Diabetes education programs are developed to serve the diabetes community by offering quality education that meets a set of standards and is then eligible for third-party insurance reimbursement. Three organizations are authorized by the U.S. Centers for Medicare and Medicaid Services to determine whether diabetes education programs meet required standards. Each of the three relies on the 2007 edition of the national Standards for Diabetes Self-Management Education. This article summarizes similarities among and unique qualities of each of the organization's approaches to assuring quality.
This article is being co-published by the American Diabetes Association's Diabetes Spectrum and the American Association of Diabetes Educators' The Diabetes Educator.
Diabetes self-management education (DSME) continues to be cited as a cornerstone of effective diabetes care and a crucial part of a patient's success in living well with diabetes. Supporting the philosophies of the Chronic Care Model1,2 and effective self-management training,3 DSME provides a forum for informing and activating patients to manage their illness, better interact with the available systems for diabetes care, and ultimately achieve the best possible outcomes. In addition, the practice of DSME has been established as crucial to the care and management of people with diabetes, and measurable behavior change has emerged as the unique proxy for evaluating the impact of working with a diabetes educator.4,5 DSME is formally defined as the knowledge, skill, and ability necessary for self-care, through informed decision making, problem solving, and collaboration with the health care team to improve clinical outcomes, health status, and quality of life.6
Diabetes educators have become even more accountable for both their approaches to patient care and their comprehensive diabetes education programs. An educational standards framework such as the National Standards for Diabetes Self-Management Education (NSDSME)6 plays an important role in standardizing the educational process, content, and outcome measurement for helping people with diabetes or at risk for diabetes enhance their quality of life and better manage their condition.
The National Diabetes Advisory Board (NDAB) pioneered this framework with the creation of the National Standards for Diabetes Self-Management Education7 in the early 1980s. These standards were designed to define quality diabetes education and to assist diabetes educators in a variety of settings in providing evidence-based education and facilitate optimal health outcomes for patients with or at risk for diabetes.
To remain current, these standards are reviewed and revised approximately every 5 years to better reflect the changes and dynamic nature of the health care community. In this decade, two sets of updated NSDSME have been presented, first in 20008 and more recently in 2007.6 The 2007 revised standards continue to offer educators a program framework of 10 standards. These standards are based on the following five evidence-based principles:
Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short term.3,9-14
DSME has evolved from primarily didactic presentations to more theoretically based empowerment models.10,15
There is no one “best” education or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes.16-18 Additional studies show that age- and culturally appropriate programs improve outcomes19-23 and that group education is effective.11,13,14,24,25
Ongoing support is crucial to sustain progress made by participants during DSME programs.10,20,26,27
Behavioral goal setting is an effective strategy to support self-management behaviors.28
The revised NSDSME7 continue to address the framework format of structure, process, and outcome guidelines for establishing or maintaining an education program, influencing third-party reimbursement, and offering educators a framework for quality evidence-based program development, implementation, and evaluation.
Participating Organizations
In 1986, the American Diabetes Association (ADA), having partnered with NDAB and other well-known community organizations in developing the standards, became the first organization to develop an application and review process to identify programs meeting the standards. During the same time period, the Indian Health Service (IHS) was developing its own internal structure and process based on the NSDSME for review of diabetes education programs in tribal communities and provision of guidelines and technical assistance for program improvement.
In 1997, the federal Balanced Budget Act passed, permitting the U.S. Health Care Finance Administration (HCFA; now called the Centers for Medicare and Medicaid Services [CMS]) to provide coverage for diabetes self-management training (DSMT). Organizations were invited to develop and implement systems to publicly acknowledge those programs following the guidelines identified in the standards.
ADA's Education Recognition Program (ERP) process was well established at this time, with 530 recognized programs, and HCFA (now CMS) awarded the first national accrediting status to ADA in preparation for the final ruling on coverage for DSMT in 2001. This process identified programs that would later qualify for payments for delivering DSMT. The IHS was approved by CMS as a national accrediting organization in 2002. A third organization approved in 2009 was the American Association of Diabetes Educators (AADE) Diabetes Education Accreditation Program (DEAP). As the only organization dedicated solely to diabetes education, this was a natural step for AADE.
There are not enough DSME programs available to meet the needs of the increasing number of people with diabetes. ADA-recognized programs increased from 39 in 1986 to 2,038 as of October 2009, while diabetes prevalence grew from 6.4 million in 1986 to 24 million currently. The additional site provision in the ADA recognition process, which allows organizations to receive accreditation for multiple sites, has facilitated the expansion of programs from some of the existing primary program sites, for a total of 3,451 currently recognized sites.29 IHS tribal and urban Indian diabetes education programs may apply for IHS accreditation. There are currently 42 IHS Diabetes Education Recognized Programs (IDERPs).30 As of December 2009, programs accredited through the AADE have also increased from 13 to 82 in 250 sites.31
Because of the increased incidence of diabetes and increased demand for DSME, diabetes education programs are needed in a variety of settings beyond hospital outpatient and doctors' office settings. Such additional settings include pharmacies and community centers. However, nontraditional settings still must be held accountable for quality, reliability, and accuracy.
According to the ADA Recognition Program database, the predominant practice setting with ERP recognition remains the hospital outpatient setting. All three organizations (AADE, ADA, and IHS) offer program flexibility and multisite accreditation, while continuing the tradition of commitment to quality.
Comparing the Process: Similarities and Differences
All three organizations (AADE, ADA, and IHS) use the recently published NSDSME6 and are deemed certifying bodies by CMS and other third-party insurers, which is required for reimbursement. Each certifying body has similar but unique requirements. Two comparative summaries are offered in this article. Table 1 (p. 68-70) offers a structured comparison of several of the key administrative points of each of the three certifying bodies (AADE's DEAP, ADA's ERP, and IHS's IDERP), including fees, application processes, audits, and a brief overview of standards.
Each certifying body has a formal application process and requires supporting documentation. AADE and ADA require a fee with applications. The certifying bodies also require annual reports and renewals and have a process for auditing existing programs to ensure continued compliance with accreditation criteria. All have volunteer auditors who are trained reviewers and conduct random program audits.
A second comparison, in Table 2 (p 71-78), offers a more detailed review of the similarities and differences related to each of the published standards6 between ADA and AADE. This table details definitions and required documents. (The IHS program was not compared because its requirements are specifically designed for the unique community it serves.)
Additionally, each organization uses similar terminology. These terms are defined in Table 3 (p. 78). For example, ADA and IHS use the term “recognition,” whereas AADE uses the term “accreditation.” Each program is also uniquely identified by a related acronym—DEAP, ERP, or IDERP. Other terminology differences noted include measurement references to the interpretation of the standards, such as “indicators” (ADA and IHS) and “essential elements” (AADE). All use a yes-or-no checklist for standards being met or not met. Although their terminology differs, the three programs' content and concepts are all based on the NSDSME.6
Summary
There are not enough DSME programs available to meet the needs of the increasing number of people with diabetes; more educational programs are needed. Educators must be prepared to review their practices, explore ways to expand their services, and be willing to meet the needs of their patients in a variety of traditional and nontraditional ways, all while maintaining quality DSME with documented, measurable outcomes. Accreditation/recognition supports the provision of quality DSME, is essential for reimbursement, and offers public acknowledgment of accomplishment. Three organizations (ADA, AADE, and HIS) have been authorized by the U.S. Centers for Medicare and Medicaid Services to determine whether diabetes education programs meet required standards. Each of these organizations supports the NSDSME and the need for more quality DSME programs. More information about each organization can be found at the following Web sites:
AADE: Information available online from: http://www.diabeteseducator.org/ProfessionalResources/accred
ADA: Information available online from: http://professional.diabetes.org/recognition.aspx?cid=57941
IHS: Information available online from: http://www.diabetes.ihs.gov/index.cfm?module=programsIDERP
Acknowledgments
The individuals listed are acknowledged for the provision of information, review, and preparation of content, which the author used and interpreted to develop this article.
Tammy L. Brown, MPH, RD, BC-ADM, CDE, Director, Integrated Diabetes Education Recognition Program, Indian Health Service Division of Diabetes Treatment and Prevention, Albuquerque, N.M.
Paulina Duker, MPH, RN, BC-ADM, CDE, Director, Education and Recognition Programs, American Diabetes Association, Alexandria, Va.
Karen Fitzner, PhD, Chief Science and Practice Officer, American Association of Diabetes Educators, Chicago, Ill.
Leslie E. Kolb, RN, BSN, MBA, Director, Diabetes Education Accreditation Program, American Association of Diabetes Educators, Chicago, Ill.
JoAnne Lafley, MSN, RN, CDE, Reviewer, Integrated Diabetes Education Recognition Program, Indian Health Service, Albuquerque, N.M.
Melinda Maryniuk, RD, MEd, LDN, CDE, Director, Joslin Diabetes Center, Boston, Mass.
Lois Moss-Barnwell, MS, RD, LDN, CDE, Director, Diabetes Education Accreditation Program, American Association of Diabetes Educators, Chicago, Ill.
Robin G. Thompson, MS, APRN, BC-ADM, CDE, Review Coordinator, Integrated Diabetes Education Recognition Program, Indian Health Service, Albuquerque, N.M.
This article is being co-published by the American Diabetes Association's Diabetes Spectrum and the American Association of Diabetes Educators' The Diabetes Educator.
