You prescribe medications for type 2 diabetes, but what about diabetes education and support? It can be just as essential.
Research shows that diabetes self-management education and support (DSMES) can improve A1C levels and have a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes. Margaret (Maggie) Powers, PhD, RD, CDE, a clinician and research scientist at the International Diabetes Center in Park Nicollet in Minneapolis, explains how.
Q: Why should health care providers promote diabetes self-management education and support (DSMES) for their patients with type 2 diabetes?
A: It’s important because over 90 percent of diabetes care is self-care; provided by the person with diabetes. Diabetes self-management education and support enables people to be the best self-managers possible.
Q: When should that educational support be provided?
A: Our goal in writing the DSMES joint position statement was to provide clear guidance on the four critical times when a person with type 2 diabetes might need more attention to diabetes self-management. The objective was to encourage health care professionals to assess, provide, and adjust DSMES. This can help to avoid crisis management and support people with diabetes to be comfortable and confident in their decision making.
The position statement includes an algorithm of care that addresses four critical time points; these time points also are relevant for the other aspects of diabetes care.
- First time point: At diagnosis, whether the person is on medication or not, to ensure that they understand their diabetes’ daily needs and to provide emotional and behavioral guidance for initial changes. We also want to start focusing on a healthy eating pattern that is individualized for that person.
- Second time point: During an annual assessment for education, nutrition, and emotional needs. This is a time to review, update, and provide additional support for all aspects of self-management.
- Third time point: When complicating factors influence self-management, such as a change in schedule or when a new disease detracts from one’s focus on the daily management of diabetes. For example, if a woman with diabetes is diagnosed with breast cancer, chemotherapy medication can affect her blood glucose, her desire to eat, or the taste of food. We can help her and others in this situation find a food plan that best fits them during this time and also adjust other aspects of their care so that they can continue to be confident in their diabetes management.
- Fourth time point: When transitions in care occur, such as when someone is transitioning from the hospital to home or from home to assisted living. These transitions can affect an individual’s activity or ability to function, and we want to be on top of that, while also attending to other adjustments that might influence daily choices.
In clinical care at these different times, there is often a focus on, “Do we need to adjust the medication?” Yet, there’s also this whole aspect of actually taking the medication, the daily self-management, and nutrition. We want the health care system to be aware of these four critical time points and refer people appropriately to recognized and certified diabetes self-management education programs, registered dietitians, and mental health professionals, or to provide that care in the clinical setting.
Q: How can clinicians be encouraged to provide diabetes education, or make referrals for that education, at these time points for their patients?
A: We recommend embedding a diabetes self-management education and support checklist into clinical health records so that referrals for diabetes education are systematized. When you have someone who’s newly diagnosed with diabetes, or who’s experiencing another health problem, even if it’s a broken elbow—as their health care provider you may not be thinking, “I need to figure out how they’re going to stay active” or “How are they going to check their blood glucose?” or “Can they do that with one hand?” If the referral process is embedded in the clinical health record for the four critical time points, it can improve clinical outcomes, quality of care, and patient satisfaction.
Q: Can you provide more in-depth information on what is involved in DSMES?
A: If you’re the primary care provider, you can answer questions and provide emotional support regarding the diagnosis. But you might not have the time to ask and problem-solve important questions for the patient such as, “What times do you eat? When do you eat? How are you going to prepare foods now? When are you going to take the medication? How are you going to remember to take the medication?”
As diabetes educators, when we meet with someone at diagnosis, our role is to assess the factors that influence the individual’s decision making—like lifestyle, cultural influences, health beliefs, current knowledge, physical limitations, family support, financial status, medical history, even literacy and numeracy—we use a lot of numbers in diabetes. And we cover a lot of ground. We work with the person on medication adherence, monitoring of blood glucose, the food plan, physical activity, prevention of heart disease, and dealing with other acute and chronic complications. Diabetes education is also about risk reduction, such as smoking cessation, daily foot checks at home, and developing personal strategies to address psychosocial issues and concerns.
Q: What’s the evidence that diabetes education improves outcomes?
A: When I was president of the ADA, I did a talk on this topic, which is reprinted in the article,“If DSME Were a Pill, Would You Prescribe It?” Typically, when somebody is diagnosed with diabetes, they’re prescribed metformin. But why is diabetes education or nutrition therapy not automatically prescribed? The ADA goes through a process of evaluating medications and they look at efficacy—does it reduce A1C? What’s the risk of hypoglycemia with the medication? Is it weight neutral? What are the side effects? What are the costs? What I did in my talk was look at the efficacy of diabetes education using the same parameters. It reduces A1C; we have that data from diabetes education programs. We know that when people are initially diagnosed with diabetes, we can actually reduce or delay the initiation of medication with nutrition therapy.
Also, research shows that diabetes education improves the quality of life, self-efficacy, empowerment, healthy coping strategies, self-care behaviors, and adherence to the food plan. It also leads to healthier food choices, more activity, and use of glucose monitoring, and it lowers blood pressure and lipids. This is all referenced and cited in the article.
Q: Is diabetes education covered by Medicare and private insurance?
A: Medicare definitely believes in the value of education and reimburses for diabetes education and medical nutrition therapy. Private insurance also reimburses, especially for nutrition therapy. However, we've found that very few people are using the reimbursement benefits.
Q: What's preventing everyone with diabetes from receiving diabetes education?
A: I don’t think that there’s been a clear expectation by health care providers that they should write a referral or by people with diabetes that they should expect to receive referrals to a dietitian and a diabetes educator. But the ADA’s Standards of Medical Care in Diabetes—2019 recommend that everybody should receive nutrition therapy from a qualified person and they should receive diabetes education. People living with diabetes need to have clear expectations for this, and the health system—including primary care providers—needs to make the referrals. Clinical systems management can help by providing automatic referrals at the four critical time points.
There are still barriers that we're working through with Medicare. For example, you can't receive nutrition therapy and diabetes education at the same time. Another barrier is that Medicare requires diabetes education to be offered within the health system. We cannot offer our program at the local church, community center, or library—Medicare will not reimburse for those programs, even though we would like to make our programs more accessible in the community.
Another barrier is that the referral to diabetes education must come from the primary care provider. It can’t be the cardiologist, for example, and the patient cannot self-refer.
Q: The 2018 update of the ADA/EASD consensus report reinforces the importance of DSMES. What do you think will be the impact of this report?
A: I am thrilled that this consensus report supports the concept of four critical time points for diabetes education as well as individualized programs of medical nutrition therapy. The original version primarily focused on medication selection, but with each revision there’s been a much clearer indication of the value of diabetes education and medical nutrition therapy. I think this report can have a major impact on diabetes education by reducing the barriers to access and supporting the self-management needs of people with diabetes.
How do you ensure that your patients with diabetes receive education and support at critical times? Share below in the comments.