Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 18:

Diabetes Education and Ongoing Support in the Management of Diabetes

Martha M. Funnell, MS, RN, CDE, FAADE,1 and Carolé R. Mensing, RN, MA, CDE, FAADE2

1Funnell is associate research scientist in the Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI. 2Mensing is a private consultant, previously from the Joslin Diabetes Center, Boston, MA.

Diabetes self-management education (DSME) and diabetes self-management support (DSMS), have long been considered cornerstones of diabetes care. Because ~98% of the glycemic outcomes in diabetes are patient-related,1 and the vast majority of the care is provided by the person with diabetes and his or her family members, effective care requires a partnership between an actively engaged patient and the health-care team. Education and ongoing support are critical for the patient to fully participate in shared decision-making and to make informed self-management decisions on a daily basis.

Most nurses think of diabetes education and ongoing support as a comprehensive program offered in an outpatient setting or by an inpatient diabetes nurse educator. In fact, each encounter with a person who has diabetes is an opportunity for education, and every nurse shares the responsibility for that education. Even when time is limited, nurses can both create and use “teachable moments” to provide and reinforce needed information. For example, giving insulin to a hospitalized patient is an excellent time to assess and review insulin injection technique, treatment of hypoglycemia, and the need to wear or carry diabetes identification and glucose tablets. Bathing a hospitalized, residential, or home care patient or performing a foot examination during an outpatient visit provides the opportunity to assess foot care self-management practices by asking, “What do you do to care for your feet at home?” and offering personalized foot care instruction based on the physical findings and the patient’s response. In a care management or nurse practitioner encounter, patients can be asked about financial concerns and offered information about programs to reduce costs or help pay for medications and other supplies. In every setting, nurses not only provide information, and demonstrate skills, but also help patients to develop strategies and overcome obstacles to effectively use that information to cope with and manage diabetes on a daily basis.

EVIDENCE FOR DSME AND DSMS

Multiple meta-analyses and reviews have documented the effectiveness of DSME in improving knowledge, psychosocial outcomes, self-management behaviors, health outcomes,2–22 and in lowering costs.16–18,23 The greatest predictive factor of the effectiveness of DSME is the amount of time spent with the educator, typically a nurse.4,6,13,18–26 A recent review and meta-analysis indicated that programs without added support, particularly those with <10 h of contact, provided little benefit.27 Table 18.1 summarizes the key findings from these studies.5

Table 18.1—Effectiveness of DSME

Characteristics of effective interventions

• Regular reinforcement is more effective than one-time or short-term education.

• Patient participation and collaboration appear to produce more favorable results than didactic interventions.

• Group education is more effective than one-on-one education for lifestyle interventions and appears to be equally effective for improving knowledge and accuracy of SMBG.

• Studies with short-term follow-up are more likely to demonstrate positive effects on glycemic control and behavioral outcomes than studies with long-term follow-up.

• Programs with <10 h of contact and without added support provide little benefit.

Effectiveness in clinical settings

• In the short term (<6 months), DSME improves knowledge levels, SMBG skills, and dietary habits (per self-report).

• In the short term (<6 months), glycemic control improves.

• Improved glycemic control does not appear to correspond to measured changes in knowledge or SMBG skills.

• Weight loss can be achieved with repetitive interventions or with short-term follow-up (<6 months).

• Physical activity levels are variably affected by interventions.

• Effects on lipids and blood pressure are variable but are more likely to be positive with interactive or individualized repetitive interventions.

Effectiveness in nonclinical settings

• Some evidence indicates that DSME is effective when given in community gathering places (e.g., churches and community centers) for adults with type 2 diabetes.

• The literature is insufficient to assess the effectiveness of DSME in the home for adults with diabetes.

• The literature is insufficient to assess the effectiveness of DSME in the workplace.

DSME, diabetes self-management education; SMBG, self-monitoring of blood glucose.

Source: Reprinted with permission from Sage Publishing.5

Although no single education program is more effective than others, interventions that incorporate affective (emotional) and behavioral aspects produce better outcomes.13–15,24,27 Tailoring the interventions to the age, culture, and health literacy of the participants,3,8,24–32 and including spouses and adult children, also may increase DSME effectiveness.31

DSME is essential but not sufficient for the type of sustained behavior change required by a chronic illness such as diabetes.4,13 As a result, the provision of ongoing diabetes self-management support (DSMS) was incorporated into the national standards for DSME in 2007,33 and was emphasized further when the name was changed to include both diabetes self-management education and support (DSME/S) in 2012.34 Without this support, most outcomes return to preeducation levels in ~6 months.4,6,13,24,27 Strategies that can be used to provide ongoing self-management support include ongoing self-directed goal setting; use of nurse care managers and diabetes educators in primary care settings, patient-centered medical homes, and accountable care organizations; use of community health workers, as well as lay or peer supporters; smartphone applications, telephone, or e-mail systems; and online support groups.26,27,35–42

Diabetes education has evolved in recent years from a didactic format to more patient-centered, theoretically based empowerment models using approaches based on principles of adult learning and now acknowledge that the person with diabetes is the primary decision maker in his or her own care.3,13 Evidenced-based educational strategies that place greater emphasis on effective psychosocial and behavioral strategies have evolved as well to match this growing body of evidence and to meet quality standards to improve outcomes and obtain reimbursement.

Practical Point

The education process includes assessment, provision of content using appropriate strategies, documentation, and outcome evaluation. Each of these steps is necessary whether DSME/S is part of a comprehensive program or focused education is provided during hospitalization, home care, nurse care management, or routine outpatient visits.

EDUCATION PROCESS FOR DSME/S

The education process incorporates both DSME and DSMS. DSME and DSMS are the ongoing processes of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes. The overall objectives of DSME and DSMS are to support informed decision-making, self-care behaviors, problem solving, and active collaboration with the health-care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner.34

The jointly developed DSME/S algorithm is designed to provide an evidence-based overview of when to identify and refer individuals with type 2 diabetes (T2D) for diabetes education and support.43 This algorithm (See Figures 18.1 and 18.2) can be used by nurses to guide the referral process for diabetes education or for the development or an individual diabetes education plan, DSME program, or DSMS program. Table 18.2 identifies guiding principles and key elements for both initial and ongoing DSMS.43,44

Figure 18.1—DSME/S for adults with type 2 diabetes: algorithm of care

Figure 18.1—DSME/S for adults with type 2 diabetes: algorithm of care. DSME, diabetes self-management education; DSMS, diabetes self-management support.

Source: Reprinted with permission from Powers et al.43

Figure 18.2—DSME/S algorithm: action steps

Figure 18.2—DSME/S algorithm: action steps. DSME, diabetes self-management education; DSMS, diabetes self-management support.

Source: Reprinted with permission from Powers et al.43

Table 18.2—Guiding Principles and Key Elements of Initial and Ongoing DSME/S

Engagement. Provide DSME/S and care that reflects person’s life, preferences, priorities, culture, experiences, and capacity.

• Solicit and respond to questions

• Focus on decisions, reasons for the decisions, and results

• Ask about strengths and challenges

• Use shared decision making and principles of patient-centered care to guide each visit

• Engage the patient in a dialogue about current self-management successes, concerns, and struggles

• Engage the patient in a dialogue about therapy and changes in treatment

• Remain “solution neutral” and support patient identifying solution(s)

• Provide support and education to patient’s family and caregiver

Information sharing. Determine what the patient needs to make decisions about daily self-management.

• Discuss that DSME/S is an important and essential part of diabetes management

• Describe that DSME/S is needed throughout the life cycle and is on a continuum from prediabetes, newly diagnosed diabetes, health maintenance/follow-up, early to late diabetes complications, and transitions in care related to changes in health status and developmental or life changes

• Avoid being didactic

• Provide “need-to-know” information and avoid providing the encyclopedia on diabetes

• Review that diabetes treatment will change over time

• Provide information to the patient using the above engagement key elements

• Take advantage of “teachable moments” to provide information specific to the patient’s care and treatment

• Assess DSME/S patient/family needs for the behavioral and psychosocial aspects of informed decision making

Psychosocial and behavioral support. Address the psychosocial and behavioral aspects of diabetes.

• Assess and address emotional and psychosocial concerns, such as diabetes-related distress and depression

• Present that diabetes-related distress and a range of emotions are common and that stress can raise blood glucose and blood pressure levels

• Discuss that diabetes self-management is challenging but worth the effort

• Support self-efficacy and self-confidence in self-management decisions and abilities

• Support action by the patient to identify self-management problems and develop strategies to solve those problems, including self-selected behavioral goal setting

• Note that it takes about 2–8 months to change a habit/learn/apply behavior

• Address the whole person

• Include family members and/or support system in the educational and ongoing support process

• Refer to community, online, and other resources

Integration with other therapies. Ensure integration and referrals with and for other therapies.

• Ensure access to ongoing medical nutrition therapy

• Recommend additional referrals as needed for behavioral therapy, medication management, physical therapy, etc.

• Address factors that limit the application of diabetes self-management activities

• Advocate for easy access to social services programs that address basic life needs and financial resources

• Identify resources and services that support the implementation of therapies in health care and community settings

Coordination of care across specialty care, facility-based care, and community organizations. Ensure collaborative care and coordination with treatment goals.

• Understand primary care provider and specialist’s treatment targets

• Provide overview of DSME/S to referring providers

• Follow medication adjustment protocols or make necessary recommendation to primary care provider

• Correspond with referring provider about education plan, progress toward treatment goals, and needs to coordinate education and support from entire clinical team; ensure documentation in the health record

• Ensure provision of culturally appropriate care

• Use evidence-based decision support

• Use performance data to identify opportunities for improvement

DSME, diabetes self-management education; DMSM, diabetes self-management support.

Source: Reprinted with permission from Powers et al.43 and Funnell et al.44

The education process parallels the nursing process. With assessment as the first step, the nurse and patient (or caregiver) identify the educational needs (nursing diagnosis) and plan and implement the intervention. In DSME/S this includes educational content, behavioral and psychosocial strategies, and a plan for monitoring and evaluating the outcomes and providing or arranging ongoing follow-up and support. This planning then is documented in the electronic or other medical record to monitor progress.

Assessment

Personalization, or developing a plan with each patient that incorporates and meets the needs identified by that individual, is a critical component of effective DSME/S. The first step in the process is assessment. (Examples of questions to ask during the assessment process are listed in Table 18.3.) The assessment then is used to develop the educational plan in collaboration with the participant and family members or caregivers. Areas of greatest concern and any questions identified by the patient need to be addressed at the beginning of the education process. This helps tailor the educational program to that particular patient and increases both the efficiency and effectiveness of the DSME/S intervention. Beginning with “What is hardest for you or the biggest struggle in managing diabetes?” “What questions do you have about . . . ?” or “What do you know about . . . ?” is an effective way to start even a brief educational or support encounter.

Table 18.3—Examples of Educational Assessment Questions

• In what language do you prefer to speak? To read?

• What is your favorite way to learn (e.g., reading, discussion, videos, computers, apps, group class, individual teaching)?

• Where do you get most of your information about health and diabetes?

• Do you have difficulty with your hearing or vision, such as reading regular-size print?

• How far did you go in school?

• Do you have any cultural or religious practices or beliefs that affect how you care for your health and diabetes?

• Do you ever have difficulty paying for your diabetes supplies or medicines?

• Do you have trouble remembering things?

• Have you ever known other people with diabetes? How did it affect them?

Do you have health problems that you manage other than diabetes? What helps you to manage them?

• Have you ever lost weight or increased your physical activity? What helped you to make those changes? What got in your way?

• What areas of diabetes are you most interested in learning more about?

• What are you currently doing to manage your diabetes at home?

• On a scale of 1 to 10, with 10 being the most important, how important is managing diabetes in your life?

• On a scale of 1 to 10, with 10 being the most sure, how confident are you that you can manage your diabetes?

• How much stress are you experiencing in your life?

• Do you often feel overwhelmed by caring for your diabetes?

• Do you often do you feel that you are failing in caring for your diabetes?

• How strongly do you believe that you will get the complications of diabetes, no matter what you do?

• Have you felt sad and blue most of the time for the past 2 weeks? Two months?

• What kind of support do you want and need from your family and friends to care for your diabetes?

• What kind of support do you receive from your family and friends to care for your diabetes?

• Who helps you the most to care for your diabetes?

• What is your greatest concern about your diabetes?

• What is the hardest thing for you in caring for your diabetes?

• What were your thoughts/feelings when you first learned that you had diabetes? What are your thoughts/feelings now?

• How can I be most helpful to you?

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A formal assessment needs to include developmental age and life-stage, cultural and religious influences, health beliefs and attitudes, diabetes knowledge, self-management skills and behaviors, psychosocial issues and coping strategies, readiness to learn, language, health literacy and numeracy, cognitive ability, physical limitations, environment, family support, other life stressors and priorities, financial concerns (e.g., medication costs), and relevant medical history.34 It is equally and especially important to find out what areas the patient wishes to learn or cause the greatest concerns or worries.

Assessment is appropriate whether the patient is newly diagnosed or has lived with diabetes for some time. Even newly diagnosed adults or parents of newly diagnosed children have some level of knowledge or experience with diabetes. A personal assessment not only is in keeping with patient-centered care and adult learning principles, but also shows respect for the patient or the caregiver and allows a true partnership to begin. The assessment also provides the opportunity to clarify misconceptions, update old information, and involve patients in the creation of their personal educational objectives and plan. Some patients also may want to include family members or caregivers in the planning process. In addition, reassessment at each follow-up appointment establishes that information has been learned and applied to everyday decisions and identifies areas of concern or areas of struggle (see Additional Resourcesat the end of this chapter).

Content

Table 18.4 outlines topic-specific content areas to be addressed in a comprehensive DSME/S program.26 These content areas are written in behavioral terms to allow for maximum creativity and flexibility in the teaching process. Specific areas to address with each patient are identified during the assessment, and only the relevant areas should be provided. Ideally, all patients with diabetes should be referred to an in-depth, formal educational program, either at diagnosis or at some point during their life with diabetes, and should receive ongoing DSME/S (Figure 18.1). Even patients who have had diabetes for a number of years can benefit from a refresher course or referral for ongoing support (Figure 18.2). Asking long-term patients whether they have questions or concerns is an effective way to begin each encounter to ensure that ongoing psychosocial, behavioral, and educational needs are met.

The recommended content areas are applicable in all settings and can be provided at basic, intermediate, or advanced levels. Generally, the depth of the content needed determines the level rather than a particular topic. For example, basic or survival education for self-monitoring of blood glucose (SMBG) may include only the skills of checking glucose levels, recording the results, monitoring times and frequency, reviewing recommended targets, and providing information about when to contact a health-care provider. Intermediate SMBG education may include developing personal blood glucose targets and interpreting the results, discussing how SMBG will be incorporated into daily life, and obtaining ongoing behavioral and psychosocial support. Advanced SMBG education may include pattern management. Standardized curricula and goals for DSME/S are available to help nurses create programs that address all of the recommended content areas and to ensure consistency among instructors (see Additional Resources at the end of this chapter), although these do need to be adapted for the specific population served. Many nurses find adopting, adapting, or modifying these curricula to fit their practice setting and population to be more efficient than developing their own. These can be useful for nurses who provide education and support on an ongoing basis to ensure that they consistently address all of the critical content areas identified on the patient’s personal plan and that the messages are provided consistently among all staff members. The level of DSME/S is based on the assessment rather than the length of time since diagnosis. In addition, patients may be at a basic level in one area and at an advanced level in others based on their self-management experience and past education. When only limited education can be provided, such as with hospitalized patients, asking about significant struggles, what they know and want to know about diabetes, current practices and concerns about home management, and fears about diabetes helps the nurse to provide relevant personalized information in a short period of time. Referral to a comprehensive DSME/S program is an important part of discharge planning and transition care, outpatient follow-up, care management, and home care for all patients with diabetes and prediabetes (Figure 18.1).

Educational Strategies

Multiple reviews and meta-analyses have been performed that are useful for understanding the underlying principles and critical elements of successful self-management education.4,5,8,11–15,24,27 Effective strategies include involving patients (or caregivers) in their own care; guiding them in actively learning about the disease by providing fewer topics and more practice, interactive, or problem-based exercises; assessing and addressing feelings related to having diabetes; teaching the skills needed to adjust behavior;4,5,11–15,24,27,45,46 and tailoring the intervention to the age, culture, ethnicity, and health literacy of the participants.27–32,47–49 Framing information to meet patient-identified goals (e.g., have more energy, better quality of life) rather than focusing strictly on metabolic goals or risk reduction also helps to increase effectiveness. Incorporating behavioral strategies into the education process by teaching patients how to use these skills to solve problems, respond to physical and self-management challenges throughout the course of their chronic illness, and make and sustain changes in their own behaviors improves outcomes resulting from education.4,7,11,13,24,27,45–46 Training in self-directed goal-setting, problem solving, skill building, action planning, healthy coping, stress management, and self-monitoring and providing links to community resources have been used effectively in successful patient education programs.5,11,13,45–51 Some evidence indicates that using more than one of these strategies increases effectiveness.13,48–51

Psychosocial issues affect behavior and can interfere with a person’s ability to self-manage a chronic illness. Both the first and second Diabetes Attitudes, Wishes, and Needs (DAWN1 and 2) studies found that diabetes-related distress was common among people with both type 1 diabetes and T2D and that these issues interfered with their self-management efforts.52,53 In DAWN1, a large majority of the patient participants (85.2%) reported a high level of distress at the time of diagnosis, including feelings of shock, guilt, anger, anxiety, sadness, and helplessness.52 Many years after diagnosis (mean duration almost 15 years), problems of living with diabetes remained common, including fear of complications and immediate social and psychological burdens of caring for diabetes. In DAWN2, diabetes-related distress was reported by 44.6% of the participants, but only 23.7% indicated that their health-care team asked how diabetes affected their life.53 From the U.S. perspective, DAWN2 reported that psychosocial outcomes, risks, and protective factors differed across and between the ethnic groups studied and that those in ethnic minority groups reported more distress than non-Hispanic whites.54

Other studies show diabetes-related distress prevalence rates of 18–35% and an 18-month incidence of 38–48%, and that diabetes-related distress has a significant impact on A1C and other self-management behaviors.15,55–57 People with diabetes, however, also demonstrate adaptive ways of coping through a positive outlook, a sense of resilience and psychosocial support provided by family members, friends, health-care professionals, and other with diabetes.58

Assessing, acknowledging, and normalizing feelings of distress, teaching strategies for healthy coping and stress management, and exploring these feelings are strategies nurses can use to enhance self-efficacy and ultimately improve patients’ ability to manage their chronic illnesses.15,57 Addressing these issues as part of group DSME/S, in which other participants can normalize these feelings by sharing their own experiences and providing social support, is particularly useful.55,56 Because of the high prevalence of diabetes distress, this issue should be assessed and addressed as part of routine care for all patients, not only at the end of the visit if time allows or for those patients whose outcomes are poor.15 Because DAWN2 also showed that adult family members of adults with diabetes also experience distress and struggle with how to be effective supporters, they also may benefit from participating in these groups and learning coping strategies as well.59

Integrating the affective or emotional and behavioral components with clinical content increases effectiveness.4,13 For example, when teaching about SMBG, avoid asking “yes” or “no” questions and instead ask open-ended questions, which can help patients incorporate these behaviors more easily. Help the patient identify action-oriented steps by asking the following:

• How important is checking your blood glucose level for you?

• How do you use the information you get from checking your blood glucose level?

• In a typical week, about how often do you forget or decide not to check your blood glucose level?

• What are some of the reasons you miss checking your blood glucose level?

• How do others respond when you check your blood glucose in front of them?

• How would you like others to respond or show support?

• How do you feel/will you respond when a reading is higher or lower than you had hoped or anticipated?

• When will you check your blood glucose level?

• How will you check blood glucose when you are away from home?

• What would help you check your blood glucose more faithfully?

• If you are ready to create an action plan (see the box SMART Goals), which goals will be the most important for you to include?

SMART Goals

S: Specific behavior (What behavior do you want to change?)

M: Measurable (How will you know if you have achieved the goal?)

A: Achievable (Is it something you know you can do?)

R: Realistic (Is it a realistic goal for you to do?)

T: Time specific (When, specifically, will you do it?)

One strategy that has been used effectively in groups and with individuals is a question-based approach, with content presented in response to participant-identified issues.44,60–62 For example, rather than presenting a lecture on medications for diabetes, ask which medications participants are taking, ask about their experiences with their medications, and ask what questions they have. This approach is much more useful than presenting a general lecture that is not of interest to most participants. When using this approach, content is monitored and recorded to be sure that all necessary areas are addressed. This helps to ensure that participants remain engaged and actively involved in the discussion, learn from the experiences of other participants in the program, and view it as personal and relevant.62 The importance of health literacy and numeracy increasingly has been recognized as an important consideration for both DSME/S and clinical interventions. Health literacy includes the capacity to obtain and understand health information and also to use that information to make health-related decisions.63 It encompasses understanding both print and spoken language and using numbers in daily life. Individuals with low health literacy are more likely to use services inappropriately, use services less often, and have difficulty understanding and following instructions; as a result, these individuals may have worse outcomes and a shorter life expectancy.64–66 Because it is estimated that about one-third of Americans have low health literacy, it is recommended that nurses use universal precautions when providing DSME/S and use materials written at a fifth- or sixth-grade reading level. Several tools are available to screen for health literacy (see Additional Resourcesat the end of this chapter).

The following strategies address health literacy in both print and spoken instruction:

• Organize information so it is easy to understand. Set the stage by letting people know the topic and why it is important to them, provide the information in simple terms, and end with a summary or teach-back to ensure that they have understood.

• Use plain language and explain specific clinical terms both when speaking and in print.

• Use the simplest words possible of no more than two or three syllables (e.g., use get instead of develop).

• Provide personal information (e.g., What this means for you is . . .), rather than abstract factual and clinical information that you expect patients to apply to their diabetes.

• Avoid ambiguous terms (e.g., positive test results, stable results, average, frequently).

• Ask open-ended questions (e.g., “What questions do you have?” rather than “Do you have any questions?”)

Documentation

Documentation of the DSME/S assessment, plan, and actual education provided is necessary to meet quality and accreditation standards.34 The content areas presented in Table 18.4 are useful categories for documentation. The documentation can occur in the electronic medical record or through other electronic systems designed specifically for DSME/S, such as the American Diabetes Association’s Chronicle Diabetes. In addition, documentation should include information about content presented, response of the patient, problems or barriers encountered, psychosocial concerns, and patient-selected goals. The documentation should provide enough information so that others can follow- up and reinforce the content as needed and assess goal attainment. Supplying this information to the referring provider promotes a patient-centered team approach and allows additional reinforcement during patient visits. Developing a specific form that includes content areas, level of education provided, problems identified, psychosocial concerns, self-selected behavioral goals and action plans, and areas to reinforce promotes consistent documentation and education among all health-care providers. Once the education is completed, a written plan for ongoing diabetes self-management support is needed both to meet certification or accreditation standards and to ensure that this education actually occurs.34

Table 18.4—DSME Content Areas

• Describing the diabetes disease process and treatment options

• Incorporating nutritional management into lifestyle

• Incorporating physical activity into lifestyle

• Using medication(s) safely and for maximum therapeutic effectiveness

• Monitoring blood glucose and other parameters and interpreting and using the results for self-management decision-making

• Preventing, detecting, and treating acute complications

• Preventing, detecting, and treating chronic complications

• Developing personal strategies to address psychosocial issues and concerns

• Developing personal strategies to promote health and behavior change

DSME, diabetes self-management education.

Source: Reprinted with permission from Haas et al.34

Outcome Evaluation

Outcomes to be evaluated include individual patient outcomes and programmatic outcomes. Attainment of self-selected behavioral goals is a critical individual outcome to assess.34 It is more effective if this follow-up occurs in <6 months.4 Programmatic outcomes can include pre- and postmetabolic measures, screening for complications, self-management behaviors, diabetes-related distress, quality of life or other validated psychosocial measures, and patient satisfaction. Knowledge tests can help patients identify areas that need more attention, but generally they are not adequate for program evaluation.

Choose programmatic outcomes that are likely to be affected by the content and format of the DSME/S intervention. For example, if foot care is of particular relevance for the target population and emphasized throughout the program, then pre- and postassessment of foot care behaviors would be an appropriate outcome measure.

Continuous quality improvement provides ongoing monitoring and documentation and allows for adjustments and improvements on an ongoing basis.34 A DSME/S program advisory group or committee made up of key staff members, stakeholders, and patients is often a useful mechanism to ensure that this process occurs by reviewing outcomes and progress and confirming that the program is modified accordingly.

INDIVIDUAL VERSUS GROUP EDUCATION

The provision of DSME/S is a constantly changing and challenging task. Nurses often are most comfortable teaching patients individually at first, yet this approach has constraints. Nurses also can provide individual DSME or DSMS as part of care management, using electronic connections (e.g., patient portals, texts, e-mails) or the telephone and during in-person follow-up.

Time and costs are two of the more compelling considerations in determining whether to provide a group or individual DSME/S program. Considerable time is required for patients to attend such educational offerings and for nurses to set aside for the purpose of teaching, and third-party reimbursement may be lower for individual teaching.

The group setting is an effective milieu for DSME/S. Group education is effective for improving metabolic and psychosocial outcomes among people with T2D.27,67–71 Various community sites (e.g., places of worship, senior centers) can be used to increase access.72,73

Group facilitation is an important skill for nurses, and they often are encouraged by their patients, their own preferences, and their administrators to offer both individual and group teaching. Group programs and shared medical visits provide the nurse with a wider variety of experiences from which to learn and gain skills. Group sessions, like individual sessions, are based on the evidence, the nurse’s personal style and teaching preferences, the patients who are in attendance, and the time available. Skills needed for effective group facilitation include preparation (e.g., choice of teaching materials and resources), development of engaging delivery options to enhance program attendance and completion, assessment of the learners, and timely documentation.5,62 Groups also provide the opportunity for nurses to offer behavioral strategies and psychosocial support, involve the group in problem solving, and include family members and caregivers without increasing the time spent.47,60–62

Creating a group DSME/S program or shared medical visits offers the nurse opportunities to learn a variety of new teaching and facilitation skills, learn new perspectives on how to deliver the “same old information,” share team creativity, and expand the team as a coordinated working unit. Whether educating in groups or individually, the most important factor is not the setting, but the ability to provide a personal, relevant, and effective intervention; an efficient learning process; and empowerment for both the nurse and the patient.

OTHER DELIVERY METHODS

Print materials, videos, Internet- or other technology-based learning programs, and smartphone applications can be useful adjuncts to the education process. Materials are more effective when they are based on the needs of the target audience and on a formative evaluation; tailored to the age, cultural background, and preferences of the target audience;31,35,36,45,62 written at a fifth- or sixth-grade reading level; and matched to a specific interest or need. Personalizing print materials by highlighting key areas or making handwritten notes helps increase their effectiveness. Print materials can be downloaded from a variety of reputable sources, such as the Association’s website (www.diabetes.org) and the National Diabetes Education Program website (www.yourdiabetesinfo.org). Downloading and providing these materials to patients has the advantage of offering more current information than keeping a number of booklets and brochures on hand.

Viewing a video or Internet-based program or listening to an audio file generally is not effective unless a corresponding interaction engages patients by asking about their concerns or questions and helps them to identify strategies to apply the information to their own lives, situations, and treatment plans. Telephone follow-up for education, goal setting, and care management commonly is used and is effective.51,61,62,71

Use of other technologies, such as smartphone applications for diabetes prevention, weight loss, and information and behavioral tracking,74,75 shows promise in some studies but implementation and rigorous testing of these programs has not been widespread. Ask patients who have questions from online, television, or other sources to bring the material to their appointment or DSME/S session. This will help the nurse better understand their questions, determine the validity and applicability of the information, and create a teachable moment for group learning. It is helpful to teach patients strategies they can use to independently evaluate these resources.

RECOGNITION OF DSME/S

Standards for DSME/S were first developed in 1983 by key diabetes organizations, including the Association and the American Association of Diabetes Educators (AADE). These standards were revised and published in 2012 and are reviewed and revised periodically.34 The standards are based on current evidence and best practices. Ten standards address the structure, process, and outcomes of DSME/S. Nutrition education and counseling may be provided as part of the program, through a separate referral to a registered dietitian, or both.

The Association sponsors the Education Recognition Program and AADE sponsors the Diabetes Education Accreditation Program to accredit DSME/S programs that meet the national standards. DSME/S programs are required to apply and to document that they meet the established review criteria. Referring patients to recognized programs helps ensure that they receive comprehensive quality education that is likely to be reimbursed. Recognized or accredited programs can be found on the websites for both the Association and AADE. In addition to these national programs, the Indian Health Service offers certification for programs provided by that agency.

CERTIFICATION FOR DIABETES EDUCATORS

All nurses who interact with people who have diabetes are diabetes educators. Registered nurses and other health-care professionals can become certified diabetes educators (CDE) and use the designation CDE. Certification is available from the National Certification Board for Diabetes Educators (NCBDE; www.ncbde.org). Nurses who wish to become certified must meet the educational and experiential requirements of the NCBDE and pass a multidisciplinary examination. Recertification is required every 5 years through continuing education credits or by retaking the examination. Certification provides documentation that the educator is qualified to provide education but does not directly affect reimbursement for services.

Board Certified–Advanced Diabetes Management (BC-ADM) is the first advanced-practice certification offered to members of more than one discipline. Nurse practitioners, clinical nurse specialists, registered dietitians, and registered pharmacists may apply. Although BC-ADM recognizes specialization and enhances professionalism and may indirectly influence financial reimbursement, this credential is not directly related to reimbursement. More information is available on the AADE website.76

REIMBURSEMENT FOR DSME/S

Insurance coverage for DSME/S is available and mandated by most states in the U.S. This reimbursement is the direct result of significant advocacy efforts by the major diabetes organizations and the growing body of evidence supporting the effectiveness of DSME/S. Although requirements vary according to the state and the individual’s health plan, most require the Association’s recognition or AADE accreditation to ensure quality. Although coverage is not yet universal, it has become more available and accessible in recent years. Before referral, it is important for patients to check with their health insurance provider to determine the level of coverage available and the requirements for reimbursement. Most education programs also have this information available. Medicare initiated reimbursement for DSME/S in 2001. Medicare requires a physician prescription and allows for 10 h of initial group education unless the patient has special needs, such as a hearing impairment, which create an additional allowance for individual education. Of this 10 h, 1 h is set aside for the assessment, and 2 h of follow-up per year may be provided individually or in groups. Unfortunately, few patients are referred to DSME/S or take advantage of this benefit. Among newly diagnosed people with diabetes in the U.S. between 2009 and 2012, ~6.8% of privately insured, newly diagnosed adults (ages 18–64 years old) participated in DSME during the first year after diagnosis.77

SUMMARY

DSME/S is a critical element of quality diabetes care. Patients and their caregivers must have information to actively engage in their own care and to form a collaborative partnership with the health-care team. DSME/S is effective when provided by nurses using strategies and interventions that incorporate the current evidence for effective teaching and strategies to support coping and behavior change. Providing ongoing self-management support using strategies, such as goal setting and social support, helps patients maintain needed health behaviors. The national standards for DSME/S and recognition or accreditation ensure quality and support reimbursement.

The future health and outcomes of people with diabetes depend on their ability to effectively manage diabetes on a daily basis. Nurses play a key role in ensuring that patients, and those who care for and about them, recognize the importance of their role in managing their diabetes, understand the need for education, and have the requisite skills to effectively manage diabetes and other health concerns on a daily basis. Nurses need to take advantage of every encounter with patients to provide and reinforce education; offer support for behavioral and psychosocial concerns; and stress the importance of self-management for metabolic outcomes, future health, and quality of life. Additionally, nurses should provide information regarding third-party reimbursement, document the patient’s need for DSME/S, outline a plan in collaboration with the patient, and refer patients to programs that meet the national standards for DSME/S. Nurses play a pivotal role in ensuring that patients have access to these vital services.

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Additional Resources

Agency for Healthcare Research and Quality. AHRQ health literacy universal precautions toolkit. Available from www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed 4 February 2017

Center for Diabetes Translational Research. The diabetes literacy and numeracy education toolkit. Available from www.mc.vanderbilt.edu/root/vumc.php?site=CDTR&doc=37816. Accessed 4 February 2017

Funnell MM, Lasichak AJ, Arnold MS, Barr PB. Life with Diabetes: A Series of Teaching Outlines. 5th ed. Alexandria, VA, American Diabetes Association, 2014

Mensing C (Ed.). The Art and Science of Diabetes Self-Management Education—a Desk Reference. 3rd ed. Chicago, American Association of Diabetes Educators, 2014

National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes health sense. Available from www.yourdiabetesinfo.org/healthsense. Accessed 4 February 2017

Peters A, Laffel L (Eds.). The American Diabetes Association/JDRF Type 1 Diabetes Sourcebook. Alexandria, VA, American Diabetes Association, 2013

Young-Hyman D, Peyrot M. Psychosocial Care for People with Diabetes. Alexandria, VA, American Diabetes Association, 2012