1. “DRESS” for Battle- How to Survive a DSMES Program Audit
Stephanie Harriman McGrath, PharmD
Executive Manager,
Pennsylvania Pharmacists Care Network
Do introductions!

2. Disclosures
The presenter has nothing to disclose relative to the content of this presentation

3. Objectives Review the purpose and intent of a DSMES program audit
Discuss the process in place for an audit
Describe how to prepare requested DSMES materials for an audit

4. DSMES Program Audits Who? What? Where? When? Why?
DSMES Accredited Programs can be audited by Medicare or AADE (or ADA)*
What?
Programs are randomly selected for audit to ensure compliance with National Standards
Where?
Audits will occur on site (AADE) or “desktop” (Medicare)
When?
Audits occur throughout the entire calendar year
Why?
CMS requires the selection of programs for audit (5% of programs must be audited per year).
If a site refuses, accreditation will be withdrawn.
*For the purpose of this program, I will be referencing AADE DEAP program requirements, but much of the process and intent is the same.
Keep in mind that these audits are really to ensure that quality education and support is provided to people with diabetes, with the intent to improve health outcomes.
Medicare likes to see a minimum of 10 patients enrolled in the program

5. True or False?
A DSMES program audit is a randomly selected on-site visit from AADE to ensure that the program is compliant with National Standards for DSMES.
TRUE
I would like to pose an assessment question to ensure that we are all on the same page:

6. DRESS for Success! Diabetes Resources Engage assistance Standards
Submit
Medicare or AADE can audit you even if you are not billing for your services. Set a goal to see at least 10 patients per year, to maintain accreditation.
This is the best time to be planning for an audit- you can set yourselves up to successfully survive an audit by designing your program in accordance with the Standards.
A broad knowledge and understanding of diabetes is necessary to pursue and maintain accreditation, and it’s important to stay up to stay on evidence based guidelines and practices.
We will discuss resources at your disposal to obtain and maintain accreditation.
In addition to the physical resources available, there are a number of people and organizations that should be utilized to help.
We will review the Standards briefly- your in-depth knowledge and understanding of them will be necessary to successfully implement DSMES
Lastly we will talk about the Audit process and what is required for submission

7. Diabetes 30.3 million people in the United States have diabetes
23.8% are undiagnosed
25.8% of people 65 years and older have diabetes
Prediabetes affects 84.1 million Americans
Nearly half (48.1%) of adults 65 years and older had prediabetes as of 2015
Diabetes self-management education and support (DSMES) is a critical element of care for all people with diabetes
More than 114 million Americans are at risk of developing the complications associated with diabetes
Diabetes self management education and support is a critical element of care for all people with diabetes
Diabetes is the 7th leading cause of death in the US
Average medical expenditures among people with diagnosed diabetes were about 2.3 times higher than expenditures for people without diabetes.
Research shows that less than 5% of Medicare beneficiaries utilize their DSMES benefits. Increasing DSMES access and utilization will results in a positive impact to beneficiaries’ clinical outcomes, quality of life, health care utilization and costs.
You are all here because you want to increase access to DSMES services, so let’s review some of the resources that are available to help make you successful.
National Diabetes Statistics Report, Accessed 2 Jan 2018.

8. Resources
Read the 2017 National Standards for DSMES….And then read them again!
Read AADE Interpretive Guidance document
Use both the AADE Interpretive Guidance document and Auditor Checklist in program development
There are many resources available to ensure your success with gaining and maintaining accreditation.

9. 2017 National Standards for DSMES
This is your DSMES doctrine for the next 4 years- until it is updated to align with current evidence-based practices and utilization needs. This document describes all 10 Standards and provides evidence-based examples of how to implement them. Read it, and read it again!

10. AADE Interpretive Guidance document
The interpretive guidance document is just that- it further describes the required elements of each standard and breaks them down to guide you on how to interpret and implement them.
Use the checklist on the far right hand side to ensure that you have all of the required materials as you prepare your Binder.

11. Auditor Checklist
Quality Coordinators will be contacted well in advance of program audit. An auditor will come on site to conduct the audit for the duration of a full business day.
Quality Coordinators must prepare a physical Binder for the auditor to review. The auditor will use this checklist during the on-site interview.
The content on the checklist is included verbatim on the interpretive guidance document, with the exception of the first 4 items.

12. Auditor Checklist
These 4 items are not listed in the interpretive guidance document but are things that the Auditor will be looking for.
We will come back to this at the end of the session when you will get the chance to work through the Auditor Checklist with another site.

13. Engage Assistance Pharmacy staff members Mentors PPA AADE
Everyone must share the mission
Mentors
Binder review
PPA
Toolkits
Webinars
AADE
call
When you get back to your sites, I would suggest starting to prepare your staff for the implementation of this new service. Discuss the mission of your site- everyone should understand and share this mission. Discuss how to recruit patients and other ways that your staff can assist the QC in DSMES.
Your Task Force Mentors are a huge resource! We will be reviewing binder materials, and are available via phone, , in person if possible, to help with this process.
We are developing toolkits for your use in addition to the webinars which Suzanne has been conducting. There are more to come this spring.
AADE has a number of devoted staff members who want programs to succeed. They gladly answer questions to help programs prepare for and complete audits.

14. 2017 National Standards for DSMES
A thorough understanding of the Standards is pertinent to your success. Read and re-read. Let’s review them briefly…

15. Standards Standard 1: Internal Structure Standard 2: Stakeholder Input
Organization Chart
Mission Statement and Program Goals
Letter of Support
Standard 2: Stakeholder Input
Evidence of a documented process
Standard 3: Evaluation of Population Served
Patient population
Allocation of resources
Action plan for barriers
Standard 1: Internal Structure
Organization Chart- illustrates where the DSMES services fit into the greater organization, includes clear channels of communication and includes all DDSMES team members
Mission Statement- answers the WHY DO WE EXIST, also includes program goals
Letter of Support- must come from the administrative level to which the program reports
Standard 2: Stakeholder Input
Evidence of a documented process- while a formal advisory committee is not required there must be evidence that the DSMES provider engages key stakeholders to elicit input on DSMES services. Input can be completed by phone, , survey or face to face. MUST BE DOCUMENTED ANNUALLY
Standard 3: Evaluation of Population Served
Patient population- must include community demographics for the area where DSMES services are provided
Allocation of resources- Considerations should be taken when designing program to meet the participants needs and accessibility.
Action plan for barriers- it is essential to identify barriers that prevent participant access to DSMES during the assessment process. Creative solutions that incororate technology should be considered.

16. Standards (cont.)
Standard 4: Quality Coordinator Overseeing DSMES Services
Job description CV
Proof of CE (NABP CPE Monitor is sufficient)
Standard 5: DSMES Team
Process for referral
Job description, CV, proof of CE for every team member
Paraprofessionals (if applicable)
Standard 4: Quality Coordinator Overseeing DSMES Services
Job description- QC must be aggregators of data and communicate outcomes to stakeholders
CV- must reflect experience in chronic disease management, experience in managing clinical services and lists current position as providing oversight of DSMES services
Proof of CE (NABP CPE Monitor is sufficient) A spreadsheet or unofficial list is not sufficient
Standard 5: DSMES Team- at least one member of the team must be a licensed RN, RD, or pharmacist with training or experience pertinent to DSMES or a CDE
Process for referral- there must be documentation of a mechanism for ensuring participant needs are met if needs are outside of the diabetes professional’s scope of practice
Job description, CV, proof of CE for every team member
Paraprofessionals (if applicable) Individuals with additional training in DSMES can effectively contribute to the team (ie. Colleague who is a personal trainer or nutritionist) THERE MUST BE DOCUMENTATION THAT THE PARAPROFESSIONAL REPORTS DIRECTLY TO THE QC OR ONE OF THE PROFESSIONAL DSMES TEAM MEMBERS

17. Standards (cont.) Standard 6: Curriculum
Evidence-based curriculum that is reviewed at least annually and updated as appropriate
Pathophysiology and treatment options
Healthy Eating
Physical Activity
Medication Usage
Monitoring
Acute and chronic complications
Healthy coping
Problem solving
There must be documentation of an evidence-based curriculum that is reviewed at least annually and updated as appropriate to reflect current evidence, practice guidelines and cultural appropriateness
Adaptive to meet needs and abilities of participant
Creative and patient-centered with considerations for technology

18. Standards (cont.) Standard 7: Individualization (Chart)
Assessment to create education plan
Evidence of ongoing education planning and behavioral goal setting with follow up
Standard 8: Ongoing Support (Chart)
Documentation of ongoing self-management support options
Ie. Weight loss support, physical activity programs, smoking cessation
Standards 7 and 8 encompass a de-identified chart
Standard 7: focuses on ensuring that the education provided is individualized for each participant
Assessment to create education plan- may be done individually or in a group. The participant may complete the assessment prior to the initial visit.
Evidence of ongoing education planning and behavioral goal setting with follow up that is developed in collaboration with the patient. This plan must be documented in the education records.
Standard 8: focuses on the importance of ongoing support beyond the initial DSMES services.
Documentation of ongoing self-management support options specific to the community where the DSMES services are delivered, with participant preferences noted.
Support can include internal or external group meetings, weight loss support, physical activity programs, smoking cessation
DSMES providers must identify community resources that may benefit their participants- ie. Local YMCA, senior center activity classes, grocery store tours, a walking group, dental school for discounted or free cleaning, local mental health services, etc.

19. Standards (cont.) Standard 9: Participant Progress (Chart)
Evidence of at least one SMART behavioral goal
Documentation of at least once clinical outcome measure
Communication back to referring provider
Standard 10: Quality Improvement
Evidence of a procedure for collecting aggregate data
Documentation of a CQI project
Standard 9: Participant Progress- the de-identified chart must also show evidence of:
Evidence of at least one SMART behavioral goal with follow up and measurement achieved (why “program completion” must be a minimum of 2 visits)
Documentation of at least once clinical outcome measure to evaluate the effectiveness of the educational intervention- outcome measures must be chosen based on population, data available. In order to determine the impact of DSMES services, the QC must compare outcomes after engagement with those at baseline.
Communication back to referring provider, including the education provided and the participant outcomes
Standard 10: Quality Improvement- relates to the process by which programs assess their operations including the delivery of education and support
Evidence of a procedure for collecting aggregate data to analyze and report on.
Process outcomes (wait time, program attrition, referrals, etc)
Clinical outcomes (A1c, % body weight lost, ER visits, foot and eye exams)
Behavioral outcomes (participant satisfaction, behavioral goal achievement)
Documentation of a CQI project measuring the effectiveness and impact of DSMES services that identifies areas of improvement through the evaluation of process and outcomes data and is reviewed and reported annually
CQI is a cyclical, data-driven process which is proactive, no reactive. Data is collected to make positive changes, rather than waiting for something to go wrong and then fixing it.
CQI projects will need to be submitted every 12 months with the annual status report after accreditation. Both the project from the previous 12 months should be reported, and the plan for the project in the next 12 months.

20. Submit Quality coordinator will be contacted prior to on-site audit
Prepare Binder using Interpretive Guidance document
Must include at least 5 de-identified charts
Prepare staff
Auditor will meet on site for full business day audit
Programs will be notified of audit results
Quality coordinator will be contacted at least 10 days prior to on-site audit (AADE is required to give at least 10 days notice)
Prepare Binder using Interpretive Guidance document
Must include at least 5 de-identified charts from patients seen in the last 6 months
Prepare staff
Auditor will meet on site for full business day audit
Programs will be notified of audit results- for AADE, the auditor must submit their report within a week and then the DEAP department has to review it. If there are issues, a call is set up with the QC. If there are no issues, the QC receives an confirmation about passing the audit.

21. True or False?
To prepare for a DSMES audit, it is prudent to have a Binder of updates DSMES materials to support the National Standards, which includes a de-identified patient chart.
TRUE

22. Time to Audit! Find the auditing checklist
Take about 5 minutes to get organized prior to switching with a partner. Write your program name at the top, and also include where you will post the certificate and patient rights documents (8x11)
Be prepared to describe how you will prepare your staff and what the space where you will provide the education looks like. …
Switch Binders/paper with a partner. Take min to audit as many of the Standards as you can make it through, or specific Standards that your partner may want feedback on.

23. Questions?