February 26, 2013

National Standards for DSME and DSMS - Part 5

Part 5 of 6 Parts

The eighth standard states, “The participant and instructor(s) will together develop a personalized follow-up plan for ongoing self-management support. The participant’s outcomes and goals and the plan for ongoing self-management support will be communicated to other members of the health care team.”

If the seventh standard is not completed, chances are this standard will go by the way also. The setting of goals is important for the patient and knowledge of the goals is also important for the healthcare team. This helps communications and lets all members of the healthcare team know what the others are working on. While DSME can be effective for short periods of time, it needs DSMS to reinforce the information and help the patient understand the importance of daily management away from the clinic or doctor's office.

While the primary responsibility for diabetes education belongs to the provider(s) of DSME, participants benefit by receiving reinforcement of content and behavioral goals from their entire health care team. It should not matter that the support (DSMS) comes from the trained peers, community health workers, or community-based programs. Because self-management takes place in participants’ daily lives and not in clinical or educational settings, patients should be assisted to formulate a plan to find community-based resources that may support their ongoing diabetes self-management.

Hopefully, DSME and DSMS providers will work with participants to identify such services and, when possible, track those that have been effective with patients, communicating with providers of community-based resources in order to better integrate them into patients’ overall care and ongoing support. This will be especially important in many rural areas where CDEs are in short supply and are not present on an every day basis.

The ninth standard states, “The provider(s) of DSME and DSMS will monitor whether participants are achieving their personal diabetes self-management goals and other outcome(s) as a way to evaluate the effectiveness of the educational intervention(s), using appropriate measurement techniques.”

For diabetes self-management to become the contributor to long-term, positive outcomes, the provider(s) of DSME and DSMS will need to assess each patient's personal self-management goals and the progress in achieving these goals. At least the AADE has their AADE7 list (found here) that outlines seven behavior changes that everyone needs to consider how they apply to them individually. Differences in behaviors, health beliefs, and culture as well as their emotional response to diabetes can have a significant impact on how participants understand and view their illness and engage in self-management. DSME providers who account for (properly assess) these differences when collaborating with participants on the design of personalized DSME or DSMS programs can improve participant outcomes.

Although this is not feasible yet, for people in rural areas may benefit in the future from telemedicine. At present, assessments of patients may be difficult in rural areas, but attempts must still be made. In some areas, guidelines from professional organizations or government agencies may prevail for time frames of this assessment.

The tenth standard states, “The provider(s) of DSME will measure the effectiveness of the education and support and look for ways to improve any identified gaps in services or service quality using a systematic review of process and outcome data.”

This could be a most important standard if this could be reviewed by a third party, but having a CDE review this is like letting the fox guard the chicken coop. Will the CDE be responsible? Will new advances in knowledge, treatment strategies, education strategies, psychosocial interventions, and the changing healthcare environment be incorporated into the ongoing education and support? If they are responsible, they will identify areas of improvement and make the necessary adjustments.

This should be in their mind at all times. “The Institute for Healthcare Improvement suggests three fundamental questions that should be answered by 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?

Once areas for improvement are identified, the DSME provider (CDE) must designate time lines and important milestones including data collection, analysis, and presentation of results. Process measures are often targeted to those processes that typically impact the most important outcomes and these must be properly assessed.

If you have read the standards, you should agree that this is putting a lot on the plate for the AADE and their CDEs. Unless they change their way of doing business, these standards will not become a reality for many people with diabetes and the people with prediabetes will continue to be ignored.

To this point, I have not mentioned the shortcomings of the ADA 2013 Guidelines. I can see many things left out of the ADA Guidelines that may impact the National Standards for Diabetes Self-Management Education and Support.

First, the ADA Guidelines totally ignore any mention of telemedicine, which could be an advantage for CDEs providing education and support for rural patients with diabetes. Second, while the group of patients who are at risk for diabetes are mentioned and some overall guidance is mentioned, this group of people need a name more descriptive than prediabetes and specific treatments need to be part of the guidelines. This could make it possible for the CDEs to be reimbursed for time spent on education in this group of patients. Under current ADA guidelines, reimbursements are very difficult for time spent on education, which discourages CDEs from even attempting education for this group.

 This information is from the National Standards for DSME and DSMS.

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