For many years, the American Diabetes Association (ADA) has annually updated their Standards of Medicare Care in Diabetes and for years these standards have included the recommendation that all people receive Diabetes Self-Management Education and Support (DSMES),1 a service covered by Medicare and other health plans. Yet several reports show that despite evidence of its effectiveness, the rate of participation is under 10%.2 This occurs for many reasons including: lack of knowledge about DSMES and/or lack of referral to DSMES by primary care providers and other front line providers; DSMES is delivered outside of the medical practice; is viewed by the patient as inconvenient; and/or not prioritized by the patient and/or provider.
A challenge in delivering optimal diabetes care is engaging the growing number of people in day-to-day self-management. With the above considerations in mind, it’s clear that going forward we need impactful solutions to deliver DSMES to more people and in ways that optimally impact their disease management and outcomes.
Newly Revised National Standards for DSMES
The National Standards for DSMES have, over the last few decades, been updated and revised every five years by the ADA and American Association of Diabetes Educators (AADE) – the two National Accrediting Organizations by the Centers for Medicare and Medicaid Services (CMS). These standards are utilized by Medicare (CMS) to accredit and recognize DSMES programs that reimbursed for delivery of this service.
The National Standards for DSMES were again revised in 2017.2 A multi-disciplinary group of 20 thought leaders from a variety of disciplines and with an array of expertise were chosen by ADA and AADE to review and revise these standards. I was privileged to be among this group of thought leaders.
Need to Integrate DSMES into Diabetes Care
The challenges to imbed DSMES within ongoing diabetes care and management are numerous. At present DSMES is, in many instances, delivered in isolation, outside of the milieu of where the person receives his/her diabetes care. It is critical; if we are to optimize care, that moving forward we integrate DSMES into the care provision and continuum.
The ADA Standards of Medical Care for Diabetes has and continues to recommend that Lifestyle Management is foundational to diabetes care and is inclusive of DSMES. The Standards note that DSMES includes Medical Nutrition Therapy, physical activity, smoking cessation counseling and psychosocial care. The 2018 ADA Standards state that “patients and care providers should focus together on how to optimize lifestyle from the time of the initial comprehensive medical evaluation, throughout all subsequent evaluation and follow-up, and during the assessment of complications and management of comorbid conditions in order to enhance diabetes care.”1
In the Pharmacologic Approaches to Glycemic Treatment section of the ADA Standards, Lifestyle Management (as described above) is listed in each stage of the antihyperglycemic therapy algorithm for adults with type 2 diabetes.1 DSMES should be implemented in accordance with the Joint Statement for DSMES in Adults with Type 2 Diabetes published by ADA, AADE and the Academy of Nutrition and Dietetics (AND) in 2015 but unfortunately this is far from today’s reality.3
As the Joint Statement delineates, DSMES is not and should not be considered as a finite set of didactic lessons and should not be considered a once and done service. Rather it should be considered as the initial and ongoing delivery of self-management knowledge and skills to enable a person to care for and manage their diabetes. DSMES can be delivered in many settings and in a variety of ways by diverse health care team members. It is a service that has the goal of meeting the needs of the individual at that time and in a way that helps them gain knowledge, skills and support to optimize their treatment and improve their diabetes management. The delivery of this service should be fluid and dynamic. It should recognize the ebb and flow of living with and managing the complexity of a chronic condition like diabetes and all too often other related chronic conditions and or chronic complications of diabetes.
Optimal Delivery of DSMES May be Technology-Enabled
Thus a key question at hand is how can DSMES be optimally delivered to the current and growing numbers of people with diabetes who expect this service, like an increasing number of services, to be easily accessible 24/7?
Evidence is mounting to support the use of technology-enabled solutions to deliver DSMES. The 2018 ADA Standards recognize that alternative and innovative models of DSMES need to be explored and cite a recently published systematic review which concludes that technology-enabled DSMES solutions improve A1C most effectively when they include two-way communication between the patient and the healthcare team, individualized feedback, use of the patient-generated health data and tailored education.4
Integrating DSMES within the medical care and management of diabetes and embedding DSMES at the point of care has been shown to improve access, clinical outcomes, and cost effectiveness.2Technology-enabled DSMES, when evidence-based, offers the opportunity to extend the reach and effectiveness of the care team allowing for individualized, contextualized on-demand delivery of DSMES cost effectively, potentially for an entire population. The patient-generated health data from this mode of delivery, if leveraged appropriately, can facilitate more impactful connections between the person with diabetes and their care team. This can inform focused two-way conversations, shared decision making and more timely therapy optimization.
In conclusion, to be successful with diabetes management people must gain self-management skills. Implementation and ongoing use of these skills requires ongoing support. To be successful and to support optimal outcomes DSMES must be provided on an ongoing basis throughout each person’s life with diabetes as needed based on life-cycle and life-changing events.2 Technology-enabled solutions, such as WellDoc’s BlueStar medical mobile app cleared by FDA for type 2 diabetes, is one such solution. Several other solutions exist today and many more will likely become available over time.
- American Diabetes Association. Standards of Medical Care in Diabetes – 2018. Diabetes Care 2018; 41 (Suppl. 1): S1-S53.
- Beck J, Greenwood DA, Blanton L, Bollinger ST, Butcher MK, Condon JE, Cypress M, Faulkner P, Fischl AH, Francis T, Kolb LE, Lavin-Tompkins JM, MacLeod J, Maryniuk M, Mensing C, Orzeck EA, Pope DD, Pulizzi JL, Reed AA, Rhinehart AS, Siminerio L, Wang J; 2017 Standards Revision Task Force. 2017 National Standards for Diabetes Self-Management and Support. Diabetes Care. 2017; 40(10):1409-1419, Jul 28. pii: dci170025.
- Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl A, Maryniuk MD, Siminerio L,Vivian E. Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015, 41(4):417-430.
- Greenwood DA, Gee M, Fatkin FJ, Peeples MA Systematic Review of Reviews. Evaluating Technology-Enabled Diabetes Self-Management Education and Support. Journal of Diabetes Science and Technology, 2017DOI: 10.1177/1932296817713506 1–13.