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Appendix 1:

Stratifying Care According to Patient Population Needs

Once the diabetes patient population is known, the team may want to stratify the population into groups according to the intensity of services required. Patients at risk for complications may require the lowest intensity of care and resources, whereas those with complications or comorbidities or those who are at break points in their disease management may require more-intensive services.

A.  Identify patients at risk for type 2 diabetes​

Risk factors for type 2 diabetes[40] include

  • Overweight adult: Body Mass Index ≥25 kg/m2 (≥23 if Asian American or ≥26 if Pacific Islander)
    with one or more of the following
  • Family history: has a first-degree relative with diabetes
  • Race/Ethnicity: African American, Hispanic/Latino, American Indian and Alaska Native, or Asian American and Pacific Islander
  • History of gestational diabetes or gave birth to a baby weighing > 9 lbs
  • Hypertension: blood pressure ≥140/90
  • Abnormal lipid levels: HDL cholesterol level 250 mg/dl
  • IGT or IFG: on previous testing
  • Signs of insulin resistance: such as acanthosis nigricans or polycystic ovarian syndrome (PCOS)
  • History of vascular disease: diagnosed by physical exam and testing
  • Inactive lifestyle: is physically active less than three times a week

In the absence of the above risk factors, people age 45 and older are considered at risk and should be tested at least at three-year intervals.

B.  Identify patients at risk for diabetes complications​

Identifying patients at risk for diabetes complications can help the team to effectively stratify services. Clinical information to assess risk includes

  • A1C
  • bood pressure control
  • lipid control
  • cardiovascular disease risk
  • eye disease risk
  • foot disease risk
  • evidence of increased urinary albumin excretion and/or reduced eGFR
  • smoking habits
  • alcohol use
  • family history of diabetes complications including premature cardiovascular disease
  • duration of the disease
  • oral exam status
  • hypoglycemia history
  • depression and other psychosocial illness
  • reduced literacy
  • inadequate social support

Patients with type 2 diabetes who are largely free of diabetes complications or other comorbidities will benefit from relatively low-cost preventive care focused on risk factor reduction and health promotion. After screening for complications, the team could offer group discussions about risk factor reduction and self-management issues such as nutrition, weight management, and ways to incorporate regular physical activity into lifestyles.

C.  Identify patients with complications and other comorbidities​

Identifying the patients who have diabetes complications or other comorbidities can help determine those who will require more extensive resources, such as allocation of additional team members, more aggressive protocol management, or more frequent follow-up.[108, 109] Analyses of administrative databases have demonstrated that a large fraction of health care dollars are allocated to a small proportion of the population with multiple comorbidities. It is important to note, however, that patients with complications are an evolving group and that for practical planning purposes, periodic reassessment is essential.

D.  Identify patients at “break points”​

To predict other potential high resource users, identifying patients at “break points” in the course of their disease may be helpful. These points include

  • new onset of type 1 or type 2 diabetes
  • A1C consistently above 8 percent
  • new onset of significant complications
  • frequent or severe hypoglycemia
  • pregnancy in a woman with diabetes
  • initiation of insulin therapy[27]

Assessing reasons for consistently elevated A1C values in the patient population also may help team planning. The level of diabetes control can be affected by several factors

  • limited provider availability and service payment
  • outdated or ineffective management protocols
  • limited medical and dental insurance coverage for patients
  • limited insurance coverage for medications or supplies
  • cognitive, psychological, and social barriers that limit patient participation in diabetes management
  • limited diabetes self-management education or self-management support


Appendix 2:​

Scope of Practice for Diab​etes Educators and Board-Certified Advanced Diabetes Management Practitioners

A.  Guidelines and Competencies​

Guidelines for the Practice of Diabetes Education delineates the roles and responsibilities for individuals and organizations involved in the facilitation and delivery of diabetes education and care for persons with or at risk for diabetes and their families/caregivers.


Competencies for Diabetes Educators provides a master list of the knowledge and skills needed for the various levels of practice. They are the basis for education, training, development, and performance appraisal of all clinicians engaged in diabetes education. 


B.  The Role of Diabetes Educators​

Diabetes educators help people with and at risk for diabetes and related conditions to achieve behavior-change goals that lead to better clinical outcomes and improved health status. Diabetes educators apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and education to provide self-management education and training.


Certified Diabetes Educators (CDE) receive certification from the National Certification Board for Diabetes Educators by taking a voluntary examination that indicates distinct and specialized knowledge in diabetes patient self-management education, thereby promoting high-quality care for people with diabetes. Objectives of the certification program are to

  • provide a mechanism to demonstrate professional accomplishment and growth
  • provide formal recognition of specialty practice and knowledge at a mastery level
  • provide validation of dedication to diabetes education to consumers and employers
  • promote continuing commitment to best practices, current standards, and knowledge


Certification can be awarded to those who meet eligibility requirements and are from the following disciplines: registered dietitian, exercise physiologist, health educator, registered nurse, nutritionist, occupational therapist, optometrist, pharmacist, physical therapist, physician (M.D. or D.O.), physician assistant, podiatrist, public health professional, clinical psychologist, or social worker.


C.  The Role of B​oard-Certified Advanced Diabetes Management (BC-ADM) Practitioners

The Board-Certified—Advanced Diabetes Manager (BC-ADM) credential was developed to verify clinical care skills among advanced practitioners. The BC-ADM credential is a multidisciplinary credential for nurses, dietitians, and pharmacists who have advanced degrees. It is different from the CDE credential in that it focuses on advanced clinical management of diabetes. The exam covers the domains of clinical practice, collaboration, research, patient and professional diabetes education, and public and community health.



Appendix 3:​

Quality Improvement Indicators for Dia​betes Care

The increasing demand for high-quality care from managed health care systems, payers, and the public is an important development. The Diabetes Quality Improvement Project was an initial national collaborative effort to improve diabetes care and the quality of life for people with diabetes, consisting of eight performance measures for diabetes care that cover A1C and lipid testing and assessment of the eyes, kidneys, and feet. Numerous public agencies (the Department of Defense, the Health Care Financing Administration, multiple state Medicaid programs, the Indian Health Service, and the Veterans Health Administration) and private groups (the National Committee for Quality Assurance, NCQA) have developed quality measures in comprehensive diabetes care.

Diabetes performance measures have been incorporated into NCQA’s HEDIS* measures; these are reported publicly for Medicare, Medicaid, and commercial and managed care plans that serve Medicare beneficiaries. The Diabetes Recognition Program (DRP) administered by NCQA, is a voluntary recognition program for physicians and nurse practitioners who demonstrate high-quality outpatient diabetes care. A number of the processes and outcomes measured in the DRP could readily involve team care (see ADA resources).

Diabetes HEDIS measures for care, screening, or testing needed for comprehensive diabetes care for adults ages 18 to 75, consist of the following

  • A1C testing twice a year
  • A1C result > 9% = poor control measure
  • A1C < 8%
  • A1C result < 7% = good control measure
  • LDL-C measurement
  • LDL-C result < 100
  • Retinal eye exam
  • Nephropathy screening test or evidence of nephropathy
  • Blood pressure < 140/90
  • Blood pressure < 130/80

*Healthcare Effectiveness Data and Information Set


Appendix 4:​

Medicare for People​ with Diabetes

Medicar​e for People with Diabetes

What Is Medicare?

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). People with diabetes who are eligible for Medicare can get the most from their Medicare benefits by learning about the types of services that are available. People with diabetes are encouraged to ask their health care team about the benefits they qualify for and visit www.medicare.gov to get specific details from Medicare.

What Benefits Does Medicare Offer for People with Diabetes?​

People with diabetes enrolled in Medicare may be covered for all or part of the cost for

  • a “Welcome to Medicare” physical exam when they enroll
  • A1C testing
  • cholesterol testing
  • diabetes self-management training to learn how to manage diabetes
  • medical nutrition therapy: nutrition and lifestyle assessments, diet management information, and nutrition counseling
  • diabetes equipment and supplies for self-monitoring of blood glucose, including special equipment for persons with low vision
  • foot exams by a podiatrist if medically necessary
  • therapeutic shoes and inserts if medically necessary
  • a dilated eye exam and glaucoma screening
  • flu and pneumonia shots
  • diabetes medications
  • insulin pumps
  • kidney function tests

What Benefits Does Medicare Offer for People At Risk for Diabetes?​

People enrolled in Medicare who are at risk for type 2 diabetes may be covered for all or part of the cost of

  • a “Welcome to Medicare” physical exam when they enroll
  • yearly diabetes screening for people who are at risk for diabetes and twice yearly screening for people diagnosed with prediabetes (people are considered at risk if they have any of the following: high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity, or a history of high blood glucose)
  • cholesterol screening—every five years

To learn more​

1-800-MEDICARE (1-800-633-4227), in English and Spanish 
TTY/TDD 1-877-486-2048 
Medicare and You – bit.ly/cms-n-u
Medicare Coverage of Diabetes Supplies &Services – bit.ly/medprtb
Medicare Information for Caregivers – bit.ly/caregvr

February 2013​​​​​​​