement Algorithm of Care   Powers MA et al. DSME/S Position Statement (2015) Diabetes Care, The Diabetes Educator, Journal of Academy of Nutrition and Dietetics