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Wondering what changes were made to the National Standards for DSMES and how they impact your DSMES service?  This blog is intended to give a brief overview of the standards, highlight the changes that were made, and how to implement them into your DSMES services.  Here is the article in full (if you are an AADE member you can access it free of charge…just sign in), published in The Diabetes Educator:  http://journals.sagepub.com/eprint/gv4N52NSqErrKxBfPJIJ/full

It can also be found on the American Diabetes Association website:  http://care.diabetesjournals.org/content/diacare/early/2017/07/26/dci17-0025.full.pdf   

At the end of this blog is my contact information. I help DSMES services with meeting the National Standards and Recognition or Accreditation, so that you can bill Medicare.  I’m happy to help any way I can!

The National Standards for Diabetes Self-Management Education and Support were developed and published in 1984, and programs were first recognized in 1987 using a review process based on the Standards.  ADA became a National Accrediting Organization (NAO) in 1986, followed by AADE in 2009.  CMS began reimbursing for education in 1997, and the National Standards have been the basis for determining quality and evidence-based diabetes education programs that could bill and be reimbursed for their services. 

I had the honor of serving on the current Revision Workgroup, and I have to say, it was an incredible learning opportunity!  The Standards are typically revised every five years; the last revision happened in 2012, when Montana’s Carla Cox was on that particular revision committee.  It is possible that the next revision might be in three years because of how healthcare and DSMES are changing so quickly right now!

One of the goals of this work was to not make things more complex for those offering DSMES services, but to continue to identify quality and highlight the importance of DSMES services to those living with diabetes and at risk for diabetes… and to payors and providers as well. 

ONE KEY THING TO REMEMBER:  The National Standards for DSMES define timely, evidence-based services to ensure wide application and quality!  Reimbursement does NOT define the Standards.  The hope is that payors view the Standards as a tool for reviewing DSMES reimbursement and consider change to align with their beneficiaries’ educational engagement preferences (including technology-based models, etc).  Also, the National Standards for DSMES are SEPARATE from ADA’s Review Criteria for Education Recognition Program (ERP) and AADE’s ‘Crosswalk’ (now called Interpretive Guidance) for Diabetes Education Accreditation Program (DEAP)…although both organizations utilize the National Standards to guide what is used to define quality programs to CMS. 

What is DSMES? Diabetes Self-Management Education and Support = the ongoing process of facilitating the knowledge, skills, and ability necessary for prediabetes and diabetes self-care, as well as activities that assist the person with diabetes/prediabetes in implementing and sustaining the behaviors needed to manage his/her condition on an ongoing basis, beyond or outside of formal self-management training. 

It incorporates the needs, goals, and life experiences of the person, is guided by evidence-based Standards, and includes support (behavioral, educational, psychosocial, clinical).  DSMES improves clinical outcomes, health status, and quality of life.

CHANGE:  DSME/S is now DSMES.  The change aims to reflect the value of ongoing support and multiple services or ‘touchpoints’ throughout the life of a person living with diabetes/prediabetes.

CHANGE:  “Program” is now called “Services.”  Again, the aim is to emphasize the need to individualize and identify elements of DSMES appropriate for an individual.  It is not a ‘scripted’ program.  Nor does it necessarily have an “end” to it.  “Programs” typically have an end, whereas people with diabetes need a lifetime of education and support for ongoing health and changing needs; therefore the word, ‘services’ was used to emphasize that need for ongoing care and educational support. 

CHANGE:  “Patient” is now called “Participant.”  This change is to coincide with the new language guidance document from AADE and the ADA.  This is primarily to recognize that people do not necessarily consider themselves ‘sick’ or be solely identified by their condition. They have a condition to manage, but do not want to be labeled as a ‘patient.’  The new language guidance document is a ‘must read,’ and not only that, but it’s something to incorporate into our work with those living with diabetes or at risk for diabetes, as well as when we communicate (in writing too) with colleagues and others.  Respect and consideration in the language we use goes a long way in building relationships with the people we serve, their families, and our communities. https://www.diabeteseducator.org/practice/educator-tools/diabetes-language-paper?utm_source=Internal&utm_medium=MAST&utm_campaign=LanguageGuide 

STANDARD 1 – Internal Structure.  The provider(s) of DSMES services will define and document a mission statement and goals.  The DSMES services are incorporated within the organization, large, small, or independently operated.  The key things required to meet this standard include a mission statement, goals, defined leadership and lines of communication, and evidence of organizational support. This is true of successful entities, and some of the evidence for this standard comes from not only health care entities, but from the business world as well. 

STANDARD 2 -  Stakeholder Input (formerly called external input).  The provider(s) of DSMES will seek ongoing input from valued stakeholders and experts to promote quality and enhance participant utilization.  “Stakeholders” reflects those working INSIDE your organization and OUTSIDE of your organization that are vital to your success and to meeting the needs of your clients.  They could include referring providers or other health professionals, your marketing department, the senior center, the local newspaper or radio staff, maybe someone who is adept with social media, people with diabetes who have used your services, etc.  The point is to look at your community, and inside your own organization, and identify who is important in your success as a service and meeting the needs of your identified population (see standard 3).  The stakeholders will provide input, information and help to foster ideas, and may help to improve utilization of services and help with quality, outcomes, and sustainability of the DSMES services.  There must a PLANNED and DOCUMENTED STRATEGY for eliciting input from stakeholders.  It does NOT have to be an in-person meeting, although it certainly can be.  Using emails, phone calls, surveys, etc, are also ways of obtaining feedback from stakeholders.  Be sure to document any feedback from your stakeholder group, regardless of how you interact with your stakeholders. 

STANDARD 3 – Evaluation of Population Served (formerly called ‘access’).  The provider(s) of DSMES will evaluate the communities they serve to determine the resources, design, and delivery methods that will align with the population’s need for DSMES services. You need to understand the community you serve…and ‘community’ can mean your physical community, but it also could mean a ‘virtual community’ for those services that are provided to a population via a mode of technology, such as telehealth or vitual services.  You need to understand who is coming to education, and who you want to educate but is not coming, as well.  Identify barriers that prevent access to DSMES, and work to overcome those barriers.  Technology-enabled DSMES can increase access, so be thinking about how to reach out to those who are not utilizing your services, and possibly pursue alternate methods of providing DSMES services to those in your service area who are not coming in-person, if that is seen as valuable to meeting the needs of those you serve.   

STANDARD 4 – Quality Coordinator Overseeing DSMES Services (used to be called ‘program coordinator’).  A quality coordinator will be designated to ensure implementation of the Standards and oversee the DSMES services.  The quality coordinator is responsible for all components of DSMES, including evidence-based practice, service design, evaluation, and continuous quality improvement.  There will be 1 qualified Quality Coordinator who manages all aspect of services.  This person can be a part of the DSMES team, or this person can be a separate person serving in this role.  The title change reflects the need to address quality at all levels of DSMES services, and aligns with new models of care and payment methods.  The position description title does NOT have to be ‘Quality Coordinator’ but duties/responsibilities must align. 

STANDARD 5 – DSMES Team (formerly called ‘instructional staff’). At least one of the team members will be a registered nurse, registered dietitian nutritionist, or pharmacist with training and experience pertinent to DSMES, or can be another health care professional holding certification as a CDE or BC-ADM.  Other health care workers or diabetes paraprofessionals may contribute to DSMES services with appropriate training and supervision/support by at least one of the team members listed above.  Key elements include:  professional educators must maintain current credentials, document appropriate CEs of diabetes-related content, paraprofessionals need continuing education specific to the role they serve on the team, and they also directly report to the quality coordinator or to the other qualified DSMES team members.  CHANGE:  ALL DSMES services must have a policy of referring services outside of the expertise and scope of DSMES providers.  This includes single discipline programs AND all other multi-discipline programs, as you probably all refer to podiatrists, opthamologists, etc. This means ALL programs must have a policy for referring to other health professionals outside of their expertise. 

STANDARD 6 – Curriculum.  A curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, will serve as the framework for the provision of DSMES.  The needs of the individual participant will determine which elements of the curriculum are required.  Key elements of DSMES services include:  dynamic, practical problem solving, psychosocial, behavior change to sustain self-management.  There are highlighted NEW topics in the ADA review criteria that need to be covered by the curriculum, but most of the newer curricula all cover these topics (such as including sick days, disaster planning, navigating the health system, e-health education, etc.).  There are a number of ‘approved’ curricula:  ADA’s “Life with Diabetes,” AADE’s “Diabetes Education Curriculum: A Guide to Successful Self-Management,” and the International Diabetes Center’s “Type 2 Basics.” These are just a few of these ‘approved’ curricula available, but are common ones being used by many programs.  One of the things that I would like to highlight is that the learning process must be engaging to participants…just reviewing power point slides and lecturing doesn’t ‘cut it’ anymore.  Please consider a few fun and participatory learning activities.  We know that diabetes can be serious, and there are times for serious conversations, but consider involving participants in a fun and engaging process that utilizes those learning theory models.  It’s so important!  We want people to WANT to come back and see us!  Find colleagues that are doing some fun things that are successful and learn from each other. 

STANDARD 7 – Individualization.  The DSMES needs will be identified and led by the participant, with assessment and support by one or more of the DSMES team members.  Together, the participant and DSMES team member(s) will develop and individualized DSMES plan.  Key elements include being person-centered, focus on the priorities and values of the person.  The assessment should be a collaborative process that assesses disease and treatment burden, peer and social support, reassessment at the 4 key times (diagnosis, yearly, when there is a change in treatment, and when there is a change in life/living situation).  Document the assessment, education plan, intervention and outcomes.  Again highlighted is an interactive teaching style (not static lecture), with goal setting and action planning, shared decision-making, teach backs, motivational interviewing, cognitive behavioral therapy (CBT), and problem-solving using data (patient self-generated data) to change behavior.  The team members will use clear health communication principles, avoid jargon, be culturally relevant, and use validated assessment tools to evaluate progress.  No participant is required to complete a certain set of DSMES classes/sessions/structure/program, and when the participant achieves their goal, they can determine that their initial DSMES intervention is complete.  HIGHLIGHTED:  DSMES is an ongoing, lifelong process!!!  Technology-enabled DSMES (texts, apps, social media) may empower participants and improves A1C, but use caution with Medicare: not currently reimburseable.  However, when used to meet Medicare criteria, telehealth (real time audio/visual) may be used to serve certain patients.

STANDARD 8 – Ongoing support.   The participant will be made aware of option and resources available for ongoing support of their initial DSMES, and will select the option that best supports their self-management needs.  Support services include those that help implement and sustain the ongoing skills, knowledge, and behavior changes needed to manage their diabetes.  These support services could be within your organization or outside of DSMES services.   The diabetes online community (DOC) is a resource where people can learn from others facing similar situations and is available 24/7.  CHANGE:  you no longer have to send this piece to the referring provider, but you must document it. 

STANDARD 9 – Participant Progress.  The provider(s) of DSMES will monitor and communicate whether participants are achieving their personal diabetes self-management goals and other outcome(s) to evaluate the effectiveness of the educational intervention(s), using appropriate measurement techniques.  Key elements include goal-setting strategies to meet personal targets (SMART goals), and behavior change is the ultimate outcome for measuring the effectiveness of DSMES.  Tracking and communicating individual outcomes (clinical, QOL, satisfaction) is required.  The AADE7 Self-Care Behaviors provide a framework for assessment, documentation, and evaluation, and utilizing validated measurement tools is suggested.  You must be able to identify individual participant progress, as well as your overall participant population progress, and provide a population outcomes report on attainment of goals. 

STANDARD 10 – Quality Improvement.   The DSMES quality coordinator will measure the impact and effectiveness of the DSMES services and identify areas for improvement by conducting a systematic evaluation of process and outcomes data.   You MUST have a PLAN to conduct that evaluation of process and outcomes data, and measure the impact and effectiveness of the DSMES services via a CQI plan.  NOTE:  It is suggested to address the quality initiatives for pay-for-performance models of reimbursement…quality and outcomes versus ‘productivity’ that previously was the focus.  The Institute for Health Care Improvement has 3 important questions that should be addressed in an improvement process:

1. What are we trying to accomplish?
2. How will we know a change is an improvement?
3. What changes can we make that will result in an improvement?

A variety of methods can be used for CQI:  Plan/Do/Study/Act, Six Sigma, LEAN, Re-AIM, Workflow mapping, etc.  Outcome measures indicate the RESULT of a process, whereas process measures provide information about what CAUSED those results.  Ideally, process measures target those processes that impact the most important outcomes.  Don’t let it become just a ‘check-box’…something you have to do.  Make it meaningful!   Measures for DSMES services could include: 

1. Behavioral measures – participant’s report on self-management activities, psychosocial behaviors, etc.
2. Clinical measures – A1C, weight, BP, etc
3. Operational measures – participant satisfaction, no show rates, marketing efforts
4. Process measures – referrals, etc

SUMMARY OF KEY CHANGES: 

1. DSMES - support is included in DSME
2. Service instead of program
3. Participant instead of patient
4. Quality Coordinator instead of Program Coordinator

Standards 4 and 10 – stronger focus on quality

1. Title changes:
   1. External input is now called Stakeholder Input
   2. Access is now called Evaluation of Population Served
   3. Program Coordinator is now called Quality Coordinator overseeing DSMES services
   4. Instructional Staff is now called DSMES Team
   5. Patient is now called participant

These changes in the National Standards are now being reflected in the ADA Review Criteria and AADE Interpretive Guidance.  ALL DSMES services (formerly called ‘programs’) will have to have the National Standards incorporated into their program by May 2018.  New applications and renewal applications MUST use the 2017 standards and the accompanying recognition or accreditation application criteria by January 1, 2018.  Both the ADA and AADE have new guidance documents on their respective websites, and both are offering FREE WEBINARS to new and current Quality Coordinators who oversee DSMES services.  Be sure to sign up for their webinars and informational phone meetings!

ADA Education Recognition Program (ERP):  https://professional.diabetes.org/diabetes-education 

https://professional.diabetes.org/files/media/1.erp_quality_coordinator_guide-print-final-11-27-17.pdf (new document outlining all the changes- highlighted in red and underlined – in the standards and therefore the review criteria)

AADE Diabetes Education Accreditation Program (DEAP):  https://www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap)    Interpretive Guidance approval from CMS is due Dec 15^th, so once that is done, their documents will be on the AADE website.  Monthly webinars will be available for updates from AADE on the DEAP process.  A toolkit is under development and sample document will be available on the website as well. 

Additional document is attached and shows the AADE and ADA timelines for implementation of the revised National Standards.  (Source: AADE webinar from Nov 2017 – The Revised National Standards)

Finally… the Montana Diabetes Program’s Quality Diabetes Education Initiative (QDEI) is available for assistance with developing a DSMES program or working toward Recognition or Accreditation.  Please contact: 

Marci Butcher, RD, CDE

Montana Diabetes Program – MT DPHHS

406-350-2658

mbutcher@midrivers.com

 I would love to help you with your DSMES services!  If you require assistance with implementing the new National Standards and Interpretive Guidance documents from ADA or AADE, please contact me!  Happy to help!