Diabetes Self-management Education and Support in Adults ... · Management of hyperglycemia in type...

2212-2672/Copyright ª 2020 AmericanDiabetes Association, American Pharma-cists Association, Academy of Nutrition andDietetics, American Academy of PhysicianAssistants, American Association of NursePractitioners, and Association of DiabetesCare & Education Specialists. Published byElsevier Inc. All rights reserved.https://doi.org/10.1016/j.jand.2020.04.020

This article is being published simultaneouslyin Diabetes Care, The Diabetes Educator, theJournal of the Academy of Nutrition andDietetics, the Journal of the AmericanAcademy of Physician Assistants, theJournal of the American Association ofNurse Practitioners, and the Journal of theAmerican Pharmacists Association. See page13 for additional resources.

ª 2020 American Diabetes Association, American Pharmacists Association, Academy of Nutrition anAmerican Academy of Physician Assistants, American Association of Nurse Practitioners, and AssDiabetes Care & Education Specialists. Published by Elsevier Inc. All rights reserved.

FROM THE ACADEMY

Diabetes Self-management Education andSupport in Adults With Type 2 Diabetes: AConsensus Report of the American DiabetesAssociation, the Association of Diabetes Care andEducation Specialists, the Academy of Nutritionand Dietetics, the American Academy of FamilyPhysicians, the American Academy of PAs, theAmerican Association of Nurse Practitioners, andthe American Pharmacists Association
Margaret A. Powers, MS, RD, CDE; Joan K. Bardsley, MBA, RN, CDE, FAADE; Marjorie Cypress, NP; Martha M. Funnell, MS, RN, CDE, FAAN;Dixie Harms, DNP, ARNP, FNP-C, BC-ADM, FAANP; Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE; Beulette Hooks, MD;Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDE; Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE;Melinda D. Maryniuk, MEd, RD, CDE, FADA; Anna Norton, MS; Joanne Rinker, MS, RDN, CDCES, LND, FADCES;Linda M. Siminerio, PhD, RN, CDE; Sacha Uelmen, RDN, CDE
Supplementary materials:Supplementary Tables 1 and 2 areavailable at www.jandonline.org

DIABETES IS A COMPLEX ANDchallenging disease that re-quires daily self-management decisions made

by the person with diabetes. Diabetesself-management education and sup-port (DSMES) addresses the compre-

hensive blend of clinical, educational,psychosocial, and behavioral aspectsof care needed for daily self-management and provides the founda-tion to help all people with diabetesnavigate their daily self-care with con-fidence and improved outcomes.1,2

The prevalence of diagnosed diabetesis projected to increase in the U.S. from22.3 million (9.1% of the total popula-tion) in 2014, to 39.7 million (13%) in2030, and to 60.6 million (17%) in 2060.3

Approximately 90e95% of those withdiabetes have type 2 diabetes.4 Diabetesis an expensive disease, and the medicalcosts of health care alone for a personwith diabetes are 2.3 times more thanfor a person without diabetes.5 Con-founding the diabetes epidemic and highcosts, therapeutic targets are not beingmet6. There is a lack of improvement inreaching clinical target goals since 2005despite advancements in medicationand technology treatment modalities.Indeed, between 2010 and 2016improved outcomes stalled or reversed.6

The goals of this Consensus Report areto improve clinical care and educationservices, to improve the health of

d Dietetics,ociation of

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individuals and populations, and toreduce diabetes associated per capitahealth care costs.1,7 This article isspecifically directed toward health careproviders (physicians, nurse practi-tioners, physician assistants [PAs]),referred to herein as providers, as itoutlines the benefits of DSMES, definesfour critical times to provide and modifyDSMES (see the Figure), proposes how tolocate DSMES related resources, anddiscusses potential solutions to accessand utilization barriers. This report pro-vides guidance to others as well: healthsystems and organizations can use thisreport to anticipate and address theneeds of persons with diabetes andcreate access to DSMES services; personswith diabetes can increase their aware-ness of DSMES services as part of qualitycare and can advocate for self-management education and support;and payers and policy makers can workto design reimbursement processes thatsupport participation in DSMES. TheConsensus Report’s recommendationsare listed in Table 1.

This Consensus Report focuses on acomponent of diabetes care that is

HE ACADEMY OF NUTRITION AND DIETETICS 1

Figure. The four critical times to provide and modify diabetes self-management ed-ucation and support.

FROM THE ACADEMY

often not accessed or utilized effec-tively–DSMES. DSMES is identified asone of the essential elements ofcomprehensive diabetes medical care,along with medical nutrition therapy(MNT) (see MEDICAL NUTRITIONTHERAPY AS A CORE COMPONENT OFQUALITY DIABETES CARE). DSMES im-proves health outcomes and quality oflife and is cost effective (see BENEFITSASSOCIATED WITH DSMES). Currentutilization is quite low because of avariety of barriers, yet solutions areavailable (see PROVIDING DSMES andIDENTIFYING AND ADDRESSING BAR-RIERS). Solutions begin with an orga-nizational commitment to the value ofaccess to, and participation in, DSMES.Financial support for DSMES services isavailable yet requires special attention(see REIMBURSEMENT). Key stake-holders can use this Consensus Reportand the current Standards of MedicalCare in Diabetes from the American

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Diabetes Association (ADA)8 to developaction plans for increased referral toand utilization of DSMES. These effortsare needed to increase the focus onachieving treatment targets early andmaintaining them throughout a per-son’s lifetime.The purpose of DSMES is to give peo-

ple with diabetes the knowledge, skills,and confidence to accept responsibilityfor their self-management. This includescollaborating with their health careteam, making informed decisions, solv-ing problems, developing personal goalsand action plans, and coping with emo-tions and life stresses.9 This ConsensusReport focuses on theparticular needs ofadults with type 2 diabetes. DSMESneeds are critical to those living withtype 1 diabetes, prediabetes, and gesta-tional diabetes mellitus; however, theevidence and examples referred to inthis Consensus Report are for adultswith type 2 diabetes.

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A call to action for all health caresystems and organizations is to engageneeded resources and to effectively andefficiently manage and address thisexpensive epidemic affecting healthoutcomes. We must address barriersthat result in therapeutic inertiacreated by health policy, health sys-tems, providers, people with diabetes,and the environment, including socialdeterminants of health,10 whichencompass the conditions in whichpeople live, work, learn, and play.11

Rather than being overwhelmed andnonattentive to this crisis, all stake-holders must be creative and respon-sive to the needs of all involved andmake it their priority.

METHODSThis Consensus Report is an update ofthe 2015 joint position statement onDSMES.12 The panel of experts author-ing this report includes representativesfrom the three national organizationsthat jointly published the originalarticle (ADA, American Association ofDiabetes Educators [AADE], and Acad-emy of Nutrition and Dietetics), and, inan effort to widen the reach andstakeholder input, the American Acad-emy of Family Physicians, AmericanAcademy of PAs, American Associationof Nurse Practitioners, American Phar-macists Association, and a patientadvocate were invited to participate. Atthe beginning of the writing process allmembers of the expert panel partici-pated in two surveys related to the2015 joint position statement and itsimpact and the desired future use ofthis Consensus Report: one surveyfrom their perspective and onecompleted while interviewing col-leagues. The expert panel agreed onthe direction for this Consensus Report,established writing teams to author thevarious sections of the report, andreviewed the entire updated manu-script after each step. An outside mar-ket research company was used toconduct the literature search and waspaid using ADA funds. Monthly callswere held between March 2019 andDecember 2019,with additional e-mailand web-based collaboration. Two in-person meetings were conducted toprovide organization to the process,establish the review process, reachconsensus on the content and keydefinitions (see Table 2), and discuss

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Table 1. DSMES Consensus Report recommendations

DSMES improves health outcomes, quality of life, and is cost effective, and people with diabetes deserve the right to DSMESservices. Therefore, it is recommended that:

Providers

1. Discuss with all persons with diabetes the benefits and value of initial and ongoing DSMES.

2. Initiate referral to and facilitate participation in DSMES at the 4 critical times: 1) at diagnosis, 2) annually and/or when notmeeting treatment targets, 3) when complicating factors develop, and 4) when transitions in life and care occur.

3. Ensure coordination of the medical nutrition therapy plan with the overall management strategy, including the DSMESplan, medications, and physical activity on an ongoing basis.

4. Identify and address barriers affecting participation with DSMES services following referral.

Health policy, payers, health systems, providers, and health care teams

5. Expand awareness, access, and utilization of innovative and nontraditional DSMES services.

6. Identify and address barriers influencing providers’ referrals to DSMES services.

7. Facilitate reimbursement processes and other means of financial support in consideration of cost savings related to thebenefits of DSMES services.

FROM THE ACADEMY

and deliberate the recommendations.Once the draft was completed, thestructured peer review process wasimplemented and the report was sentto two additional representatives fromeach of the seven participating organi-zations. A final draft was completedand submitted to all seven nationalorganizations for final review andapproval. The recommendations arethe informed, expert consensus of theseven contributing organizations.

BENEFITS ASSOCIATED WITHDSMES

Consensus recommendation

� Providers should discusswith all persons with dia-betes the benefits andvalue of initial andongoing DSMES.


� Health policy, payers,health systems, providers,and health care teamsneed to expand awareness,access, and utilization ofinnovative and nontradi-tional DSMES services.

The benefits of DSMES are multifac-eted and include clinical, psychosocial,and behavioral outcomes benefits. Keyclinical benefits are improved hemo-globin A1c (A1C) with reductions thatare additive to lifestyle and drugtherapy.13e16 Based on recentdata,13,14,16 DSMES results in an averageA1C reduction of 0.45e0.57% whencompared with usual care for peoplewith type 2 diabetes treated with avariety of modalities (lifestyle alone,oral and injected medication),13e17 aswell as reduction in the onset and/orworsening of diabetes-related


complications18,19 and reduction ofall-cause mortality.20 DSMES improvesquality of life15,21e23 and promoteslifestyle behaviors including healthfulmeal planning and engagement inregular physical activity.24 In addition,participation in DSMES services showsenhancement of self-efficacy andempowerment,25 increased healthycoping,26 and decreased diabetesrelated distress.27 These improvementsclearly affirm the importance andbenefits of utilizing DSMES and justifyefforts to facilitate participation as anecessary part of quality diabetes care.Table 3 highlights the multiple andvaried benefits that make DSMES ser-vices a critical component of qualitydiabetes care and compares its effectsto metformin therapy.17

Evidence supports that better healthoutcomes are associated with anincreased amount of time spent with adiabetes care and educationspecialist.13,28,29 People with diabeteswho completedmore than 10hofDSMESover the course of 6e12 months andthose who participated on an ongoingbasis were found to have significant re-ductions in mortality20 and A1C (averageabsolute reduction of 0.57%)16 comparedwith those who spent less time with adiabetes care and education specialist.Research shows that those who

participate in diabetes education aremore likely to use best practices andhave lower health care costs.28,30 Eventhough outpatient and pharmacy costsare higher for those who use diabeteseducation, these costs are offset by

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lower acute care costs.28 DSMES iscosteffective by reducing emergencydepartment visits, hospital admissions,and hospital readmissions.28,30e33 Thecost of diabetes in the U.S. in 2017 wasreported to be $327 billion includingdirect medical costs ($176 billion) andlost productivity ($69 billion).5 The costof care for people with diabetes ac-counts for about one in four health caredollars spent in the U.S.; 61%of costs areattributed to people over age 65 and areincurred by Medicare.5

The U.S. health care system cannotsustain the costs of care associated withthe increasing incidence of diabetes anddiabetes-related complications. DSMESoffers a pathway to decrease these costsand improve outcomes.

DSMES improves quality of life andhealth outcomes and is cost-effective.All members of the health care teamand health systems should promote thebenefits, emphasize the value, andsupport participation in initial andongoing DSMES for all people withdiabetes (see Table 4).

PROVIDING DSMES

DEMY OF NUTRITION AND DIETETICS 3

Table 2. Key definitions

Diabetes self-management education and support (DSMES)

� DSMES40: The ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-management aswell as activities that assist a person in implementing and sustaining the behaviors needed to manage his or hercondition on an ongoing basis, beyond or outside of formal self-management training. This process incorporates theneeds, goals, and life experiences of the person with diabetes.

� Support40: Helps implement informed decision making, self-management behaviors, problem solving, and activecollaboration with the health care team to improve clinical outcomes, health status, and quality of life.

Note: Diabetes services and specialized providers and educators often provide both education and support. Yet on-goingsupport from the primary health care team, family and friends, specialized home services, and the community are necessaryto maximize implementation of needed self- management.

Note: CMS uses the term “training” (DSMT) instead of “education” (DSMES) when defining the reimbursable Medicare benefit.Education is used in the National Standards for Diabetes Self-Management Education and Support and more commonlyused in practice. In the context of this article, the terms have the same meaning.

Person-centered care96

� Providing care and education that is respectful of and responsive to an individual person’s preferences, needs, and valuesand ensuring that those values guide all clinical decisions.

Diabetes-related distress23,26,97

� Diabetes-related distress is defined as the emotional burden of diabetes, the constant demands from diabetes self-management (taking and adjusting medications, monitoring blood glucose, meal planning, and physical activity) andthe possibility of developing complications, and the lack of support and access to care.

� The emotional burden of diabetes has the greatest impact on diabetes distress and outcomes.

Diabetes care and education specialist (DCES)98

� A trusted expert of the integrated care team who provides collaborative, comprehensive, and person-centered care andeducation to persons with diabetes and related cardiometabolic conditions.

Note: In 2019 a new title to identify health professionals who specialize in diabetes care and education was created by theAssociation of Diabetes Care and Education Specialists. Clinical staff who qualify for this title may or may not be a CDCES orBC-ADM, yet all who hold the CDCES and BC-ADM certifications are diabetes care and education specialists. Certified DiabetesCare and Education Specialist (CDCES)99

� A health care professional who has completed a minimum number of hours in clinical diabetes practice, passed theCertification Examination for Diabetes Care and Education (administered by the Certification Board for Diabetes Care andEducation [CBDCE]), and has responsibilities that include the direct provision of diabetes education.

Note: The Certified Diabetes Educator (CDE) certification title is now CDCES.

Board Certified-Advanced Diabetes Management (BC-ADM)100

� A health care professional who has completed a minimum number of hours in advanced diabetes management, holds agraduate degree, passed the BC-ADM certification exam (administered by the Association of Diabetes Care & EducationSpecialists), and has responsibilities of an increased complexity of decision making related to diabetes management andeducation.

Social determinants of health11,83

� The conditions in which people live, work, learn, play, and the wider set of forces and systems shaping the conditions ofdaily life. These forces and systems include economic policies and systems, development agendas, social norms, socialpolicies, and political systems.

FROM THE ACADEMY

A variety of DSMES approaches andsettings need to be presented and dis-cussed with people with diabetes, thusenabling self-selection of a methodthat best meets their specific needs.34

Historically, DSMES services were


provided in a formal series of didacticclasses where people with diabetes andtheir family members participated at ahospitalbased/ health care facilitylocation. Evolving health care deliverysystems, primary care needs, and the

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needs of people with diabetes haveresulted in the incorporation of DSMESservices into additional and nontradi-tional settings such as those locatedwithin patient-centered medicalhomes, community health centers,


Table 3. Comparing the benefits of DSMES/MNT vs. metformin therapy17

Criteria

Benefits Rating

DSMES/MNT Metformin

Efficacy High Low High Low

Hypoglycemia risk Weight Neutral/loss Neutral/loss

Side effects None Gastrointestinal

Cost Low/savings Low

Psychosocial benefits* High N/A

N/A, not applicable. *Psychosocial benefits include improvements to quality of life, self-efficacy, empowerment, healthycoping, knowledge, self-care behaviors, meal planning, healthier food choices, more activity, use of glucose monitoring,lower blood pressure and lipids and reductions in problems in managing diabetes, diabetes distress, and the risk of long-term complications (and prevention of acute complications).

FROM THE ACADEMY

pharmacies, and accountable careorganizations (ACOs), as well asfaith-based organizations and homesettings.Technology-based services including

web-based programs, telehealth, mo-bile applications, and remote moni-toring enable and promote increasedaccess and connectivity for ongoingmanagement and support.35 Recenthealth care concerns are rapidlyexpanding the use of these services,especially telehealth. In conjunctionwith formal DSMES, online peer sup-port communities are growing inpopularity. Involvement in thesegroups can be a beneficial adjunct tolearning, serving as an option forongoing diabetes peer support36,37

Table 4. Summary of DSMES benefits to ddiabetes15-28,30-33,40,89

� Provides critical education andsupport for implementing treat-ment plan

� Reduces emergency departmentvisits, hospital admissions, andhospital readmissions

� Reduces hypoglycemia

� Reduces all-cause mortality

� Lowers A1C

No negative side effects

Medicare and most insurers cover the cost


(Supplementary Table 1, available atwww.jandonline.org).Creative, person-centered ap-

proaches to meet individual needs thatconsider various learning preferences,literacy, numeracy, language, culture,physical challenges, scheduling chal-lenges, social determinants of health,and financial challenges should bewidely available. It is important toensure access in communities at high-est risk for diabetes, such as racial andethnic minorities and underservedcommunities.Office-based health care teams

without in-house resources can partnerwith local diabetes care and educationspecialists within their community toexplore opportunities to reach people

iscuss with people with

� Promotes lifestyle behaviorsincluding healthful meal planningand engagement in regular phys-ical activity

� Addresses weight maintenance orloss

� Enhances self-efficacy andempowerment

� Increases healthy coping

� Decreases diabetes-related distress

� Improves quality of life

s

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with diabetes and overcome somebarriers to participation at the point ofcare.38 If the office-based care teamassumes responsibility for providingdiabetes education and support, everyeffort should be made to ensure theyreceive up-to date training in diabetescare and education and utilize the de-tails in Tables 5 and 6.

Regardless of the DSMES approach orsetting, personalized and comprehen-sive methods are necessary to promoteeffective self-management required forday-to-day living with diabetes. Effec-tive delivery involves expertise inclinical, educational, psychosocial, andbehavioral diabetes care.39,40 It isessential for the referring provider tomutually establish personal treatmentplans and clinical goals with the personwith diabetes and communicate theseto the DSMES team. Ongoing commu-nication and support of recommenda-tions and progress toward goalsbetween the person with diabetes, ed-ucation team, referring provider, andother members of the health care teamare critical.

A person-centered approach toDSMES beginning at diagnosis of dia-betes provides the foundation for cur-rent and future decisions. Without thefocus on a person’s beliefs and desires,ongoing treatment goals can rarely bemet. Diabetes self-management is not astatic process and requires ongoingassessment and modification, as iden-tified by the four critical times (see theFigure). Initial and ongoing DSMEShelps the person overcome barriersand cope with the enduring andchanging demands throughout thecontinuum of diabetes treatment andlife transitions.

Providers and other members of theimmediate health care team have animportant role in providing educationand ongoing support for self-management needs. New behaviorscan be difficult to maintain and requirereinforcement at a minimum of every 6months.41 In addition to the providers,the care team may include diabetescare and education specialists (DCES);registered dietitian nutritionists(RDNs); nutrition and dietetics techni-cians, registered (NDTRs); nurse edu-cators; care managers; pharmacists;exercise and rehabilitation specialists;and behavioral or mental health careproviders. In addition, others have arole in helping to sustain the benefits


FROM THE ACADEMY

gained from DSMES, including com-munity health workers, nurses, caremanagers, trained peers, home healthcare service workers, social workers,and mental health counselors andother support people (e.g., familymembers).42e46 Professional associa-tions may help identify specific ser-vices in the local area such as theVisiting Nurse Association and blocknurse programs (see SupplementaryTable 1, available at www.jandonline.org).Family members and peers are an

underutilized resource for ongoingsupport and often struggle with how tobest provide help.47,48 Including familymembers in the DSMES process canhelp facilitate their involvement.49e51

Such support people can be especiallyhelpful and serve as cultural navigatorsin health care systems and as liaisonsto the community.52 Community pro-grams such as healthy cooking classes,walking groups, peer support commu-nities, and faith-based groups may lendsupport for implementing healthybehavior changes, promotingemotional health, and meeting per-sonal health goals.12

All health care providers and/or sys-tems need to identify adequate re-sources available in their respectivecommunities, demonstrate commit-ment to support these services, andoffer them as part of quality diabetescare. Health care providers need to beaware of the DSMES resources in theirhealth system and communities andmake appropriate referrals.

FOUR CRITICAL TIMES TO REFERTO DSMES


� Providers should initiatereferral to and facilitateparticipation in DSMES atthe four critical times 1) atdiagnosis, 2) annually and/or when not meetingtreatment targets, 3) whencomplicating factorsdevelop, and 4) whentransitions in life and careoccur.

There are four critical times to pro-vide and modify DSMES: 1) at


diagnosis, 2) annually and/or when notmeeting treatment targets, 3) whencomplicating factors develop, and 4)when transitions in life and care occur.These critical times are moments whenpeople with diabetes may need themost assistance to achieve and/oradjust their goals and care plans forsuccessful daily self-management.Although these four critical times arelisted, it is important to recognize dia-betes is a chronic disease that pro-gresses over time and requires vigilantcare to meet changing physiologicneeds and goals.53

The existing treatment plan maybecome ineffective due to changingsituations that can arise at any time.Such situations include progression ofthe disease, changes in personal goals,unmet targets, major life changes, ornew barriers identified when assessingsocial determinants of health.It is prudent to be proactive when

changes are identified or emerging.Additional support from the entire careteam and referral to DSMES areappropriate responses to any of theseneeds. Quality ongoing, routine dia-betes care includes continuous assess-ment, ongoing education and learning,self-management planning, andongoing support.The AADE7 Self-Care Behaviors pro-

vide the overarching framework foridentifying key components of educa-tion and support.54 The seven self-carebehaviors are healthy coping, healthyeating, being active, taking medication,monitoring, reducing risks, and prob-lem solving. Mastery of skills and be-haviors related to each of these areasrequires practice and experience.Often, a series of ongoing educationand support visits are necessary toallow participants the time to practicenew skills and behaviors, to developproblem-solving skills, and to improvetheir ability and self-efficacy to set andreach personal self-managementgoals.55 Targeted questions, such asthose now used in social determinantsof health surveys utilized by many or-ganizations, systems, and credentialedDSMES programs, can identify andfacilitate addressing the immediateneeds of the person with diabetes56

and/or facilitate referral to the mostappropriate team member (seeTable 7).Care and education plans at each of

the four critical times focus on the

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needs and personal goals of the indi-vidual. Therefore, the plan should bebased on personal experiences that arerelevant to self-management andapplicable to personal goals, treatmenttargets, and objectives and acknowl-edge that adults possess expertiseabout their own lives.57 Tables 5 and 6serve as checklists to ensure clinicalteams and health systems offer neces-sary diabetes services (factors thatindicate DSMES needs and whatDSMES provides).

1. AT DIAGNOSISFor an individual and family, the diag-nosis of diabetes is often over-whelming,58,59 with fears, anger,myths, and personal, family, and lifecircumstances influencing this reac-tion. Immediate care addresses theseconcerns through listening, providingemotional support, and answeringquestions. Providers typically first setthe stage for a lifetime chronic condi-tion that requires focus, hope, and re-sources to manage on a daily basis. Aperson-centered approach at diag-nosis is essential for establishingrapport and developing a personal andfeasible treatment plan.

Despite the wide range of knowledgeand skills that are required to self-manage diabetes, caution should betaken to not confound the over-whelming nature of the diagnosis butto determine what the person needsfrom the care team at this time tosafely navigate self-management dur-ing the first days and weeks. Responsesto such questions as shown in Table 7(also see Tables 5 and 6) guide andset direction for each person. Immedi-ate referral to DSMES services estab-lishes a personal education andsupport plan and highlights the valueof initial and ongoing education. InitialDSMES at diagnosis typically includes aseries of visits or contacts to build onclinical, psychosocial, and behavioralneeds. See Table 6 for suggestedcontent.

Education at diagnosis focuses onsafety concerns, often referred to assurvival-level skills education, and ad-dresses “what do I need to do once Ileave your office?” To begin the processof managing the diagnosis and incor-porating self-management into dailylife, a diabetes care and educationspecialist and/or other members of the


Table 5. Factors that indicate referral to DSMES services is needed

At diagnosis � Newly diagnosed—all newly diagnosed people with type 2 diabetes shouldreceive DSMES

� Ensure that both nutrition and emotional health are appropriately addressed ineducation or make separate referrals

Annually and/or when not meetingtreatment targets

� Review of knowledge, skills, psychosocial, and behavioral outcomes or factorsthat inhibit or facilitate achievement of treatment target and goals

� Long-standing diabetes with limited prior education� Treatment ineffective for attaining therapeutic target� Change in medication, activity, or nutritional intake or preferences� Maintenance of clinical and quality of life outcomes� Unexplained hypoglycemia or hyperglycemia� Support to attain or sustain improved behavioral or psychosocial outcomes

When complicating factors develop Change in:� Health conditions, such as renal disease and stroke, need for steroids, or

complicated medication plan� Health status requiring changes in nutrition, physical activity, etc.� Planning pregnancy or pregnant� Physical limitations such as cognitive impairment, visual impairment, dexterity

issues, movement restrictions� Emotional factors such as diabetes distress, anxiety, and clinical depression� Basic living needs such as access to shelter, food, health care, medicines, and

financial limitations

When transitions in life and care occur Change in:� Living situation such as inpatient or outpatient or other change in living situ-

ation (i.e., living alone, with family, assisted living, etc.)� Clinical care team� Initiation or intensification of insulin, new devices or technology, and other

treatment changes� Insurance coverage that results in treatment change (i.e., provider changes,

changes in medication coverage)� Age-related changes affecting cognition, vision, hearing, self-management, etc.

FROM THE ACADEMY

health care team work closely withthe person with diabetes and his orher family members and/or signifi-cant others to answer questions,address initial concerns, and providesupport and referrals to neededresources.It is recommended that all persons

with diabetes be offered a referral forindividualized MNT with a registereddietitian nutritionist (RD/RDN) knowl-edgeable and skilled in diabetes-specific MNT and a mental healthassessment, as indicated, from quali-fied providers with expertise in dia-betes management60 (seeSupplementary Table 1, available atwww.jandonline.org). These teammembers are critical at all four criticaltimes.


Important discussions at diagnosisinclude the natural history of type 2diabetes, what the journey will involvein terms of lifestyle and possiblymedication, and acknowledgment thata range of emotional responses iscommon. Emphasizing the importanceof involving family members and/orsignificant others in ongoing educationand support is also a key part of theprocess.47e51 Diabetes is largely self-managed and care management in-volves trial and error. The role of thehealth care team is to provide infor-mation and discuss effective strategiesto reach chosen treatment targets andgoals. The many tasks of self-management are not easy, yet worththe effort61 (see BENEFITS ASSOCIATEDWITH DSMES).

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2. ANNUALLY AND/OR WHENNOT MEETING TREATMENTTARGETSThe health care team and others sup-port the adoption and maintenance ofdaily self-management tasks,8,40 asmany people with diabetes find sus-taining these behaviors difficult. Theyneed to identify education and otherneeds expeditiously in order to addressthe nuances of self-management andhighlight the value of ongoing educa-tion. Table 6 provides details of DSMESat this critical time. Annual assessmentof knowledge, skills, and behaviors isnecessary for those who achieve dia-betes treatment targets and personalgoals as well as for those who do not.

Primary care visits for people withdiabetes typically occur every 3e6


Table 6. Checklist for providing and modifying DSMES at four critical times

Four critical timesPrimary care provider/endocrinologist/clinicalcare team’s role in diabetes education

Diabetes care and education specialist’s role indiabetes education

At diagnosis (series ofvisits)

� Answer questions and provide emotionalsupport regarding diagnosis

� Assess cultural influences, social determinantsof health, health beliefs, current knowledge,physical limitations, family support, financialand work status, medical history, learningpreferences and barriers, literacy, andnumeracy to determine which content to pro-vide and how

� Shared decision-making of treatment andtreatment targets

� Medication - choices, access, action, titration,side effects

� Teach survival skills to address immediaterequirements (safe use of medication, hy-poglycemia treatment if needed, introduc-tion of eating guidelines)

� Monitoring blood glucose - when to check,interpreting and using glucose pattern man-agement for feedback

� Identify and discuss resources for educationand ongoing support

� Physical activity - safety, short-term vs. long-term goals/recommendations

� Make referrals for DSMES and MNT � Preventing, detecting, and treating acute andchronic complications

� Nutrition - food plan, planning meals, pur-chasing food, preparing meals, portioning food

� Risk reduction - smoking cessation, foot care,cardiac risk

� Developing personal strategies to addresspsychosocial issues and concerns; adjusting toa life with diabetes

� Developing personal strategies to promotehealth and behavior change

� Problem identification and solutions� Identifying and accessing resources

Annually and/orwhen not meetingtreatment targets

� Refer for new techniques, technology, andupdated information

� Review and reinforce treatment goals and self-management needs

� Assess and refer if self-management targetsnot met to address barriers to self-care

� Review barriers to treatment effectiveness� Emphasize reducing risk for complications and

promoting quality of life� Discuss how to adjust diabetes treatment and

self- management to life situations andcompeting demands

� Support efforts to sustain initial behaviorchanges and cope with the ongoing burden ofdiabetes

(continued on next page)

FROM THE ACADEMY

months.60 These visits are opportu-nities to assess all areas of self-management, including laboratory re-sults, and a review of behavioralchanges and coping strategies,problem-solving skills, strengths and


challenges of living with diabetes, useof technology, questions about medi-cation therapy and lifestyle changes,and other environmental factors thatmight impact self-management.40 It ischallenging for primary care providers

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to address all assessments during avisit, which points to the need to utilizeestablished DSMES resources andchampion new ones to meet theseneeds, ensuring personal goals are met.See Table 5 for indications for referral.


Table 6. Checklist for providing and modifying DSMES at four critical times (continued)

Four critical timesPrimary care provider/endocrinologist/clinicalcare team’s role in diabetes education

Diabetes care and education specialist’s role indiabetes education

When complicatingfactors develop

� Identify presence of factors that inhibit orfacilitate achievement of treatment targetsand personal goals

� Provide support for the provision of self-management skills in an effort to delayprogression of the disease and prevent newcomplications

� Discuss impact of complications and suc-cesses with treatment and self-management

� Provide/refer for emotional support for dia-betes- related distress and depression

� Develop and support personal strategies forbehavior change and healthy coping

� Develop personal strategies to accommodatesensory or physical limitation(s), adapt to newself- management demands, and promotehealth and behavior change

When transitions inlife and care occur

� Develop diabetes transition plan � Adjust diabetes self-management plan asneeded

� Communicate transition plan to new healthcare team members

� Provide support for independent self- man-agement skills and self-efficacy

� Establish DSMES regular follow-up care � Identify level of significant other involvementand facilitate education and support

� Assist with facing challenges affecting usuallevel of activity, ability to function, healthbenefits and feelings of well-being

� Maximize quality of life and emotional supportfor the person with diabetes (and familymembers)

� Provide education for others now involved incare

� Establish communication and follow-up planswith the provider, family, and others

� Develop goals and personal strategies to pro-mote health and behavioral change andimprove quality of life

FROM THE ACADEMY

Possible barriers to achieving treat-ment goals, such as financial and psy-chosocial issues, life stresses, diabetes-related distress, fears, side effects ofmedications, misinformation, culturalbarriers, or misperceptions, should beassessed and addressed. People withdiabetes are sometimes unwilling orembarrassed to discuss these problemsunless specifically asked.62,63

Frequent DSMES visits may beneeded when the individual is startinga new diabetes medication such as in-sulin,64 is experiencing unexplainedhypoglycemia or hyperglycemia, hasworsening clinical indicators, or hasunmet goals. Importantly, diabetes careand education specialists are charged


with communicating the revised planto the referring provider and assistingthe person with diabetes in imple-menting the new treatment plan.

3. WHEN COMPLICATINGFACTORS DEVELOPThe identification of diabetes-relatedcomplications or other individual fac-tors that may influence self-management should be considered acritical indicator of the need for DSMESthat requires immediate attention andadequate resources. During clinicalcare, the provider may identify factorsother than diabetes that may influencethe individual’s diabetes treatment and

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associated self-management plan (seeTables 5 and 6). These factors mayrequire a change in self-managementor affect an individual’s ability tomanage their diabetes and may involveadditional medications, new physicallimitations, and/or new emotionalneeds. Examples could include a newdiagnosis of renal disease or visualimpairment, starting steroids, planningpregnancy, and/or psychosocial factorssuch as depression and anxiety.

The diagnosis of other health condi-tions often makes management morecomplex and adds additional tasksonto daily management. DSMES ad-dresses the integration of multiplemedical conditions into overall care


Table 7. Sample questions to guide a person-centered assessment56

� How is diabetes affecting your daily life and that of your family?

� What questions do you have?

� What are one to two positive things you are doing right now to manage your diabetes?

� What is the hardest part about your diabetes right now, causing you the most concern, or is most worrisome to you aboutyour diabetes?

� How can we best help you?


� Providers should ensure

FROM THE ACADEMY

with a focus on maintaining or appro-priately adjusting medication, mealplans, and physical activity levels tomaximize outcomes and quality of life.In addition to the need to adjust orlearn new self-management skills,effective coping, defined as a positiveattitude toward diabetes and self-management, positive relationshipswith others, and enhanced quality oflife are addressed in DSMES ser-vices.16,26 Focused emotional supportmay be needed for anxiety, stress, anddiabetes-related distress and/ordepression.The progression of diabetes can in-

crease the emotional and treatmentburden of diabetes and distress.65,66

Diabetes-related distress, which isdistinct from major depressive disor-der, is particularly common, withoverall prevalence rates reported to be36%.67 It has a greater impact onbehavioral and metabolic outcomesthan does depression.66 Diabetes-related distress is responsive to inter-vention, including DSMES-focused in-terventions68 and family support.49

However, additional mental health re-sources are generally required toaddress severe diabetes-relateddistress, clinical depression, and anxi-ety.65 It is important to recognize thepsychological issues related to diabetesand prescribe treatment asappropriate.

coordination of the medi-cal nutrition therapy planwith the overall manage-ment strategy, includingthe DSMES plan, medica-tions, and physical activityon an ongoing basis.

4. WHEN TRANSITIONS IN LIFEAND CARE OCCURThroughout the life span many factorssuch as aging, living situation, schedulechanges, or health insurance coveragemay require a re-evaluation of diabetestreatment and self-management needs(see Tables 5 and 6). Critical transitionperiods may include transitioning intoadulthood, living on one’s own, hospi-talization, and moving into an assisted


living or skilled nursing facility,correctional facility, or rehabilitationcenter. They may also include lifemilestones: marriage, divorce,becoming a parent, moving, death of aloved one, starting or completing col-lege, loss of employment, starting anew job, retirement, and other life cir-cumstances. Changing health careproviders can also be a time at whichadditional support is needed.DSMES affords important benefits to

people with diabetes during transitionsin life and care. Providing input into thedevelopment of practical and realisticself-management and treatment planscan be an effective asset for successfulnavigation of changing situations.The health care provider can make a

referral to a diabetes care and educa-tion specialist to add input to thetransition plan, provide education andproblem solving, and support success-ful transitions. The goal is to minimizedisruptions in therapy during anytransition, while addressing clinical,psychosocial, and behavioral needs.

MEDICAL NUTRITION THERAPYAS A CORE COMPONENT OFQUALITY DIABETES CARE

MNT can reduce A1C by up to 2%,making it an essential component ofinitial and ongoing diabetes care.1,69,70

Additionally, MNT helps prevent,

N AND DIETETICS

delay, or treat other complicationscommonly found with diabetes such ashypertension, cardiovascular disease,renal disease, celiac disease, and gas-troparesis. MNT provided by an RD/RDN is costeffective, and people whohave received MNT show improvedclinical outcomes and quality of life.69

MNT is integral to quality diabetescare and should be incorporated intothe overall care plan, medication plan,and DSMES plan on an ongoingbasis1,40,69e72 (Table 8).

Referral to the RD/RDN for MNTalong with DSMES is recommended asa separate and distinct service pro-vided by an RD/RDN. Although basicnutrition content is covered as part ofDSMES, people with diabetes needboth initial and ongoing MNT andDSMES; referrals to both can be madethrough many electronic health recordsas well as through hard copy or faxedreferral methods (see SupplementaryTable 1 [available at www.jandonline.org] for specific resources).

Everyday decisions about what to eatmust be driven by evidence and per-sonal, cultural, religious, economic, andother preferences and needs.69e71 Withan in-depth understanding of a per-son’s food intake, factors influencingeating behaviors, coping strategiesrelated to stress, and nutrition goals,the RD/RDN can work closely with thehealth care team to attain treatmentgoals, optimize medication manage-ment, or minimize the need for medi-cations to meet glycemic targets andsupport progress toward other goalsinfluenced by food intake.

The entire health care team shouldprovide consistent messages and rec-ommendations regarding nutritiontherapy and its importance as a foun-dation for quality diabetes care basedon national recommendations.70

Ongoing collaboration and communi-cation with RD/RDNs can facilitate this


FROM THE ACADEMY

aspect of care and support self-management and everyday fooddecisions.

IDENTIFYING AND ADDRESSINGBARRIERS

Consensus recommendations

� Providers should identifyand address barriersaffecting participationwith DSMES servicesfollowing referral.

� Health policy, payers,health systems, providers,and health care teamsshould identify andaddress barriers influ-encing providers’ referralsto DSMES services.

Despite the proven value and effec-tiveness of DSMES, a looming threat toits success is low utilization due to avariety of barriers. In order to reducebarriers, a focus on processes thatstreamline referral practices must beimplemented and supported systemwide. Once this major barrier is

Table 8. Overview of MNT: an evidence-ba

1. Characteristics of MNT reducing A1C by

� Initial series of MNT encounters

� 3-6 during first 6 months of diagnos

� Determine if more encounters are n

MNT follow-up encounters are based on n

� Health care team assesses needs atactivity, stress, access to food, need

� Minimum of one annual follow-up e

� Key areas of focus and action stepsplanning meals, purchasing food, prdifficult to take advantage of the ful

2. MNT provides nutrition assessment, nutrpersonal food plan and support

� Development of food plan/physicalprevention, and overall glycemic im

� Ongoing weight management plann

� Development of food plan for managastroparesis, eating disorders/disor

Note: The Academy of Nutrition and Dietetics recognizes the usby the Commission on Dietetic Registration.


addressed, the diabetes care and edu-cation specialist can be invaluable inaddressing other barriers that the per-son may have. Without this, it will beincreasingly difficult to access DSMESservices, particularly in rural and un-derserved communities. With focusand effort, the challenges can beaddressed and benefits realized.The Centers for Disease Control and

Prevention reported that only 6.8% ofprivately insured individuals withnewly diagnosed type 2 diabetesparticipated in DSMES within 12months of diagnosis.73 Furthermore,the Centers for Medicare and MedicaidServices (CMS) state that only 5% ofMedicare participants receive DSMESduring the first year of diagnosis.74 Thislow initial participation in DSMES wasalso reported in a recent AADE practicesurvey, with most people engaging in adiabetes program diagnosed for morethan a year.75 These low numbers areseen even in areas where cost is less ofa barrier because of national healthinsurance. Analysis of National HealthService data in the U.K. reveals thatonly 8% of those referred to formaldiabetes education, an annuallyreviewed standard of care, attended.This highlights the need to identify and

sed application of the nutrition care process

0.5-2% for type 2 diabetes:

is

eeded based on a personal assessment and

eeds

critical times and makes referrals - changefor on-going support, etc.

ncounter

for positive outcomes: persons with diabeteseparing meals, and portioning food. If they al impact of nutrition therapy. Implementation

ition diagnosis, and an intervention and man

activity/medication dosing for improved poprovement

ing and coaching

ging related complications and comorbiditiedered eating, kidney disease, disorders of lip

e of registered dietitian (RD) and registered dietitian nutritionist (R

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utilize resources that address all bar-riers including those related to healthsystems, health care providers, partici-pants, and the environment. In addi-tion, efforts are being made by nationalorganizations to correct the identifiedaccess and utilization barriers.

Health system or programmaticbarriers include lack of administrativeleadership support, limited numbers ofdiabetes care and education specialists,geographic location, limited or lack ofaccess to services, referral to DSMESservices not effectively embedded inthe health system service structure,limited resources for marketing, andlimited or low reimbursement rates.76

DSMES services should be designedand delivered with input from thetarget population and critically evalu-ated to ensure they are patient-centered.

Despite the value and proven bene-fits of these services, barriers withinthe benefit design of Medicare andother insurance programs limit access.Using Medicare as an example, some ofthese barriers include the following:hours allowed in the first year thebenefit is used and subsequent yearsare predefined and not based on indi-vidual needs; a referral is required and

provided by the RDN1,40,69-72

person’s goals

in medication, health status, schedule,

should have knowledge of food plan,re not confident in these areas it isand assessment will drive confidence

agement plan including the creation of

stprandial glucose level, hypoglycemia

s such as hypertension, celiac disease,id metabolism, etc.

DN). RD and RDN can only be used by those credentialed

EMY OF NUTRITION AND DIETETICS 11


� Health policy, payers,health systems, providers,and health care teamsneed to facilitate reim-bursement processes andother means of financialsupport in considerationof cost savings related tothe benefits of DSMESservices.

FROM THE ACADEMY

must be made by the primary providermanaging diabetes; there is a require-ment of diabetes diagnosis usingmethods other than A1C; and costlycopays and deductibles apply. A personcannot have Medicare DSMES and MNTvisits either face to face or throughtelehealth on the same day, thusrequiring separate days to receive bothof these valuable services and possiblydelaying questions, education, andsupport.Referring health care providers’

barriers include lack of awareness ofDSMES services, limitations of referringproviders to those providing ongoingtreatment of diabetes, misunder-standing of the necessity and effec-tiveness of DSMES, confusion regardingwhen and how to make referrals, andinconvenient or limited access.77e80

Referrals may also be limited by un-conscious or implicit bias, which per-petuates health care disparities andleads to therapeutic inertia. The pro-vider may too quickly judge an in-dividual’s potential to benefit fromDSMES81 and may incorrectly assumethe person’s willingness/ability toparticipate. To address these barriers,providers can meet with thosecurrently providing DSMES services intheir area to better understand thebenefits, access, and referral processesand to develop collaborativepartnerships.Participant-related barriers include

logistical factors such as cost, timing,transportation, and medical sta-tus.34,77,78,82 For those who availthemselves of DSMES services, fewcomplete their planned education dueto such factors. The 2017 AADE practicesurvey of over 4,696 diabetes educatorsreported that only 23% of participantsin diabetes education servicescompleted 75% or more of the pro-gram.75 Underutilization of servicesmay be because of a lack of under-standing or knowledge of the benefits,cultural factors, a desire to keep dia-betes private due to perceived stigmaand shame, lack of family support, andperceptions that the standard programdid not meet their needs and is notrelevant for their life, and the referringproviders may not emphasize the valueand benefits of initial and on goingDSMES.34,79,80,82

Health systems, clinical practices,people with diabetes, and thoseproviding DSMES services can


collaborate to identify solutions to thebarriers to utilization of DSMES for thepopulation they serve. Creative andinnovative solutions include offering avariety of DSMES options that meetindividual needs within a populationsuch as telehealth formats, coachingprograms, just-in-time services, onlineresources, discussion groups, andintense programs for select groups,while maximizing community re-sources related to supporting healthybehaviors.Credentialed DSMES programs as

well as individual diabetes care andeducation specialists perform acomprehensive assessment of needsfor each participant, including factorscontributing to social determinants ofhealth such as food access, financialmeans, health literacy and numeracy,social support systems, and health be-liefs and attitudes. This allows thediabetes care and education specialistto individualize a plan that meets theneeds of the person with diabetes andprovide referrals to resources thataddress those factors that may not bedirectly addressed in DSMES. It is bestthat all potential participants are notfunneled into a set program; classesbased on a person-centered curriculumdesigned to address social de-terminants of health and self-determined goal setting can meet thevaried needs of each person.Environment-related barriers

include limited transportation servicesand inadequate offerings to meet thevarious cultural, language, and ethnicneeds of the population. Additionally,these types of barriers include thoserelated to social determinants of health—the economic, environmental, politi-cal, and social conditions in which onelives.83 The health system may belimited in changing some of theseconditions but needs to help each per-son navigate their situation to maxi-mize their choices that affect theirhealth. It is important to recognize thatsome individuals are less likely toattend DSMES services, including thosewho are older, male, nonwhite, lesseducated, of lower socioeconomic sta-tus, and with clinically greater diseaseseverity.84,85 Further, studies supportthe importance of cultural consider-ations in achieving successful out-comes.84e87 Solutions includeexploring community resources toaddress factors that affect health

N AND DIETETICS

behaviors, providing seamless referraland access to such programs, and of-fering flexible programing that isaffordable and engages persons frommany backgrounds and living situa-tions. The key is creating community-clinic partnerships that provide theright interventions, at the right time, inthe right place, and using the rightworkforces.88

REIMBURSEMENT

Several common payment modelsand newer emerging models thatreimburse for DSMES services aredescribed below. For a list of diabeteseducation codes that can be submittedfor reimbursement, see SupplementaryTable 2 (available at www.jandonline.org) (Billing codes to maximize returnon investment (ROI) in diabetes careand education).

CMS has reimbursed diabetes edu-cation services billed as diabetes self-management training since 2001.40,89

DSMES services must receive accredi-tation by one of the current nationalaccrediting organizations (Associationof Diabetes Care & Education Special-ists and ADA) to be eligible for reim-bursement. In order to meet therequirements, DSMES services mustadhere to National Standards for Dia-betes Self-Management Education andSupport and meet the billing providerrequirements.40,89

Ten hours are available for the firstyear of receiving this benefit and 2 h insubsequent years. Any provider(physician, nurse practitioner, PA) whois the primary provider of diabetestreatment can make a referral; there isa copay to use these services.

CMS also reimburses for diabetesMNT, which expands access to needededucation and support. Three hours are


Additional resources are available at www.diabeteseducator.org/consensusreport.Diabetes Care (https://doi.org/10.2337/dci20-0023). The Diabetes Educator (https://doi.org/10.1177/0145721720930959). Journalof the Academy of Nutrition and Dietetics(https://doi.org/10.1016/j.jand.2020.04.020). Journal of the American Academy ofPhysician Assistants (https://doi.org/10.1097/01.JAA.0000668828.47294.2a). Jour-nal of the American Association of NursePractitioners (https://doi.org/10.1097/JXX.0000000000000473). Journal of theAmerican Pharmacists Association (https://doi.org/10.1016/j.japh.2020.04.018).

FROM THE ACADEMY

available the first year of receiving thisbenefit and 2 h are available in subse-quent years. A physician can requestadditional MNT hours through an MNTreferral that describes why more hoursare needed, such as a change in diag-nosis, medical condition, or treatmentplan. There are no specific limits set foradditional hours. There is no copay-ment or need to meet a Part Bdeductible in order to use these ser-vices. Many other payers also providereimbursement for diabetes MNT.90

Additional discipline-specific coun-seling that further enhances DSMESincludes medication therapy manage-ment delivered by pharmacists andpsychosocial counseling offered bymental health professionals, alsoreimbursed through CMS and/orthirdparty payers.40,77

Reimbursement by private payers ishighly variable. Many will match CMSguidelines, and those who recognizethe immediate and longer-term costsavings associated with DSMES willexpand coverage, sometimes with nocopay.With the transition to value-based

health care, organizations may receivefinancial returns if they meet specifiedquality performance measures. Dia-betes is typically part of a set of con-tracted quality measures impacting thepayment model. Health systems shouldmaximize the benefits of DSMES andfactor them into the potential financialstructure.There are reimbursable billing codes

available for remote monitoring ofblood glucose and other health pa-rameters that are related to diabetes.The use of devices that can monitorglucose, blood pressure, weight, andsleep allow the health care team toreview the data, provide intervention,and recommend treatment changesremotely.Sample referral forms that provide

the information required by CMS andother payers for referral to DSMES andMNT are available along with reim-bursement resources (seeSupplementary Tables 1 and 2, avail-able at www.jandonline.org). These orsimilar forms can be embedded into anelectronic health record for easyreferral.Health systems and clinical organi-

zations can maximize billing potentialby facilitating the reimbursement pro-cess, ensuring all applicable codes are


being utilized and submitted appro-priately. This usually requires supportfrom those who frequently work withhealth care codes such as staff in billingand compliance departments. Sharedmedical appointments can be per-formed with DSMES and they arereimbursable medical visits.

CONCLUSIONSThis Consensus Report is a resource forthe entire health care team and de-scribes the four critical times to refer toDSMES services with very specific rec-ommendations for ensuring that alladults with diabetes receive thesebenefits. Diabetes is a complex condi-tion that requires the person with dia-betes to make numerous dailydecisions regarding their self-management. DSMES delivered byqualified personnel using best practicemethods has a profound effect on theability to effectively undertake theseresponsibilities and is supported bystrong evidence presented in thisreport. DSMES has a positive effect onclinical, psychosocial, and behavioralaspects of diabetes. DSMES providesthe foundation with ongoing supportto promote achievement of personalgoals and influence optimal outcomes.Despite proven benefits and demon-strated value of DSMES, the number ofpeople with diabetes who are referredto and receive DSMES is significantlylow.73e75 Barriers will not disappearwithout intentional, holistic in-terventions recognizing the roles of theentire health care team, individualswith diabetes, and systems in over-coming issues of therapeutic inertia.10

The increasing prevalence of type 2diabetes requires accountability by allstakeholders to ensure these importantservices are available and utilized.The U.S. health care system has

changed with increased attention onprimary care, technology, and qualitymeasures91. DSMES services thatdirectly connect with primary care areeffective in improving clinical, psycho-social, and behavioral outcomes.92e95

This changing health care environ-ment provides a platform to useDSMES services as an effective, costsaving, high-impact resource integralto a person’s ability to self-managediabetes. A variety of culturally appro-priate services need to be offered in avariety of settings, utilizing technology

JOURNAL OF THE ACAD

to facilitate access to DSMES services,support self-management decisions,and decrease therapeutic inertia.

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68. Gonzalvo JD, Hamm J, Eaves S, et al.Apractical approach to mental health forthe diabetes educator. AADE Pract.2019;7:29-44.

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72. Briggs Early K, Stanley K. Position of theAcademy of Nutrition and Dietetics: Therole of medical nutrition therapy andregistered dietitian nutritionists in theprevention and treatment of prediabetesand type 2 diabetes. J Acad Nutr Diet.2018;118:343-353.

73. Li R, Shrestha SS, Lipman R,Burrows NR, Kolb LE, Rutledge S;Centers for Disease Control and Pre-vention (CDC). Diabetes self-management education and trainingamong privately insured persons withnewly diagnosed diabetes-UnitedStates, 2011-2012. MMWR Morb Mor-tal Wkly Rep. 2014;63:1045-1049.

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77. Centers for Disease Control and Preven-tion. Diabetes Self-Management Educa-tion and Support (DSMES) Toolkit[Internet], 2018Accessed 3 September2019. Available from https://www.cdc.gov/diabetes/dsmes-toolkit/index.html.

78. Peyrot M, Rubin RR, Funnell MM,Siminerio LM. Access to diabetes self-management education: results of na-tional surveys of patients, educators, andphysicians. Diabetes Educ. 2009;35:246-248. 252e256, 258e263.

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83. World Health Organization. About socialdeterminants of health [Internet]Accessed 28 January 2020. Availablefrom http://www.who.int/social_determinants/sdh_definition/en/.

84. Harris S, Mulnier H, Amiel S. The Barriersto Uptake of Diabetes Education study(Abstract). Lancet. 2017;389:S44.

85. Ross S, Benavides-Vaello S, Schumann L,Haberman M. Issues that impact type-2diabetes self-management in ruralcommunities. J Am Assoc Nurse Pract.2015;27:653-660.

86. Gonzales KL, Lambert WE, Fu R, Jacob M,Harding AK. Perceived racial discrimi-nation in health care, completion ofstandard diabetes services, and diabetescontrol among a sample of AmericanIndian women. Diabetes Educ. 2014;40:747-755.

87. Jones V, Crowe M. How people fromethnic minorities describe their experi-ences of managing type-2 diabetesmellitus: a qualitative metasynthesis. IntJ Nurs Stud. 2017;76:78-91.

88. Hill-Briggs F. 2018 Health Care & Edu-cation Presidential Address: The Amer-ican Diabetes Association in the era ofhealth care transformation. DiabetesCare. 2019;42:352-358.

89. Centers forMedicare &Medicaid Services.Diabetic Self-Management Training(DSMT) Accreditation Program [Internet]Accessed 4 December 2019. Availablefrom https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/DSMT-Accreditation0-Program.

90. Does Medicare Cover Medical NutritionTherapy? [Internet]Accessed 4December 2019. Available from,Medicare.com, https://medicare.com/coverage/does-medicare.com-cover-medical-nutrition-therapy/.

91. Cusack CM, Knudson AD, Kronstadt JL,Singer RF, Brown AL. Practice-Based Popu-lation Health: Information Technology toSupport Transformation to Proactive PrimaryCare. Rockville, MD: Agency for HealthcareResearch and Quality; 2010AHRQ Publica-tion No. 10-0092-EF [Internet]. Accessed3 September 2019. Available from https://pcmh.ahrq.gov/sites/default/fi les/attachments/Information%20Technology%20to%20Support%20Transformation%20to%20Proactive%20 Primary%20Care.pdf.

92. Siminerio L, Ruppert K, Huber K,Toledo FGS. Telemedicine for Reach,Education, Access, and Treatment


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(TREAT): linking telemedicine with dia-betes self-management education toimprove care in rural communities.Diabetes Educ. 2014;40:797-805.

93. Phillips LS, Barb D, Yong C, et al. Trans-lating what works: a new approach toimprove diabetes management.J Diabetes Sci Technol. 2015;9:857-864.

94. Shea S, Weinstock RS, Teresi JA, et al;IDEATel Consortium. A randomizedtrial comparing telemedicine casemanagement with usual care in older,ethnically diverse, medically under-served patients with diabetes melli-tus: 5 year results of the IDEATelstudy. J Am Med Inform Assoc. 2009;16:446-456.

95. Hunt JS, Siemienczuk J, Gillanders W,et al. The impact of a physician-


directed health information technol-ogy system on diabetes outcomes inprimary care: a pre- and post-implementation study. Inform PrimCare. 2009;17:165-174.

96. Institute of Medicine Committee onQuality of Health Care in America.Crossing the Quality Chasm: A NewHealth System for the 21st Century[Internet]. Washington, DC: NationalAcademies Press; 2001Accessed 1October 2019. Available from https://www.ncbi.nlm.nih.gov/books/NBK222274/.

97. Fisher L, Hessler DM, Polonsky WH,Mullan J. When is diabetes distressclinically meaningful?: establishingcut points for the Diabetes DistressScale. Diabetes Care. 2012;35:259-264.

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98. Association of Diabetes Care and Edu-cation Specialists. Repositioning theSpecialty and Association [Internet]Accessed 15 November 2019. Availablefrom https://www.diabeteseducator.org/practice/new-name-title.

99. NDBDE. What is a CDE? CertificationInfo, Diabetes Education, Certification,Examination [Internet]Accessed 15November 2019. Available from https://www.ncbde.org/certification_info/what-is-a-cde/.

100. Association of Diabetes Care and Educa-tion Specialists. Board Certified-Advanced Diabetes Management (BC-ADM) [Internet]Accessed 15 November2019. Available from https://www.diabeteseducator.org/education/certification/bc_adm.

AUTHOR INFORMATIONM. A. Powers is with HealthPartners, Bloomington, MN. J. K. Bardsley is with the Medstar Health Research Institute, MedStar Diabetes Institute,and MedStar Health System Nursing, Hyattsville, MD. M. Cypress is an independent consultant, Albuquerque, NM. M. M. Funnell is with theUniversity of Michigan Medical School, Ann Arbor, MI. D. Harms is with MercyOne Clive Internal Medicine, Clive, IA. A. Hess-Fischl is with theSection of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL. B. Hooks is with Martin ArmyCommunity Hospital, Fort Benning, GA. D. Isaacs is with the Cleveland Clinic Diabetes Center, Cleveland, OH. E. D. Mandell is with Johnson &Wales University, Providence, RI. M. D. Maryniuk is with Maryniuk & Associates, Boston, MA. A. Norton is with DiabetesSisters, Chicago, IL. J. Rinkerand S. Uelmen are with the Association of Diabetes Care & Education Specialists, Chicago, IL. L. M. Siminerio is with the University of Pittsburgh,Pittsburgh, PA.

Address correspondence to: Margaret A. Powers, MS, RD, CDE. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTERESTM. A. Powers reports research funding from Abbott Nutrition, is a senior advisor for ADA’s Nutrition Interest Group, and is a member of ADA/American Heart Association Science Advisory Group for Know Diabetes by Heart. J. K. Bardsley reports being a past chair of the CertificationBoard for Diabetes Care and Education, is the program chair for the Association of Diabetes Care & Education Specialists annual meeting, and hasbeen a consultant to Joslin Diabetes Center. M. M. Funnell is on an advisory board of Eli Lilly. D. Harms is the treasurer for the American Academyof Nurse Practitioners Certification Board of Commissioners and Vice President of the American Nurse Practitioner Foundation. A. Hess-Fischlreports receiving an honorarium from ADA as an Education Recognition Program auditor and is a participant in a speakers bureau spon-sored by Abbott Diabetes Care and Xeris. D. Isaacs reports being a participant in a speakers bureau/ consultant for Xeris Pharmaceuticals, NovoNordisk, Dexcom, and Lifescan. M. D. Maryniuk reports being a paid consultant of Diabetes e What to Know, Arkray, and DayTwo. A. Nortonreports being a participant in speakers bureaus sponsored by Boehringer Ingelheim, Novo Nordisk, and Xeris. L. M. Siminerio reports researchgrant funding from Becton Dickinson. S. Uelmen has received honoraria from ADA. No other potential conflicts of interest relevant to this articlewere reported.

FUNDING/SUPPORTThis activity was funded by the ADA and the Association of Diabetes Care & Education Specialists.

ACKNOWLEDGEMENTSThe authors would like to acknowledge Mindy Saraco (Managing Director, Scientific and Medical Affairs) from the ADA for her help with thedevelopment of the Consensus Report and related meetings and presentations, as well as the ADA Professional Practice Committee for providingvaluable review and feedback. The authors also acknowledge Leslie Kolb, Chief Science and Practice Officer, Association of Diabetes Care &Education Specialists, for her review and support of the Consensus Report. The authors acknowledge the invited peer reviewers who providedcomments on an earlier draft of this report: Christine Beebe (Quantumed Consulting, San Diego, CA), Anne L. Burns (American PharmacistsAssociation, Alexandria, VA), Amy Butts (Wheeling Hospital at the Wellsburg Clinic, Wellsburg, PA), Susan Chiarito (Mission Primary Care Clinic,Vicksburg, MS), Maria Duarte- Gardea (The University of Texas at El Paso, El Paso, TX), Joy A. Dugan (Touro University California, Vallejo, CA),Paulina N. Duker (Health Solutions Consultant, King of Prussia, PA), Lisa Hodgson (Saratoga Hospital, Saratoga Springs, NY), Wahida Karmally(Columbia University, New York, NY), Darlene Lawrence (MedStar Health, Washington, DC), Anne Norman (American Association of NursePractitioners, Austin, TX), Jim Owen (American Pharmacists Association, Alexandria, VA), Diane Padden (American Association of Nurse Practi-tioners, Austin, TX), Teresa Pearson (Innovative Health Care Designs, LLC, Minneapolis, MN), Barb Schreiner (Capella University, Pearland, TX), EvaM. Vivian (University of Wisconsin, Madison, WI), and Gretchen Youssef (MedStar Health, Washington, DC).

AUTHOR CONTRIBUTIONSAll authors were responsible for drafting the article and revising it critically for important intellectual content. All authors approved the version tobe published.


Supplementary Table 1. Diabetes self-management education and support resources

A diabetes education program/service that meets quality standards*:

� ADCES https://nf01.diabeteseducator.org/eweb/DynamicPage.aspx?Site¼aade&WebCode¼DEAPFindApprovedProgram

� ADA https://professional.diabetes.org/erp_list_zip

Finding educators and additional team members:

� Certified Diabetes Care and Education Specialist (CDCES) https://www.ncbde.org/living-with-diabetes/findcde/

� Registered dietitian nutritionist (RD/RDN) https://www.eatright.org/find-an-expert

� ADA mental health provider directory https://professional.diabetes.org/mhp_listing

� Community health worker resources https://www.professional.diabetes.org/content-page/resources-community-health-workers-chws

� Peer support (including links to social media sites) https://www.diabeteseducator.org/peersupport

Free or low-cost patient education resources (most alsoin Spanish)

� National Diabetes Education Program—patienteducation resources

https://www.cdc.gov/diabetes/ndep/index.html

� American Diabetes Association https://www.diabetes.org

o Diabetes Food Hub https://www.diabetesfoodhub.org/

� Learning About Diabetes (multiple languages) https://www.learningaboutdiabetes.org/

DSMES and MNT are separate benefits from Medicarewhen delivered by an approved quality programand/or educator/dietitian. Referral:*

� DSMES services e ordered by MD/DO/NP/PA; up to10 h first year, 2 h subsequent years

� MNT e ordered by MD or DO; up to 3 h in first year,2 h in subsequent years (additional hours can berequested)

� Sample order form https://www.diabeteseducator.org/practice/provider-resources/make-a-referral

Other resources for DSMES

� American Diabetes Association website for professionals https://professional.diabetes.org/diabetes-education

� Association of Diabetes Care and Education Specialists https://www.diabeteseducator.org/docs/default-source/default-document-library/diabetes-services-order-formcb55dc36a05f68739c53ff0000b8561d.pdf?sfvrsn¼0


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Supplementary Table 1. Diabetes self-management education and support resources (continued)

� Academy of Nutrition and Dietetics http://www.eatrightpro.org/,http://www.eatrightpro.org/-/media/eatrightpro-files/about-us/what-is-an-rdn-and-dtr/mntreferralform.pdf,https://www.eatright.org/food/resources/learn-more-about-rdns/find-an-rdn-anywhere-you-need-one

� American Academy of Family Physicians https://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId¼7

� American Association of PAs Diabetes Leadership Edge website https://www.aapa.org/cme-central/national-health-priorities/diabetes-leadership-edge

� American Pharmacists Association https://www.pharmacist.com/diabetes-management-sig, https://www.pharmacist.com/education/pharmacist-patient-centered-diabetes-care?is_sso_called¼1, https://www.pharmacist.com/apha-asp-operation-diabetes

DO, doctor of osteopathic medicine; MD, doctor of medicine; NP, nurse practitioner.*DSMES and MNT are often covered by most private insurance payers.

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Supplementary Table 2. Coding Table: Billing codes to maximize return on investment (ROI) in diabetes care and education. Please consult with your billing andcompliance teams before implementing billing codes as they are subject to change

Code/Type Description/service providers Who can bill/other notes Increments/Frequency/Limits

G0108 Diabetes outpatient self-management trainingservices, individual

ADCES Accredited or ADARecognized ONLY andvaries by provider type.

per 30 minutes (do not round up)

G0109 Diabetes outpatient self-management trainingservices, group session (2 or more)

ADCES Accredited or ADARecognized ONLY andvaries by provider type.

per 30 minutes (do not round up); FQHC’s andRHC’s excluded.

G0108 or G0109 withPOS 02 modifier forMedicare; 95 modifieris often used forprivate payers, but mayvary.

By reporting place of service (POS) 02 modifier withHCPCS code G0108

(Diabetes outpatient self-management trainingservices, individual, per 30 minutes) or G0109(Diabetes outpatient self-management trainingservices, group session (2 or more), per 30minutes), the distant site practitioner attests thatthe beneficiary has received or will receive 1hour of in-person DSMT services for purposes ofinjection training when it is indicated during theyear

ADCES Accredited or ADARecognized ONLY andbilled under program NPI#.(same as in person visits)

per 30 minutes (do not round up)Medicare telehealth services, including individualand group DSMT services furnished as atelehealth service, could only be furnished by aphysician, PA, NP, CNS, CNM , clinicalpsychologist, clinical social worker, or registereddietitian or nutrition professional, as applicable.RNs, Pharmacists and other instructors areexcluded.

97802 MNT; initial assessment and intervention,individual, face-to-face with the patient

RD/RDN ONLY each 15 minutes

97803 MNT; re-assessment and intervention, individual,face-to-face with the patient


97804 MNT; group (2 or more individual(s)) RD/RDN ONLY each 30 minutes

G0270 Medical nutrition therapy; reassessment andsubsequent intervention(s) following secondreferral in same year for change in diagnosis,medical condition or treatment regimen(including additional hours needed for renaldisease), individual, face to face with the patient


G0271 Medical nutrition therapy, reassessment andsubsequent intervention(s) following secondreferral in same year for change in diagnosis,medical condition, or treatment regimen(including additional hours needed for renaldisease), group (2 or more individuals)



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Supplementary Table 2. Coding Table: Billing codes to maximize return on investment (ROI) in diabetes care and education. Please consult with your billing andcompliance teams before implementing billing codes as they are subject to change (continued)


99091 Collection and interpretation of physiologic data(e.g., ECG, blood pressure, glucose monitoring)digitally stored and/or transmitted by the patientand/or caregiver to the physician or otherqualified healthcare professional, qualified byeducation, training, licensure/regulation (whenapplicable)

cannot be reported inconjunction with CPT�codes 95249, 95250 and/or 95251.

requiring a minimum of 30 minutes of time.

95249 Ambulatory CGM of interstitial tissue fluid via asubcutaneous sensor for a minimum of 72 hours;patient provided equipment, sensor placement,hook-up, calibration of monitor, patient training,and printout of recording.

For Medicare - An MA, RN,LPN, or CDE may performthe elements in CPT codes95249/95250 if “incident toguidelines” are met,meaning they are providingthe service directed by aphysician or other qualifiedhealthcare provider.

sensor for a minimum of 72 hours; printout ofrecording; may not be reported more than oncefor the duration that the patient owns the datareceiver. Obtaining a new sensor and/ortransmitter without a change in the receiverdoes not warrant reporting 95249 subsequenttimes.

95250 Ambulatory CGM of interstitial tissue fluid via asubcutaneous sensor for a minimum of 72 hours;physician or other qualified health careprofessional (office) provided equipment, sensorplacement, hook-up, calibration of monitor,patient training, removal of sensor, and printoutof recording.

For Medicare - An MA, RN,LPN, or CDE may performthe elements in CPT codes95249/95250 if “incident toguidelines” are met,meaning they are providingthe service directed by aphysician or other qualifiedhealthcare provider.

sensor for a minimum of 72 hours; once per month.

95251 Ambulatory CGM of interstitial tissue fluid via asubcutaneous sensor for a minimum of 72 hours;analysis, interpretation and report.

MD, DO, NP, PA. once per month

98960 Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardizedcurriculum, face-to-face with the patient (couldinclude caregiver/family); individual patient

MEDICARE WILL NOTREIMBURSE: Other payersoften do.

each 30 minutes


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98961 Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardizedcurriculum, face-to-face with the patient (couldinclude caregiver/family); 2-4 patients


each 30 minutes

98962 Education and training for patient self-management by a qualified, nonphysician healthcare professional using a standardizedcurriculum, face-to-face with the patient (couldinclude caregiver/family); 5-8 patients


each 30 minutes

99211 Office or other outpatient visit for the evaluationand management of an established patient, thatmay not require the presence of a physician orother qualified health care professional. Usually,the presenting problem(s) are minimal. Typically,5 minutes are spent performing or supervisingthese services.

Physicians can report 99211,but it is intended to reportservices rendered by otherindividuals in the practice,such as a nurse or otherstaff member.Unlike other office visit E/Mcodes, a 99211-office visitdoes not have any specifickey-componentdocumentationrequirements.

5 minutes

G0466 Federally qualified health center (FQHC) visit, newpatient; a medically-necessary, face-to-faceencounter (one-on-one) between a new patientand a FQHC practitioner during which time oneor more FQHC services are rendered andincludes a typical bundle of Medicare-coveredservices that would be furnished per diem to apatient receiving a FQHC visit

FQHC one or more FQHC services are rendered andincludes a typical bundle of Medicare-coveredservices that would be furnished per diem


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G0467 Federally qualified health center (FQHC) visit,established patient; a medically-necessary, face-to-face encounter (one-on-one) between anestablished patient and a FQHC practitionerduring which time one or more FQHC servicesare rendered and includes a typical bundle ofMedicare-covered services that would befurnished per diem to a patient receiving a FQHCvisit

FQHC one or more FQHC services are rendered andincludes a typical bundle of Medicare-coveredservices that would be furnished per diem

99490 Chronic care management services, at least 20minutes of clinical staff time directed by aphysician or other qualified health careprofessional, per calendar month, with thefollowing required elements:� Multiple (two or more) chronic conditions

expected to last at least 12 months, or untilthe death of the patient;

� Chronic conditions place the patient at sig-nificant risk of death, acute exacerbation/decompensation, or functional decline;

� Comprehensive care plan established,implemented, revised, or monitored.

The CCM codes describingclinical staff activities (CPT99487, 99489, and 99490)are assigned generalsupervision under theMedicare PFS. Generalsupervision means whenthe service is not personallyperformed by the billingpractitioner, it is performedunder his or her overalldirection and controlalthough his or her physicalpresence is not required.

at least 20 minutes; once per month


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99491 Chronic care management services, providedpersonally by a physician or other qualifiedhealth care professional, at least 30 minutes ofphysician or other qualified health careprofessional time, per calendar month, with thefollowing required elements:� Multiple (two or more) chronic conditions

expected to last at least 12 months, or untilthe death of the patient

� Chronic conditions place the patient at sig-nificant risk of death, acute exacerbation/decompensation, or functional decline

� Comprehensive care plan established,implemented, revised, or monitored

Physicians and the followingnon-physician practitionersmay bill CCM services:� Certified Nurse Mid-

wives Clinical NurseSpecialists

� Nurse Practitioners� PAs

at least 30 minutes, once per month

99487 Complex chronic care management services, withthe following required elements:� Multiple (two or more) chronic conditions

expected to last at least 12 months, or untilthe death of the patient Chronic conditionsplace the patient at significant risk of death,acute exacerbation/ decompensation, orfunctional decline

� Establishment or substantial revision of acomprehensive care plan

� Moderate or high complexity medical deci-sion making

� 60 minutes of clinical staff time directed by aphysician or other qualified health careprofessional, per calendar month

The CCM codes describingclinical staff activities (CPT99487, 99489, and 99490)are assigned generalsupervision under theMedicare PFS. Generalsupervision means whenthe service is not personallyperformed by the billingpractitioner, it is performedunder his or her overalldirection and controlalthough his or her physicalpresence is not required.

60 minutes, once per month


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99489 Each additional 30 minutes of clinical staff timedirected by a physician or other qualified healthcare professional, per calendar month (Listseparately in addition to code for primaryprocedure).

Complex CCM services of less than 60 minutes induration, in a calendar month, are not reportedseparately. Report 99489 in conjunction with99487. Do not report 99489 for caremanagement services of less than 30 minutesadditional to the first 60 minutes of complexCCM services during a calendar month.

Time spent directly by thebilling practitioner orclinical staff counts towardthe threshold clinical stafftime required to be spentduring a given month. CCMservices that are notprovided personally by thebilling practitioner areprovided by clinical staffunder the direction of thebilling practitioner on an“incident to” basis (as anintegral part of servicesprovided by the billingpractitioner), subject toapplicable state law,licensure, and scope ofpractice. The clinical staffare either employees orworking under contract tothe billing practitionerwhom Medicare directlypays for CCM.

Additional 30 minutes, once per month; ComplexCCM services of less than 60 minutes in duration,in a calendar month, are not reported separately.Report 99489 in conjunction with 99487. Do notreport 99489 for care management services ofless than 30 minutes additional to the first 60minutes of complex CCM services during acalendar month.

99457 Remote physiologic monitoring treatmentmanagement services requiring interactivecommunication with the patient/caregiverduring the month

Clinical staff/physician/otherqualified healthcareprofessional time

20 minutes or more of clinical staff/physician/otherqualified healthcare professional time in acalendar month

99605 Medication therapy management service(s)provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, withassessment, and intervention if provided

Pharmacist initial 15 minutes, new patient


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99606 Medication therapy management service(s)provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes, establishedpatient

Pharmacist initial 15 minutes, established patient

99607 Medication therapy management servicesprovided by a pharmacist, individual, face-to-face with patient, each additional 15 minutes(List separately in addition to code for theprimary service)

Pharmacist each additional 15 minutes (Use 99607 inconjunction with 99605, 99606)

MDPP: Medicare Diabetes Prevention Program utilizes a number of codes that are further clarified at the following link: https://innovation.cms.gov/Files/x/mdpp-billingpayment-refguide.pdf

References� Use Medicare’s Physician Fee Schedule Look-up Tool to Search Medicare’s database by CPT� code and Medicare Administrative Contractor (MAC)� Contact your MAC for specific coverage and billing guidelines and requirements.� Refer to the most recent edition of the CPT� code book for current CPT� code information.� Medicare Reimbursement Guidelines for DSMT� AAFP Guide to 99211� AACE Guide to CGM Codes

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