DSMES Service and Session Planning

The purpose of Diabetes Self-Management Education and Support (DSMES) is to give people with diabetes and prediabetes the knowledge, skills, and confidence to accept responsibility for their diabetes care. This includes collaborating with their healthcare team, making informed decisions, solving problems, developing personal goals and action plans, and coping with emotions and life stresses.

A great deal has been learned in recent years about the effectiveness of diabetes education and support and about particular programmatic and teaching strategies. As examples, multiple meta-analyses have shown that diabetes educational and behavioral services are effective in producing positive clinical and psychosocial outcomes, at least in the short term. These studies also have shown that group education is effective and that patient participation and collaboration appear to produce more favorable results than didactic presentations. We also have learned that while no one education program is more effective than others, programs that incorporate the behavioral and emotional aspects of diabetes with the clinical content result in better outcomes. We also have greater appreciation for the impact of psychosocial and emotional concerns on self-management behaviors and the need for ongoing diabetes self-management education and support to sustain the gains made during the initial education process and service. We encourage you to use this evidence-based advice as you prepare your program and work with participants.

Ongoing diabetes self-management support (DSMS) was initially included in the 2007 American Association of Diabetes Educators (now the Association of Diabetes Care & Education Specialists) and the American Diabetes Association National Standards for diabetes self-management education (DSME) and was further emphasized in the 2012 and 2017 revisions. The evidence continues to demonstrate that the initial significant gains made during DSME begin to diminish after approximately 6 months without further intervention. This does not mean that DSME is not effective or that the educators did not do a good job. It simply means that people need more than initial DSME to sustain and continue making behavioral changes and to cope with diabetes-related distress and other emotions and burdens associated with this chronic disease.

DSMES is a lifelong process. It can be emotional, behavioral, educational, or clinical. Both education and support need to be incorporated throughout the entire DSMES service and continuing care. Effective DSMES is patient-centered and designed to help participants address the more complex and difficult tasks of managing diabetes in the context of their real lives, which often are filled with other stresses and competing demands.

An approach based on patient empowerment and adult learning principles we have found to be effective is “ask the experts.” When using this problem-based learning (PBL) method, session topics are generated by questions and concerns raised by participants. The instructor then builds on content generated by these questions to present related topics. Over the course of a program, a comprehensive curriculum can be presented. Keeping track of topics through a paper or Web-based system, such as Chronicle Diabetes, will help ensure that all content areas are addressed. Programs that need to provide specific clinical content during planned sessions can also use this approach by reminding participants of the topic area and asking if there are any questions or concerns. In addition, suggesting that participants try “behavioral experiments” between sessions gives them valuable, practical experience with behavior change and creating I-SMART action steps. Beginning the following sessions with a discussion of what was learned from their experiment (regardless of its outcome) can be used to generate topics and content areas for the group to address at that session and keeps participants actively involved.

The following outline provides a format for providing DSMES services. It is not necessary to provide DSMES in a particular order, and it is meant to be fluid, conversational, and responsive to participant-identified questions, issues, and preferences.

Each session includes five essential components. Each component will likely be discussed more than once in a particular session, and is important to ensure that all components are addressed at each session. The bulleted questions in the Instructor’s Notes are a useful way to raise or address a particular component if it does not occur naturally as part of the group discussion. The five components include the following: reflection, emotional burden, problem-solving, providing diabetes information, and choosing an action step experiment.

The first session is used to introduce participants to the program.

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  Introduce yourself and state why you have chosen to facilitate this session or service. Describe your role as a facilitator rather than a teacher. Point out that one of your goals is for participants to learn from each other about their experiences and effective self-management strategies.

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  Ask members of the group to introduce themselves, say how long they have had diabetes, and how it is treated. Ask them also to identify their primary reason for attending and what they hope to get from DSMES. You may want to use an icebreaker activity. Encourage family members or other support persons to actively and fully participate in the sessions.

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  Review the format of the sessions, discussing each of the five components and why it is important. You may want to list these on a permanent poster or the board each session. Ask the group to create ground rules. Examples include maintaining confidentiality, respect for others’ opinions, no judgments, and no cell phones during class.

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  Ask if there are any issues, concerns, or questions they would like to discuss. If none are forthcoming after 20–30 seconds of silence, open with a question, such as “What is hardest for you about managing diabetes?” or “What is your biggest struggle or your greatest worry?” Include each of the stated issues during the discussion. Avoid making judgments, being dismissive, or trying to change their feelings or perceptions of their experiences.

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  Close by asking each person to identify an I-SMART or action step they will take before the next session to better manage their diabetes. This step should be something they can attain before the next session and should be a behavior (e.g., eat one sandwich instead of two at lunch), rather than an outcome (e.g., lose 1–2 lb in the next week).

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  Reflection on self-management experiments.

At the end of each group session, most participants chose a self-management experiment designed to help them achieve a self-selected short-term or I-SMART action plan. Invite participants to reflect on what they learned from their experiment. Avoid success and failure designations based on outcomes. As long as participants learn about what does or does not work in their lives, then the experiment was successful.

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  Discuss the emotional impact of living with diabetes.

Living with diabetes raises emotional issues related to relationships, work, family, economic circumstances, overall health, physical functioning, and other aspects of life. Emotion often has a strong influence on participants’ self-management decisions. Discussing the emotional aspects of living with diabetes is usually therapeutic in and of itself. During group sessions, participants are encouraged to discuss the emotional impact of living with diabetes. Keep in mind that emotions are not problems to be solved, and it is not the role of the facilitator to attempt to change, ease, or diminish these feelings.

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  Engage participants in systematic problem-solving.

The fundamental principle informing the structure and process of this service is that the questions and concerns of participants are the focus of each session. The topics and issues discussed during the group sessions are ones introduced by participants. The problems addressed include interacting with healthcare providers as well as personal self-management struggles, concerns, and psychosocial issues. The flow of each session is determined by the questions and concerns introduced by participants during that session.

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  Discuss diabetes self-management questions and concerns.

The question-and-answer component provides the diabetes self-management information usually presented in lectures during traditional programs. Instead, participants are given the opportunity to ask questions and raise issues and concerns related to diabetes self-management. When responding to questions, focus on practical information designed to support decision-making, effective self-management, problem-solving, and collaboration with healthcare team members.

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  Choose a self-management action-step experiment.

This provides participants with an opportunity to identify an I-SMART or other self-management experiment to help them achieve a meaningful, self-determined long-term goal. Participants do not have to conduct an experiment if they do not wish to, but participants who do should be given the opportunity to share their long-term goal and action plan experiment. While participants sometimes revise their plans based on the discussion, emphasize that the person carrying out the experiment is the best judge of what will and will not work.