Diabetes Educators Release Updated Report on DSMES Accessibility, Usage

The Association of Diabetes Care & Education Specialists (ADCES) released a consensus report outlining strategies health care stakeholders can follow to increase access to and utilization of diabetes self-management education and support (DSMES). The model includes access to clinical, educational, psychosocial, and behavioral aspects of care needed for daily self-management for those with type 2 diabetes (T2D). The last joint position statement on DSMES was issued in 2015.

In 2014, 22.3 million (9.1%) Americans were diagnosed with diabetes, while by 2060, prevalence of diagnosed diabetes is estimated to increase to 60.6 million Americans (17%). Currently, 90% to 95% of individuals living with diabetes have T2D.

“The cost of diabetes in the U.S. in 2017 was reported to be $327 billion including direct medical costs ($176 billion) and lost productivity ($69 billion),” according to researchers. “The cost of care for people with diabetes accounts for about 1 in 4 health care dollars spent in the U.S.; 61% of costs are attributed to people over age 65 and are incurred by Medicare.”

Despite advancements made in medication and technology treatment modalities, authors argue there has been a lack of improvement in reaching clinical target goals since 2005. In addition, researchers point out that between 2010 and 2016, improved outcomes stalled or even reversed.

The report was made in collaboration with several other organizations including the American Diabetes Association and Academy of Nutrition and Dietetics. It calls for making DSMES widely available to the public and argues health systems, payers, and providers address barriers to utilization.

“The purpose of DSMES is to give people with diabetes the knowledge, skills, and confidence to accept responsibility for their self-management,” researchers said. “This includes collaborating with their health care team, making informed decisions, solving problems, developing personal goals and action plans, and coping with emotions and life stresses.”

Although research shows DSMES provides beneficial outcomes to those with diabetes and is cost-effective, CDC data show only 6.8% of privately insured individuals with newly diagnosed T2D participated in DSMES within the first 12 months of diagnosis, while CMS reports only 5% of Medicare participants receive DSMES within the first year of diagnosis.

Benefits

In addition to specific recommendations for increasing access to DSMES, the report outlines 4 key times DSMES is most beneficial to patients. These instances include at diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop, or when transitions in life and care occur. It is during these times that individuals may need the most assistance to achieve goals and care plans to successfully carry out daily self-management.DSMES is identified as one of the essential elements of comprehensive diabetes medical care, in addition to nutrition therapy, according to authors. The cost-effective model has been proven to improve health outcomes and quality of life in individuals living with T2D.

“Even though outpatient and pharmacy costs are higher for those who use diabetes education, these costs are offset by lower acute care costs,” authors note. Use of DSMES results in reductions of emergency department visits, hospital admissions, and hospital readmissions.

Specific benefits associated with DSMES include:

• improved hemoglobin A_1c (A1C) with reductions that are additive to lifestyle and drug therapy
• reduction in the onset and/or worsening of diabetes-related complications
• reduction of all-cause mortality
• enhancement of self-efficacy and empowerment, increased healthy coping, and decreased diabetes-related distress

Additional studies show incorporation of DSMES is superior to metformin therapy, the foundation of T2D care for decades. When compared, DSMES resulted in no side effects, high psychosocial benefits, and cost savings as opposed to gastrointestinal side effects and low costs associated with metformin.

A core component of quality diabetes care is medical nutrition therapy (MNT). This facet ought to be coordinated with any overall management strategy, including the DSMES plan, authors note. “MNT helps prevent, delay, or treat other complications commonly found with diabetes such as hypertension, cardiovascular disease, renal disease, celiac disease, and gastroparesis.”

Accessibility

Researchers recommend referral to a registered dietitian for MNT in addition to DSMES as a separate and distinct service, as individuals with diabetes need both initial and ongoing MNT and DSMES. In the past, DSMES services were provided in a series of classes attended by individuals with diabetes and family members. However, researchers argue technology-based services like telehealth and mobile applications can promote increased access and connectivity for ongoing support outside of classes.

As racial and ethnic minorities and underserved communities are at the highest risk for diabetes, creative approaches to meet individual needs ought to be widely available. These needs can include learning preferences, literacy, language differences, and social determinants of health.

One potential solution to barriers proposed by authors is having office-based healthcare teams without in-house resources partner with local diabetes care and education specialists. “If the office-based care team assumes responsibility for providing diabetes education and support, every effort should be made to ensure they receive up-to-date training in diabetes care and education.”

Communication between the referring provider, patient, and DSMES team is also essential. This way, ongoing treatment goals can be met with a focus on the individual’s beliefs and desires. Care teams might include diabetes care and education specialists, registered dietitian nutritionists, nutrition and dietetics technicians, registered nurse educators, care managers, pharmacists, exercise and rehabilitation specialists, and behavioral or mental health care providers.

Furthermore, processes that streamline referral practices “must be implemented and supported system wide,” in order to reduce barriers. Without this measure, “it will be increasingly difficult to access DSMES services, particularly in rural and underserved communities.”

Reimbursement

Overall, lack of administrative leadership support, awareness of DSMES services, and logistical factors including timing, cost, and transportation, along with other barriers, all contribute to low rates of DSMES utilization.The consensus recommendation is that health policy, systems, providers, and care teams should facilitate reimbursement processes and financial support for DSMES implementation.

Since 2001, CMS has reimbursed diabetes education services billed as self-management training, while DSMES must receive accreditation by one of the national accrediting organizations to be eligible for reimbursement.

“CMS also reimburses for diabetes MNT…Three hours are available the first year of receiving this benefit, and 2 hours are available in subsequent years,” authors said.

However, reimbursement by private payers varies. While some will match CMS guidelines, others will expand coverage, in some instances without a copay.

Researchers purport health systems and clinical organizations can maximize billing potential by facilitating the reimbursement process. To do so, they must ensure all applicable codes are being utilized and submitted correctly.

“Evidence shows that DSMES can improve outcomes for people with diabetes, reduce costs to the health care system and slow an epidemic that continues to impact nearly one-third of Americans,” said Kellie Antinori-Lent, president of ADCES, in a statement. “We must make this service available to every single person with diabetes through a collaborative approach with payers, health systems, providers and the diabetes care team.”

Reference

Powers MA, Bardsley JK, Cypress M, et al. Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association Of Nurse Practitioners, and the American Pharmacists Association. Diabetes Educ. Published online June 8, 2020. doi:10.1177/0145721720930959