2017 National Standards for Diabetes Self-Management Education and Support

Documentation of a defined structure, mission, and goals supports effective provision of DSMES. Mission defines the core purpose of the organization and assists in developing professional practice and services. Business literature, case studies, and reports of successful organizations emphasize the importance of clear and shared missions, goals, and defined relationships (31,32). The absence of these common goals and relationships is cited as one barrier to success (32). Defined leadership is needed to remove any service-related obstacles and find resources to advance DSMES services (33). Therefore, entities providing DSMES services must develop lines of communication and support to be clear on their mission, outcomes, and quality improvement measurement (34). The Chronic Care Model supports the need for documented organizational mission and goals (33).

According to The Joint Commission, documentation of an organization’s structure is equally important for both small and large health care organizations (35). Providers of DSMES working within a larger organization will have the organization document recognition of and support of quality DSMES as an integral component to their mission (35). For smaller or independent providers of DSMES, they will identify and document their own appropriate mission, goals, and structure to fit the function in the communities they serve (34).

The purpose of seeking stakeholder input in the ongoing planning process is to gather information and foster ideas that will improve the utilization, quality, measurable outcomes, and sustainability of the DSMES services. Stakeholders can be identified from DSMES participants, referring practitioners, and community-based groups that support DSMES (e.g., health clubs and health care professionals [both within and outside of the organization]) who provide input to promote value, quality, access, and increased utilization (36,37). Social determinants related to the population served will be used to guide stakeholder selection and facilitate the connection between the DSMES services, the participant population, the health care providers, and the community (38,39).

A planned, documented strategy to engage and elicit input from stakeholders will shape how DSMES is developed, utilized, monitored, and evaluated (33,37,40,41). If the provider of DSMES is experiencing a lack of referrals or low utilization, the stakeholders can assist with the solution (42,43). The goal is to provide effective and dynamic DSMES services that are person-centered, culturally relevant, and responsive to the referring practitioner and participant-identified needs (38), ultimately engaging participants in lifelong learning (13,41).

Currently, the majority of people with and at risk for diabetes do not receive DSMES (2,3,10,44,45). While there are many barriers to DSMES, one crucial issue is access (46–48). Providers of DSMES, after clarifying the specific populations they are able to serve, must understand their community and regional demographics (47,49–53).

Individuals, their families, and communities require education and support options and tools that align with their needs (54–56). The provider(s) of DSMES must ensure the necessary educational alternatives are available (40,54). Understanding the population’s demographic characteristics, including ethnic/cultural background, sex, age, levels of formal education, literacy, and numeracy (57–60) as well as perception of diabetes risk and associated complications is necessary (45).

It is essential to identify the barriers that prevent access to DSMES during the assessment process (61–63). Individuals’ barriers may include socioeconomic or cultural factors, participant schedules, health insurance shortfalls, perceived lack of need, and limited encouragement from other health care practitioners to engage in DSMES (15,64–68).

Models that include population health and disease management, an interprofessional team, and ongoing social support improve both practice and individual outcomes (40,69,70). Medical management integrated with DSMES improves access, clinical outcomes, and cost-effectiveness (71,72). Creative solutions incorporating technology to increase reach and engagement must be examined (73,74). Telehealth, electronic health records (EHR), mobile applications, and cognitive computing will proactively identify and track participants while offering endless opportunities for individualized and contextualized DSMES (16,75–78).

Ensuring quality is an essential component of the chronic care model (33). Person-centered health care is associated with improved outcomes (79–81) and better relationships between referring practitioners, individuals, and teams (82,83). For DSMES services to be sustainable, quality must be a priority (84,85).

Previous versions of the Standards used the term program coordinator; however, with new models of care and payment methods evolving, DSMES services need to demonstrate how these services affect overall participant outcomes. The change to quality coordinator reflects the need to address quality within all levels of DSMES services offered, concurrent with implementation. Most importantly, the quality coordinator is charged with collecting and evaluating data to identify gaps in DSMES, providing feedback on the performance of the DSMES services to team members, referring practitioners, and the organization’s administration. The use of EHR and person-centric software improves care (86–92) and assists the quality coordinator in evaluating the effectiveness of DSMES. The quality coordinator utilizes data mining to inform payers and members of the health care team of the clinical outcomes of DSMES. Although the quality coordinator does not require additional degrees or certifications in informatics, developing an understanding of these skills—as well as marketing, health care administration, and business management—will be helpful as the health care environment evolves. The quality coordinator does need to understand the process of identifying, analyzing, and communicating quality data. In large health systems, the quality coordinator may partner with other team members to support quality improvement. In most DSMES entities the quality coordinator will manage the overall services and may be part of the instructional team.

The evidence supports an interprofessional team approach to diabetes care, education, and support (93). Current research continues to support nurses, dietitians, and pharmacists as providers of DSMES responsible for curriculum development (13,14,94–98). Expert consensus supports the need for specialized clinical knowledge in diabetes and behavior change principles for DSMES team members (99). Certification as a CDE (National Certification Board for Diabetes Educators [NCBDE]) (86,100) or BC-ADM (AADE) (86,101) demonstrates specialized training beyond basic discipline preparation and mastery of a specific body of knowledge. All DSMES team members must document appropriate continuing education of diabetes-related content, ensuring their continuing competence in their respective roles.

Registered nurses, registered dietitian nutritionists, pharmacists, and members of health care disciplines that hold a certification as a CDE or BC-ADM can perform all the DSMES services including clinical assessments (14,100–102). Paraprofessionals with additional training in DSMES effectively contribute to the DSMES team. Diabetes paraprofessionals (e.g., medical assistants, community health workers, peer educators, etc.) can instruct, reinforce self-management skills, support behavior change, facilitate group discussion, and provide psychosocial support and ongoing self-management support (102). Paraprofessionals must receive continuing education specific to the role they serve within the team and must directly report to the quality coordinator or one of the qualified DSMES team members (14,71,99,102–106). For services outside the expertise or scope of the DSMES provider, a mechanism must be in place to ensure that the participant is given the information needed to be referred to the appropriate health care professionals (99,107).

Individuals with diabetes, and those supporting them, have much to learn to enable effective self-management. DSMES provides this education in an up-to-date, evidence-based, and flexible curriculum (108,109). The options for delivery of the curriculum have grown dramatically as technology has been incorporated into health care.

The curriculum is the evidence-based foundation from which the appropriate content is drawn to build an individualized education plan based on each participant’s concerns and needs. The curriculum content must be supplemented with appropriate resources and supporting education materials. A curriculum also specifies effective teaching strategies and methods for evaluating learning outcomes (5,110,111). The curriculum must be dynamic (5,97,111–113). Recent education research endorses the inclusion of practical problem-solving approaches and collaborative care, addressing psychosocial issues, behavior change, and strategies to sustain self-management efforts (40,114–120).

The following core content areas, including the AADE7 Self-Care Behaviors, demonstrate successful outcomes (13,109,121,122) and must be reviewed to determine which are applicable to the participant:

• Diabetes pathophysiology and treatment options

• Healthy eating

• Physical activity

• Medication usage

• Monitoring and using patient-generated health data (PGHD)

• Preventing, detecting, and treating acute and chronic complications

• Healthy coping with psychosocial issues and concerns

• Problem solving

The content areas listed, as well as educating the participant on navigating the health care system, learning self-advocacy, and e-health education (24,105,106,115–117), can be adapted for all practice settings and provide a solid outline and agenda for a DSMES curriculum. It is crucial that the content be tailored to match individuals’ needs and be adapted as necessary for age, developmental stage, type of diabetes, cultural factors, health literacy and numeracy, and comorbidities (123–127).

People with diabetes should engage in DSMES during various stages after their diabetes diagnosis (5,13). Regardless of the stage, people with diabetes have their own priorities and needs. The DSMES services must be designed using person-centered care practices, in collaboration with the participant, focusing on the participant’s priorities and values (5,13,128). The most important element to appreciate is that no participant is required to complete a set DSMES structure. When participants have achieved their goals, they can determine that their initial DSMES intervention is complete. However, DSMES is an ongoing, lifelong process, with ongoing assessments of AADE7 Self-Care Behaviors (122) and continual support (5,13).

Research indicates the importance of individualizing DSMES to each participant (129,130). The assessment process is collaboratively conducted by a health care professional with the participant to identify needs and potential self-management support strategies. The health care professional uses the information gleaned on assessment to determine the appropriate educational and behavioral interventions, including enhancing the participant's problem-solving skills (8,11,130). The assessment must incorporate information about the individual’s medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, diabetes self-management skills and behaviors, emotional response to diabetes, disease burden, ability, readiness to learn, literacy level (including health literacy and numeracy), physical limitations, family support, peer support (in person or via social networking sites), financial status, and other barriers (29,131–134). After the initial assessment, additional assessments can be incremental over time as indicated based on participant need (13).

The DSMES team member(s) will use clear health communication principles, using plain language, avoiding jargon, making information culturally relevant, using language- and literacy-appropriate education materials, and using interpreter services when indicated (135). Evidence-based communication strategies such as collaborative goal setting, action planning, motivational interviewing, shared decision making, cognitive behavioral therapy, problem solving, self-efficacy enhancement, teach-back, and relapse-prevention strategies are also effective (120,136–139). It is crucial to develop action-oriented behavior change goals and objectives (130,140). Creative, person-centered, experience-based delivery methods beyond the mere acquisition of knowledge are effective for supporting informed decision making and meaningful behavior change and addressing psychosocial concerns (122,141). Moving beyond static lecture methodology, incorporating meaningful discussions to address individual needs, and using interactive teaching styles are required. Incorporating PGHD, especially blood glucose and/or continuous glucose monitoring data, into decision making individualizes self-management and empowers participants to fully engage in personal problem solving to change behavior and improve outcomes (16,142–144). There is strong evidence that incorporating text messaging into DSMES interventions improves engagement and outcomes (25,145–147). Use of digital technology (cloud-based, telehealth, data management platforms, apps, and social media) enhances the ability to employ a technology-enabled self-management feedback loop with four key elements: two-way communication, analysis of PGHD, customized education, and individualized feedback to provide real-time engagement in self-management, as well as to enable and empower participants (16).

Reassessment during key times, such as when complicating factors influence self-management and during transitions of care, can determine whether there is need for additional or different DSMES services (13,148). A variety of assessment modalities, including online assessments via consumer portals and EHR, tablet computers that integrate with EHR, text messaging, web-based tools, automated telephone follow-up, and remote monitoring tools can be used (77,149–152). Selecting validated tools, used for assessment and ongoing evaluation, will generate more evidence to support DSMES (153). Although not an exhaustive list or applicable to all populations, examples of assessment tools can be found in the Standards’ glossary (Table 1).

The assessment and education plan, intervention, and outcomes will be documented in the participant’s health record. Documentation of participant contact with DSMES team members will guide the education process, provide evidence of communication among other members of the individual’s health care team, and demonstrate adherence to guidelines, all of which will assist in long-term management of diabetes care and diabetes self-management support (86). Using technology tools will increase access to information for all team members to work collaboratively and have access to documentation.

While initial DSMES is necessary, it is not sufficient for participants to sustain a lifetime of diabetes self-management (13,115). Initial improvements in metabolic and other outcomes have been shown to diminish after six months (13,115). To maintain behavior at the level needed to effectively self-manage diabetes, participants with type 1 diabetes (12) and type 2 diabetes (11) need ongoing diabetes self-management support. Ongoing support is defined as resources which help the participant implement and sustain the ongoing skills, knowledge, and behavior changes needed to manage their condition (13). The vital point is that the participant selects the resource or activity that best suits their self-management needs.

A variety of strategies are available for engaging in ongoing support both within and outside DSMES services. Support can include internal or external group meetings (connection to community and peer groups [online or locally]), ongoing medication management, continuing education, resources to support new or adjustments to existing behavior change goal-setting, physical activity programs, weight-loss support, smoking cessation, and psychosocial support among others (154–159). Connecting the participant to existing community resources outside of the DSMES entity is more realistic for smaller organizations.

The effectiveness of providing support through diabetes educators, disease-management programs, trained peers, diabetes paraprofessionals, community-based programs, or through the use of technology (text, e-mail, social media, web-based, mobile, digital, and wearable and wireless devices) has also been established (154–156,160–165). Peer support using social networking sites improves glucose management, especially in people with type 2 diabetes (25). Practitioners can highlight the benefits and accessibility of online diabetes communities as a resource to help participants learn from others living with the condition, facing similar issues, available 24 h a day, seven days a week, when it is convenient for them to engage. A person-centered approach is recommended to incorporate ongoing support plans in clinical care (115,128,166).

Effective DSMES is a significant contributor to long-term, positive health outcomes and clinical improvement (8). Assessing needs and communicating information and skills that promote effective coping and self-management must involve a personalized and comprehensive approach (13). The provider(s) of DSMES will rely on behavior change goal-setting strategies to help participants meet their personal targets (167). There are proven steps based on goal-setting theory that improve outcomes. The role of the DSMES team is to aid the goal-setting process and adjust based on participant needs and circumstances (168,169). Validly measuring the achievement of SMART goals (specific, measurable, achievable, realistic, and time-bound) and action planning including an assessment of confidence and conviction is essential (170,171).

To demonstrate the benefits of DSMES, it is important for DSMES providers to track relevant evidence-based DSMES outcomes such as knowledge, behavior, clinical, quality of life, cost-savings, and satisfaction outcomes. The AADE Outcome Standards for Diabetes Education specify behavior change as the key outcome and the AADE7 Self-Care Behaviors (healthy eating, being active, taking medication, monitoring, problem solving, reducing risk, and healthy coping) provide a useful framework for assessment, documentation, and evaluation (111,122). Providers of DSMES should select validated measurement tools to accurately track outcomes.

Tracking and communication of individual outcomes must occur at appropriate intervals, e.g., before and after engaging in DSMES. The interval depends on the nature of the outcome itself (e.g., A1C every three to six months) and the timeframe specified based on the individual’s personal goals. For some areas, the indicators, measures, and timeframes will be based on guidelines from professional organizations or government agencies (8).

Formal quality improvement strategies can lead to improved diabetes outcomes (84,85). DSMES must be responsive to advances in knowledge, treatment strategies, education strategies, and psychosocial interventions, as well as consumer trends and the changing health care environment. By measuring and monitoring both process and outcome data on an ongoing basis, providers of DSMES can identify areas of improvement and adjust participant engagement strategies and service offerings accordingly. Evaluation can contribute to the sustainability of the service. Positive results from quality initiatives can be used in marketing efforts and shared with administration in larger health systems. A focus on quality is also part of overall medical quality initiatives including pay-for-performance and the Medicare Access and CHIP Reauthorization Act (MACRA), which has shifted provider payment based on productivity to one that focuses on quality and outcomes (172).

The Institute for Healthcare Improvement suggests three fundamental questions that should be answered by an improvement process: What are we trying to accomplish? How will we know a change is an improvement? And what changes can we make that will result in an improvement (173)?

Once areas for improvement are identified, the DSMES quality coordinator determines timelines and important milestones, including data collection, analysis, and presentation of results. Measuring a variety of outcomes ensures that change is successful without causing additional problems in the system. Outcome measures indicate the result of a process (i.e., whether changes are leading to improvement, e.g., a change in a behavior or a biomarker [A1C]), while process measures provide information about what caused those results (e.g., if the participant attended DSMES sessions or had an exam done) (173). Process measures are often targeted to those processes that affect the most important outcomes. Measures generally recommended for DSMES services include behavioral measures (e.g., participant’s report of self-management activities and psychosocial behaviors including distress), clinical measures (e.g., changes in weight or A1C), operational measures (e.g., participant satisfaction, financial indicators, no-show rates, or results of marketing efforts), and process measures (e.g., participants receiving services, referral to DSMES, or referral for an eye exam). A variety of methods can be used for quality improvement initiatives, such as the Plan-Do-Study-Act model, Six Sigma, Lean, Re-AIM, and workflow mapping. There are resources available to assist those initiating quality improvement programs for the first time or for those looking for new options (84,85,172,174).

Acknowledgments. The authors thank Lindsey Wahowiak, Washington, DC, for her editorial assistance in preparing this manuscript.