722968

research-article2017
TDEXXX10.1177/0145721717722968Short titleBeck et al

National Standards

449

2017 National Standards for

Diabetes Self-Management
Education and Support

Joni Beck, PharmD, BC-ADM, CDE (Co-Chair) (Butcher); American Diabetes Association, Arlington, Virginia (Ms Condon);
Consultant, Albuquerque, New Mexico (Cypress); University of Northern
Deborah A. Greenwood, PhD, RN, BC-ADM, CDE, FAADE (Co-Chair) Colorado, Fort Collins, Colorado (Faulkner); University of Chicago, Chicago,
Illinois (Fischl); San Diego City College, San Diego, California (Francis);
Lori Blanton, MS, CHES, CDE
American Association of Diabetes Educators, Chicago, Illinois (Ms Kolb);
Sandra T. Bollinger, PharmD, CGP, CDE, FASCP HealthPartners, Minneapolis, Minnesota (Lavin-Tompkins); WellDoc,
Columbia, Maryland (MacLeod); Joslin Diabetes Center, Boston,
Marcene K. Butcher, RD, CDE Massachusetts (Maryniuk); National Certification Board for Diabetes
Educators, Arlington Heights, Illinois (Mensing); Endocrinology Associates,
Jo Ellen Condon, RDN, CDE
Houston, Texas (Orzeck); Creative Pharmacists, Evans, Georgia (Pope);
Marjorie Cypress, PhD, C-ANP, CDE Livongo, Mountain View, California (Pulizzi); TMF Health Quality Institute,
Austin, Texas (Reed); Glytec, Abingdon, Virginia (Rhinehart); University of
Priscilla Faulkner, MS, MA, CNS, RN, CDE Pittsburgh Diabetes Institute, Pittsburgh, Pennsylvania (Siminerio); The
Amy Hess Fischl, MS, RDN, LDN, BC-ADM, CDE University of Texas Health Science Center at Houston, Houston, Texas

standards
national
(Wang); and Technical Writer, Washington, DC (Wahowiak).
Theresa Francis, MSN, RN, CDE
Leslie E. Kolb, MBA, BSN, RN Correspondence to Leslie E. Kolb, MBA, BSN, RN, American Association of
Diabetes Educators, 200 W. Madison, Suite 800, Chicago, IL 60606, USA
Jodi M. Lavin-Tompkins, MSN, RN, BC-ADM, CDE (lkolb@aadenet.org).
Janice MacLeod, MA, RD, LD, CDE
Acknowledgments: The authors wish to thank Lindsey Wahowiak,
Melinda Maryniuk, MEd, RD, CDE Washington DC, for her editorial assistance in preparing this manuscript.
Carolé Mensing, MA, RN, CDE, FAADE
This article is co-published in Diabetes Care.
Eric A. Orzeck, MD, FACP, FACE, CDE
David D. Pope, PharmD, CDE The previous version of this article, also co-published in Diabetes Care
Jodi L. Pulizzi, RN, CDE, CHC can be found at Diabetes Educator 2012;38(5):619-629 (https://doi
.org/10.1177/0145721712455997). Please note that this article was
Ardis A. Reed, MPH, RD, LD, CDE revised after its original OnlineFirst publication in The Diabetes Educator.
The corrections are noted in the Erratum associated with this article.
Andrew S. Rhinehart, MD, BC-ADM, CDE, FACP
Linda Siminerio, PhD, RN, CDE DOI: 10.1177/0145721717722968
Jing Wang, PhD, MPH, RN
© 2017 The Author(s)
On behalf of the 2017 Standards Revision Task Force
From the University of Oklahoma Health Sciences Center, College of Medicine,
Oklahoma City, Oklahoma (Dr Beck); Consultant, Granite Bay, California (Ms
Greenwood); Florida Hospital, Tampa, Florida (Blanton); Health Priorities, Cape
Girardeau, Missouri (Bollinger); Montana Diabetes Program, Lewistown, Montana

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Purpose to be living with undiagnosed diabetes. At the same time,

84.1 million people are at increased risk for type 2 diabe-
The purpose of this study is to review the literature for tes. Thus, more than 114 million Americans are at risk for
Diabetes Self-Management Education and Support developing the devastating complications of diabetes.1
(DSMES) to ensure the National Standards for DSMES Diabetes self-management education and support
(Standards) align with current evidence-based practices (DSMES) is a critical element of care for all people with
and utilization trends. diabetes. Diabetes self-management education and sup-
port is the ongoing process of facilitating the knowledge,
skills, and ability necessary for diabetes self-care as well
Methods as activities that assist a person in implementing and
sustaining the behaviors needed to manage his or her
The 10 Standards were divided among 20 interdisciplin- condition on an ongoing basis, beyond or outside of for-
ary workgroup members. Members searched the current mal self-management training. In previous National
research for diabetes education and support, behavioral Standards for Diabetes Self-Management Education and
health, clinical, health care environment, technical, reim- Support (Standards), DSMS and DSME were defined
bursement, and business practice for the strongest evi- separately, but these Standards aim to reflect the value of
dence that guided the Standards revision. ongoing support and multiple services.
The Standards define timely, evidence-based, quality
Results DSMES services that meet or exceed the Medicare dia-
betes self-management training (DSMT) regulations;
Diabetes Self-Management Education and Support facil- however, these standards do not guarantee reimburse-
itates the knowledge, skills, and ability necessary for ment. These Standards provide evidence for all diabetes
diabetes self-care as well as activities that assist a person self-management education providers, including those
in implementing and sustaining the behaviors needed to that do not plan to seek reimbursement for DSMES. The
manage their condition on an ongoing basis. The evi- current Standards’ evidence clearly identifies the need to
dence indicates that health care providers and people provide person-centered services that embrace the ever-
affected by diabetes are embracing technology, and this increasing technological engagement platforms and sys-
is having a positive impact of DSMES access, utilization, tems. The hope is that payers will view these Standards
and outcomes. as a tool for reviewing DSMES reimbursement require-
ments and consider change to align with the way their
beneficiaries’ engagement preferences have evolved.
Conclusion Research confirms that <5% of Medicare beneficiaries
utilize their DSMES benefits.2,3 Changes in reimburse-
Quality DSMES continues to be a critical element of care ment policies stand to increase DSMES access and utili-
for all people with diabetes. The DSMES services must zation, which will result in positive impact to beneficiaries’
be individualized and guided by the concerns, prefer- clinical outcomes, quality of life, health care utilization,
ences, and needs of the person affected by diabetes. Even and costs.4
with the abundance of evidence supporting the benefits It is necessary to learn how to manage diabetes and
of DSMES, it continues to be underutilized, but as prevent or delay the complications.5,6 The Standards are
with other health care services, technology is changing designed to define quality DSMES and assist those who
the way DSMES is delivered and utilized with positive provide DSMES services to implement evidence-based
outcomes. DSMES. Numerous studies have shown the benefits of
DSMES, which include improved clinical outcomes and
Introduction quality of life while reducing hospitalizations and health
care costs.2,7-12 Four critical time points for providing
By the most recent estimates, 30.3 million people in DSMES—at diagnosis, annually, when complicating fac-
the US have diabetes. An estimated 23.1 million have tors occur, and during transitions in care—have been
been diagnosed with diabetes and 7.2 million are believed documented and should be used to guide health care

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professionals’ referrals.13 Engagement in DSMES ser- This equates to the person with diabetes spending <1%
vices improves A1C by 0.6%, as much as many medica- of their life with their health care team accessing ser-
tions, with no side effects.8 However, greater A1C vices.23 Thus, the focus of the Standards should include
improvement was associated with DSMES services >10 helping the person with diabetes develop problem-solving
hours.8,11 skills and attain ongoing decision-making support neces-
The Standards are applicable to educators in solo sary to self-manage diabetes. In addition, encouraging
practice as well as those in large multicenter programs,14 e-health tools24 and online peer support25 will allow for
care coordination programs, population health programs, the implementation of a complete feedback loop essen-
and technology-enabled models of care.15,16 By follow- tial to facilitate ongoing self-management.16,26 Diabetes
ing the Standards, DSMES should be incorporated in also carries with it a risk for burnout, which, as it devel-
new and emerging models of care, including virtual vis- ops, can lead to poorer health outcomes.27 Health care
its, Accountable Care Organizations, Patient-Centered teams must consider the burden of treatment placed on
Medical Homes, population health programs, and value- those living with diabetes—in essence, the “work of
based payment models.17-20 The Standards do not endorse being a patient”—and consider all decisions within the
any one approach but rather seek to delineate the com- lens of the individual’s capacity.28 All DSMES services
monalities among effective and evidence-based DSMES must focus on the priorities, concerns, and preferred
strategies. These Standards are used in the field for rec- delivery method and timing of the individual, incorporat-
ognition by the American Diabetes Association (ADA) ing a person-centered approach. The minimally disrup-
and accreditation by the American Association of tive model of care defines a goal of maximizing
Diabetes Educators (AADE). They also serve as a guide participant outcomes with the minimal amount of work
for nonaccredited and nonrecognized providers of diabe- required by the person with diabetes to help simplify
tes education. diabetes management and not add complexity.29
Many DSMES services encounter people who are Previous Standards have used the term program; how-
diagnosed with prediabetes. It is important to note that ever, when focusing on the needs of an individual, this
DSMES and the National Diabetes Prevention Program term is no longer relevant. The use of DSMES services
(National DPP) lifestyle change program are tailored for more clearly delineates the need to individualize and
different audiences with different needs and different identify the elements of DSMES appropriate for an indi-
desired outcomes. The Centers for Disease Control and vidual. This revision encourages providers of DSMES to
Prevention’s (CDC) Diabetes Prevention Recognition embrace a contemporary view of the new complexities of
Program assures that organizations can deliver the life- the evolving health care landscape.13,30
style change program effectively and achieve the out- Because of the dynamic nature of health care and
comes necessary to prevent or delay onset of type 2 diabetes-related research, the Standards have previously
diabetes. To achieve CDC recognition, organizations been reviewed and revised approximately every 5 years
must use a CDC-approved curriculum and meet national by key stakeholders and experts within the diabetes care
quality standards designed specifically for type 2 diabe- and education community. In 2016, the Task Force was
tes prevention programs. Those who deliver DSMES jointly convened by AADE and ADA. Members of the
programs are well positioned to also offer the National Task Force included experts from numerous health care
DPP lifestyle change program, but they should meet the professional disciplines and individuals with diabetes.
standards for the National DPP.21 The National DPP and Representatives from public health; those practicing with
DSMES co-located within organizations have been underserved populations including rural primary care
found to be successful, and the outcome of this partner- and other rural health services; virtual, pharmacy, insurer
ship allows for the sharing of expertise and the easy programs; individual practices and large urban specialty
transition from one service to another.22 practices; and urban hospitals served on the Task Force.
This revision of the Standards highlights the focus of The Task Force was charged with reviewing the current
the individual with diabetes as the center of their care National Standards for DSMES for appropriateness, rel-
team, recognizing that a person with diabetes visits their evance, and scientific basis and updating them based on
primary care provider (PCP) 4 times per year on average, the available evidence and expert consensus. Given
and the average PCP appointment is 18 to 20 minutes.23 the rapidly changing health care environment and the

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ever-growing field of technology, the 2017 Standards ideas that will improve the utilization, quality, measur-
Revision Task Force recognizes the potential need to able outcomes, and sustainability of the DSMES ser-
review the literature for evidence-driven updates more vices. Stakeholders can be identified from DSMES
frequently in the future as advances in health care delivery participants, referring practitioners, and community-
are evolving. based groups that support DSMES (eg, health clubs and
health care professionals [both within and outside of the
organization]) who provide input to promote value, qual-
Standard 1
ity, access, and increased utilization.36,37 Social determi-
Internal Structure nants related to the population served will be used to
guide stakeholder selection and facilitate the connection
The provider(s) of DSMES services will define and
between the DSMES services, participant population,
document a mission statement and goals. The DSMES
health care providers, and community.38,39
services are incorporated within the organization—large,
A planned, documented strategy to engage and elicit
small, or independently operated.
input from stakeholders will shape how DSMES is
Documentation of a defined structure, mission, and
developed, utilized, monitored, and evaluated.33,37,40,41 If
goals supports effective provision of DSMES. Mission
the provider of DSMES is experiencing a lack of refer-
defines the core purpose of the organization and assists
rals or low utilization, the stakeholders can assist with
in developing professional practice and services. Business
the solution.42,43 The goal is to provide effective and
literature, case studies, and reports of successful organi-
dynamic DSMES services that are person-centered, cul-
zations emphasize the importance of clear shared mis-
turally relevant, and responsive to the referring practitio-
sions, goals, and defined relationships.31,32 The absence
ner and participant-identified needs,38 ultimately
of these common goals and relationships is cited as one
engaging participants in lifelong learning.13,41
barrier to success.32 Defined leadership is needed to
remove any service-related obstacles and find resources
to advance DSMES services.33 Therefore, entities pro- Standard 3
viding DSMES services must develop lines of communi- Evaluation of Population Served
cation and support to be clear on their mission, outcomes,
and quality improvement measurement.34 The Chronic The provider(s) of DSMES services will evaluate the
Care Model supports the need for documented organiza- communities they serve to determine the resources,
tional mission and goals.33 design, and delivery methods that will align with the pop-
According to the Joint Commission, documentation of an ulation’s need for DSMES services.
organization’s structure is equally important for both small Currently, the majority of people with and at risk for
and large health care organizations.35 Providers of DSMES diabetes do not receive DSMES.2,3,10,44,45 While there are
working within a larger organization will have the organiza- many barriers to DSMES, one crucial issue is access.46-48
tion document recognition of and support of quality DSMES Providers of DSMES, after clarifying the specific popu-
as an integral component to their mission.35 For smaller or lations they are able to serve, must understand their com-
independent providers of DSMES, they will identify and munity and regional demographics.47,49-53
document their own appropriate mission, goals, and struc- Individuals, their families, and communities require
ture to fit the function in the community they serve.34 education and support options and tools that align with
their needs.54-56 The provider(s) of DSMES must ensure
the necessary educational alternatives are available.40,54
Standard 2 Understanding the population’s demographic character-
istics, including ethnic/cultural background, sex, age,
Stakeholder Input
levels of formal education, literacy, and numeracy57-60 as
The provider(s) of DSMES services will seek ongoing well as perception of diabetes risk and associated com-
input from valued stakeholders and experts to promote plications, is necessary.45
quality and enhance participant utilization. It is essential to identify the barriers that prevent access
The purpose of seeking stakeholder input in the ongo- to DSMES during the assessment process.61-63 Individuals’
ing planning process is to gather information and foster barriers may include socioeconomic or cultural factors,

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participant schedules, health insurance shortfalls, per- require additional degrees or certifications in informatics,
ceived lack of need, and limited encouragement from developing an understanding of these skills—as well as
other health care practitioners to engage in DSMES.15,64-68 marketing, health care administration, and business man-
Models that include population health and disease man- agement—will be helpful as the health care environment
agement, an interprofessional team, and ongoing social evolves. The quality coordinator does need to understand
support improve both practice and individual out- the process of identifying, analyzing, and communicating
comes.40,69,70 Medical management integrated with DSMES quality data. In large health systems, the quality coordina-
improves access, clinical outcomes, and cost-effectiveness.71,72 tor may partner with other team members to support quality
Creative solutions incorporating technology to increase improvement. In most DSMES entities, the quality coordi-
reach and engagement must be examined.73,74 Telehealth, nator will manage the overall services and may be part of
electronic health records (EHR), mobile applications, and the instructional team.
cognitive computing will proactively identify and track
participants while offering endless opportunities for indi- Standard 5
vidualized and contextualized DSMES.16,75-78
DSMES Team

Standard 4 At least one of the team members responsible for facil-

itating DSMES services will be a registered nurse, regis-
Quality Coordinator Overseeing
tered dietitian nutritionist, or pharmacist with training
DSMES Services
and experience pertinent to DSMES or be another health
A quality coordinator will be designated to ensure care professional holding certification as a diabetes edu-
implementation of the Standards and oversee the DSMES cator (CDE) or Board Certification in Advanced Diabetes
services. The quality coordinator is responsible for all Management (BC-ADM). Other health care workers or
components of DSMES, including evidence-based prac- diabetes paraprofessionals may contribute to DSMES
tice, service design, evaluation, and continuous quality services with appropriate training in DSMES and with
improvement. supervision and support by at least one of the team mem-
Ensuring quality is an essential component of the bers listed previously.
chronic care model.33 Person-centered health care is The evidence supports an interprofessional team
associated with improved outcomes79-81 and better rela- approach to diabetes care, education, and support.93
tionships between referring practitioners, individuals, Current research continues to support nurses, dietitians,
and teams.82,83 For DSMES services to be sustainable, and pharmacists as providers of DSMES responsible for
quality must be a priority.84,85 curriculum development.13,14,94-98 Expert consensus sup-
Previous versions of the Standards used the term pro- ports the need for specialized clinical knowledge in dia-
gram coordinator; however, with new models of care and betes and behavior change principles for DSMES team
payment methods evolving, DSMES services need to dem- members.99 Certification as a CDE (National Certification
onstrate how these services affect overall participant out- Board for Diabetes Educators [NCBDE])86,100 or
comes. The change to quality coordinator reflects the need BC-ADM (AADE)86,101 demonstrates specialized train-
to address quality within all levels of DSMES services ing beyond basic discipline preparation and mastery of a
offered, concurrent with implementation. Most impor- specific body of knowledge. All DSMES team members
tantly, the quality coordinator is charged with collecting must document appropriate continuing education of
and evaluating data to identify gaps in DSMES, providing diabetes-related content, ensuring their continuing com-
feedback on the performance of the DSMES services to petence in their respective roles.
team members, referring practitioners, and the organiza- Registered nurses, registered dietitian nutritionists,
tion’s administration. The use of EHR and person-centric pharmacists, and members of health care disciplines that
software improves care86-92 and assists the quality coordi- hold a certification as a CDE or BC-ADM can perform all
nator in evaluating the effectiveness of DSMES. The qual- the DSMES services, including clinical assessments.14,100-102
ity coordinator utilizes data mining to inform payers and Paraprofessionals with additional training in DSMES
members of the health care team of the clinical outcomes effectively contribute to the DSMES team. Diabetes para-
of DSMES. Although the quality coordinator does not professionals, for example, medical assistants, community

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health workers, peer educators, and so on can instruct, •• monitoring and using patient-generated health data
reinforce self-management skills, support behavior change, (PGHD);
facilitate group discussion, and provide psychosocial •• preventing, detecting, and treating acute and chronic com-
plications;
support and ongoing self-management support.102
•• healthy coping with psychosocial issues and concerns;
Paraprofessionals must receive continuing education spe- •• problem solving.
cific to the role they serve within the team and must
directly report to the quality coordinator or one of the The content areas listed, as well as educating the par-
qualified DSMES team members.14,71,99,102-106 For services ticipant on navigating the health care system, learning
outside the expertise or scope of the DSMES provider, a self-advocacy, and e-health education,24,105,106,115-117 can
mechanism must be in place to ensure that the participant be adapted for all practice settings and provide a solid
is given the information needed to be referred to the appro- outline and agenda for a DSMES curriculum. It is crucial
priate health care professionals.99,107 that the content be tailored to match individuals’ needs
and be adapted as necessary for age, developmental
Standard 6 stage, type of diabetes, cultural factors, health literacy
and numeracy, and comorbidities.123-127
Curriculum

A curriculum reflecting current evidence and practice

Standard 7
guidelines, with criteria for evaluating outcomes, will
serve as the framework for the provision of DSMES. The Individualization
needs of the individual participant will determine which
The DSMES needs will be identified and led by the par-
elements of the curriculum are required.
ticipant with assessment and support by one or more DSMES
Individuals with diabetes, and those supporting them,
team members. Together, the participant and DSMES team
have much to learn to enable effective self-management.
member(s) will develop an individualized DSMES plan.
DSMES provides this education in an up-to-date, evidence-
People with diabetes should engage in DSMES during
based, and flexible curriculum.108,109 The options for
various stages after their diabetes diagnosis.5,13 Regardless
delivery of the curriculum have grown dramatically as
of the stage, people with diabetes have their own priori-
technology has been incorporated into health care.
ties and needs. The DSMES services must be designed
The curriculum is the evidence-based foundation from
using person-centered care practices, in collaboration
which the appropriate content is drawn to build an indi-
with the participant, focusing on the participant’s priori-
vidualized education plan based on each participant’s
ties and values.5,13,128 The most important element to
concerns and needs. The curriculum content must be sup-
appreciate is that no participant is required to complete a
plemented with appropriate resources and supporting
set DSMES structure. When participants have achieved
education materials. A curriculum also specifies effective
their goals, they can determine that their initial DSMES
teaching strategies and methods for evaluating learning
intervention is complete. However, DSMES is an ongo-
outcomes.5,110,111 The curriculum must be dynamic.5,97,111-113
ing, lifelong process, with ongoing assessments of
Recent education research endorses the inclusion of prac-
AADE7 Self-Care Behaviors122 and continual support.5,13
tical problem-solving approaches and collaborative care,
Research indicates the importance of individualizing
addressing psychosocial issues, behavior change, and
DSMES to each participant.129,130 The assessment pro-
strategies to sustain self-management efforts.40,114-120
cess is collaboratively conducted by a health care profes-
The following core content areas, including the
sional with the participant to identify needs and potential
AADE7 self-care behaviors, demonstrate successful out-
self-management support strategies.
comes13,109,121,122 and must be reviewed to determine
The health care professional uses the information
which are applicable to the participant:
gleaned on assessment to determine the appropriate edu-
•• diabetes pathophysiology and treatment options; cational and behavioral interventions, including enhanc-
•• healthy eating; ing the participant’s problem-solving skills.8,11,130
•• physical activity; The assessment must incorporate information about
•• medication usage; the individual’s medical history, age, cultural influences,

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health beliefs and attitudes, diabetes knowledge, diabetes via consumer portals and EHR, tablet computers that
self-management skills and behaviors, emotional integrate with EHR, text messaging, web-based tools,
response to diabetes, disease burden, ability, readiness to automated telephone follow-up, and remote monitoring
learn, literacy level (including health literacy and numer- tools, can be used.77,149-152 Selecting validated tools, used
acy), physical limitations, family support, peer support for assessment and ongoing evaluation, will generate
(in person or via social networking sites), financial sta- more evidence to support DSMES.153 Although not an
tus, and other barriers.29,131-134 After the initial assess- exhaustive list or applicable to all populations, examples
ment, additional assessments can be incremental, over of assessment tools can be found in the Standards’ glos-
time, as indicated based on participant need.13 sary (Table 1).
The DSMES team member(s) will use clear health The assessment and education plan, intervention, and
communication principles, using plain language, avoid- outcomes will be documented in the participant’s health
ing jargon, making information culturally relevant, using record. Documentation of participant contact with
language and literacy appropriate education materials, DSMES team members will guide the education process,
and using interpreter services when indicated.135 provide evidence of communication among other mem-
Evidence-based communication strategies such as col- bers of the individual’s health care team, and demon-
laborative goal setting, action planning, motivational strate adherence to guidelines, all of which will assist in
interviewing, shared decision making, cognitive behav- long-term management of diabetes care and diabetes
ioral therapy, problem solving, self-efficacy enhance- self-management support.86 Using technology tools will
ment, teach-back, and relapse-prevention strategies are increase access to information for all team members to
also effective.120,136-139 It is crucial to develop action- work collaboratively and have access to documentation.
oriented behavior change goals and objectives.130,140
Creative, person-centered, experience-based delivery Standard 8
methods beyond the mere acquisition of knowledge are
Ongoing Support
effective for supporting informed decision making and
meaningful behavior change and addressing psychoso- The participant will be made aware of options and
cial concerns.122,141 Moving beyond static lecture meth- resources available for ongoing support of their initial
odology, incorporating meaningful discussions to address education and will select the option(s) that will best
individual needs, and using interactive teaching styles maintain their self-management needs.
are required. Incorporating PGHD, especially blood glu- While initial DSMES is necessary, it is not sufficient
cose and/or continuous glucose monitoring data, into for participants to sustain a lifetime of diabetes self-
decision making individualizes self-management and management.13,115 Initial improvements in metabolic and
empowers participants to fully engage in personal prob- other outcomes have been shown to diminish after 6
lem solving to change behavior and improve out- months.13,115 To maintain behavior at the level needed to
comes.16,142-144 There is strong evidence that incorporating effectively self-manage diabetes, participants with type 1
text messaging into DSMES interventions improves diabetes12 and type 2 diabetes11 need ongoing diabetes
engagement and outcomes.25,145-147 Use of digital tech- self-management support. Ongoing support is defined as
nology (cloud-based, telehealth, data management plat- resources that help the participant implement and sustain
forms, apps, and social media) enhances the ability to the ongoing skills, knowledge, and behavior changes
employ a technology-enabled self-management feedback needed to manage their condition.13 The vital point is that
loop with 4 key elements: 2-way communication, analy- the participant selects the resource or activity that best
sis of PGHD, customized education, and individualized suits their self-management needs.
feedback to provide real-time engagement in self-management A variety of strategies are available for engaging in
as well as to enable and empower participants.16 ongoing support both within and outside DSMES ser-
Reassessment during key times, such as when compli- vices. Support can include internal or external group
cating factors influence self-management and during meetings (connection to community and peer groups
transitions of care, can determine whether there is need [online or locally]), ongoing medication management,
for additional or different DSMES services.13,148 A variety continuing education, resources to support new or adjust-
of assessment modalities, including online assessments ments to existing behavior change goal setting, physical

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Table 1

Glossary of Terms

Assessment. A process to gather the information necessary to make a diabetes self-management education and support (DSMES) plan
with the participant. The DSMES assessment must be completed by a health care professional.
Assessment Tools.
•  The Diabetes Distress Scale (short form)
175
  A 2-question initial screening tool to assess diabetes-specific distress (followed by the full 17-item scale when indicated).

•  The WHO-5 Well-being Index

 Validated in many languages, is a reliable measure of emotional functioning and screen for depression and has been used
extensively in research and clinical care,176 including the DAWN2 study (Diabetes Attitudes Wishes and Needs 2).177
•  Problem Areas in Diabetes (PAID)
178
 A 20-item measure of diabetes-specific distress identifying emotional distress and burden associated with diabetes (pediatric
179,180
and teen versions are also available).
•  Diabetes Self-Efficacy
181
  An 8-item self-report scale designed to assess confidence in performing diabetes self-care activities.

•  Self-Care Inventory-Revised (SCI-R)

182
  A survey that measures what people with diabetes do, versus what they are advised to do in their diabetes treatment plan.

•  Summary of Diabetes Self-Care Activities (SDSCA)

183
  An 11-item or expanded 25-item measure of diabetes self-care behaviors.

•  Starting the Conversation (STC)

184
  An 8-item simplified food frequency instrument designed for use in primary care and health-promotion settings.

•  3-Item Screen
 A tool to measure health literacy. It asks how often someone needs help reading hospital materials, how confident they are filling
out forms, and how often they have difficulty understanding their medical condition.185
Behavioral goal setting. The practice of identifying health behaviors to modify, setting a target to reach, and planning a course to
achieve the target.
Capacity. The ability a person has to understand and manage their condition.
Cognitive computing. The simulation of human thought processes in a computerized model to mimic the way the human brain works.
Data mining. The ability of a coordinator to aggregate data from within their organization’s documentation system.
Diabetes professional. A person with a medical background who is part of a diabetes care team.
Diabetes paraprofessional. A person with a nonmedical background who can provide support as part of a diabetes care team.
Diabetes self-management education and support (DSMES). The ongoing process of facilitating the knowledge, skills, and ability
necessary for prediabetes and diabetes self-care and the activities that assist the person with diabetes or prediabetes in implementing
and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management
training. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by
evidence-based standards. Support (whether behavioral, educational, psychosocial, or clinical) helps implement informed decision
making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes,
health status, and quality of life.
Disease burden. The impact a disease has on the various components of a participant’s life, such as physical, financial, or mental
aspects.
Electronic health records (EHR). The digital version of a patient’s chart. EHRs are available in real time and available to patients and
their care team immediately.
Goals. The desired results for DSMES, set by those receiving DSMES services and their care teams.
Health care stakeholder. Anyone involved in or affected by the financing, implementation, or outcome of a service, practice, process, or
decision made by another—for example, health care, health policy. Examples of stakeholders with interest in health care are providers,
patients (health care consumers), payers, and so on.
Mission. Core purpose, direction, and why the organization exists. It describes who it serves and how it does it.
(continued)

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Table 1

(continued)

National Diabetes Prevention Program (National DPP). An evidence-based intervention that allows purchasers, payers, and providers
to prevent or delay onset of type 2 diabetes in patients with prediabetes or at high risk for type 2 diabetes. The intervention is founded
on the science of the Diabetes Prevention Program research study and several translation studies. These studies showed that making
modest behavior changes helped participants lose 5% to 7% of their body weight and reduced the risk of developing type 2 diabetes
by 58% in adults with prediabetes (71% for people over 60 years old). The National DPP’s lifestyle change program is a year-long
structured program (in-person group, online, or combination) consisting of:
• an initial 6-month phase offering at least 16 sessions over 16 to 24 weeks and a second 6-month phase offering at least 1 session a
month (at least 6 sessions);
•  facilitation by a trained lifestyle coach;
•  use of a CDC-approved curriculum;
•  regular opportunities for direct interaction between the lifestyle coach and participants;
•  focus on behavior modification, managing stress, and peer support.
CDC’s Diabetes Prevention Recognition Program assures that organizations can deliver the lifestyle change program effectively and
achieve the outcomes necessary to prevent or delay onset of type 2 diabetes. To achieve CDC recognition, organizations must use a
CDC-approved curriculum and meet national quality standards.
Patient-generated health data (PGHD). Information gathered by patients or health care professionals from diabetes technology or
devices (eg, diabetes software, diabetes glucose monitors, etc).
Person-centered care practice. Efforts to recognize the people using health services as equal members of the care team in planning,
executing, and monitoring their care and keeping their needs at the forefront.
Prediabetes. Blood glucose levels that are higher than normal but not high enough to be diagnosed as diabetes.
Service. A system or actions dedicated to supplying a demand.
Social determinants. The conditions in which someone lives, learns, works, and ages that affect their health.
Abbreviation: CDC, Centers for Disease Control and Prevention.

activity programs, weight loss support, smoking cessa- Standard 9

tion, and psychosocial support, among others.154-159
Participant Progress
Connecting the participant to existing community
resources outside of the DSMES entity is more realistic The provider(s) of DSMES services will monitor and
for smaller organizations. communicate whether participants are achieving their
The effectiveness of providing support through diabe- personal diabetes self-management goals and other
tes educators, disease management programs, trained outcome(s) to evaluate the effectiveness of the educa-
peers, diabetes paraprofessionals, community-based pro- tional intervention(s), using appropriate measurement
grams, or use of technology (text, email, social media, techniques.
web-based, mobile, digital, and wearable and wireless Effective DSMES is a significant contributor to long-
devices) has also been established.154-156,160-165 Peer sup- term, positive health outcomes and clinical improve-
port using social networking sites improves glucose man- ment.8 Assessing needs and communicating information
agement, especially in people with type 2 diabetes.25 and skills that promote effective coping and self-manage-
Practitioners can highlight the benefits and accessibility of ment must involve a personalized and comprehensive
online diabetes communities as a resource to help partici- approach.13 The provider(s) of DSMES will rely on
pants learn from others living with the condition, facing behavior change goal-setting strategies to help participants
similar issues, available 24 hours a day, 7 days a week, meet their personal targets.167 There are proven steps
when it is convenient for them to engage. A person-cen- based on goal-setting theory that improve outcomes. The
tered approach is recommended to incorporate ongoing role of the DSMES team is to aid the goal-setting process and
support plans in clinical care.115,128,166 adjust based on participant needs and circumstances.168,169

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Validly measuring the achievement of SMART goals pay-for-performance and the Medicare Access and CHIP
(specific, measurable, achievable, realistic, and time- Reauthorization Act (MACRA), which has shifted pro-
bound) and action planning including an assessment of vider payment based on productivity to one that focuses
confidence and conviction is essential.170,171 on quality and outcomes.172
To demonstrate the benefits of DSMES, it is important The Institute for Healthcare Improvement suggests 3
for DSMES providers to track relevant evidence-based fundamental questions that should be answered by an
DSMES outcomes such as knowledge, behavior, clinical, improvement process: What are we trying to accom-
quality of life, cost-savings, and satisfaction outcomes. plish? How will we know a change is an improvement?
The AADE Outcome Standards for Diabetes Education And what changes can we make that will result in an
specify behavior change as the key outcome, and the improvement?173
AADE7 Self-Care Behaviors (healthy eating, being Once areas for improvement are identified, the
active, taking medication, monitoring, problem solving, DSMES quality coordinator determines timelines and
reducing risk, and healthy coping) provide a useful important milestones, including data collection, analysis,
framework for assessment, documentation, and evalua- and presentation of results. Measuring a variety of out-
tion.111,122 Providers of DSMES should select validated comes ensures that change is successful without causing
measurement tools to accurately track outcomes. additional problems in the system. Outcome measures
Tracking and communication of individual outcomes indicate the result of a process (ie, whether changes are
must occur at appropriate intervals, for example, before leading to improvement, eg, a change in a behavior or a
and after engaging in DSMES. The interval depends on biomarker [A1C]), while process measures provide
the nature of the outcome itself (eg, A1C every 3-6 information about what caused those results (eg, if the
months) and the timeframe specified based on the indi- participant attended DSMES sessions or had an exam
vidual’s personal goals. For some areas, the indicators, done).173 Process measures are often targeted to those
measures, and timeframes will be based on guidelines processes that affect the most important outcomes.
from professional organizations or government agen- Measures generally recommended for DSMES services
cies.8 include behavioral measures (eg, participant’s report of
self-management activities and psychosocial behaviors
including distress), clinical measures (eg, changes in
Standard 10
weight or A1C), operational measures (eg, participant
Quality Improvement satisfaction, financial indicators, no-show rates, or results
of marketing efforts), and process measures (eg, partici-
The DSMES services quality coordinator will measure
pants receiving services, referral to DSMES, or referral
the impact and effectiveness of the DSMES services and
for an eye exam). A variety of methods can be used for
identify areas for improvement by conducting a system-
quality improvement initiatives, such as the Plan Do
atic evaluation of process and outcome data.
Study Act model, Six Sigma, Lean, Re-AIM, and work-
Formal quality improvement strategies can lead to
flow mapping. There are resources available to assist
improved diabetes outcomes.84,85 DSMES must be
those initiating quality improvement programs for the
responsive to advances in knowledge, treatment strate-
first time or for those looking for new options.84,85,172,174
gies, education strategies, and psychosocial interventions
as well as consumer trends and the changing health care
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