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Diabetes Self-Management Education and Support

Diabetes Self-Management Education and Support

Introduction

Defining diabetes - self management education and support (DSME & DSMS)

Role of the diabetes educator

Specific components of DSME/S

Duration of sessions

Methods towards effective DSME/S

Essential components of DSME

Efficacy of DSME

The role of technology in DSME/S

Remuneration and reimbursement for DSME

(See Strength of Recommendations Taxonomy (SORT) for explanation of Grade A-C)

 

SEMDSA 2017 Recommendations  
People living with diabetes should be offered structured diabetes education at diagnosis and this should be consolidated at regular intervals B
Diabetes self-management education and support (DSME/S) should be patient-centred, respectful and receptive to individual needs and values; and non-discriminatory towards cultural, ethnic language, socio-economic and educational differences B
DSME/S should incorporate cognitive-behavioural interventions, the practical application of knowledge and aim to increase patient participation in decision making B
DSME/S should be managed by accredited health care professionals who have been appropriately trained in the execution of evidence-based principles B
Trained community health workers should provide education through home visits, create awareness and encourage adherence C
SEMDSA recommends that DSME, provided by health professionals in a format endorsed by SEMDSA and DESSA, should be reimbursed according to NHRPL guidelines C


INTRODUCTION

Diabetes is a heterogenous condition and adequate management thereof requires input from various role players. It requires continuous support from a multidisciplinary team of health care providers (HCP) and constant effort in assisting people living with diabetes to make the right choices around food, medication, and exercise.1 People living with diabetes, their caregivers and families should be skilled in numerous self-management activities in order to manage this effectively.1 The ultimate goal is to empower people living with diabetes to be more engaged and informed about the condition. It is crucial for successful self-management of diabetes to ensure that treatment and quality of life goals are achieved.1 DSME has been shown to improve glycaemic control which is one of the strongest predictors of disease progression and the development of diabetes complications.2,3 It is the educator’s role to assist with this endeavour and make it as trouble-free as possible.

The words of Elliot P. Joslin still holds true: “The person with diabetes who knows the most lives the longest.”4

DEFINING DIABETES-SELF MANAGEMENT EDUCATION & SUPPORT (DSME & DSMS)

DSME is the ongoing process of facilitating knowledge, skill, ability and motivation for diabetes self-care that involves active participation of the people living with diabetes. It integrates the needs, goals and life experiences of the people and is grounded on evidence-based principles. DSME is not a once-off event but a lifelong necessity starting at diagnosis.1,5 DSME/S is one of the core elements of the Care Model that is advocated for people living with a chronic condition. DSME content should be patient centred, considerate of cultural background and practices, tradition, religion, literacy levels and family values, as all of these factors impact on the motivation for learning.6,7,8 Four crucial time points where DSME is advocated: at diagnosis, annually, when new complicating factors e.g. pregnancy arise, and when transition into different life stage occurs.1 Diabetes education algorithms defining these four time points and including the topics that need coverage are available at http://professional.diabetes.org/.

ROLE OF THE DIABETES EDUCATOR

The joint position statement on DSME of the Diabetes, Diabetes Educators and the Academy of Nutrition and Dietetics of America advocate that the person responsible for providing the DSME should be a health professional (e.g. nurse, dietician or pharmacist) who is trained by means of an accredited programme. The Diabetes Educator (DE) should meet specific competency and ongoing education requirements.1,6 The DE should have good interpersonal skills and must prioritise motivational interview techniques to cultivate patient commitment and participation.21The primary DE may support and educate other health carers such as community health workers, peers and family-members with DSME/S. Diabetes self-management and education by trained health care workers are equally effective in improving glycaemic control, self-care activities and quality of life.2,9,10,11,12

SPECIFIC COMPONENTS OF DSME/S

Duration of sessions

Better outcomes are directly linked to the amount of time spent on education.1 In a South-African community based programme a 5% weight loss and 1% reduction in HbA1C was achieved after just four (4) education sessions of 20-60 minutes each.13

Methods towards effective DSME/S

The person living with diabetes (and family members) should be the centre of the care model encouraging active partnership with health care professionals and all decision making must be guided by the values of the person with diabetes.14 Interactive interventions such as cognitive behavioural techniques, joint decision making, problem solving skills and the generation of action plans towards realistic patient-chosen goals should be fostered. The identification and addressing of barriers to self-care are just some of the steps to successful DSME.1,15 Table I gives examples of questions to ensure a patient centred approach.

Table I. Examples of questions to ensure a patient centred approach 15

How is diabetes affecting your daily life and that of your family?
What questions do you have?
What about your diabetes is the hardest part right now, or causing you the most concern, or is the most worrisome to you?
How can we best help you?
What is one thing you are doing or can do to better manage your diabetes?


Essential components of DSME

Successful diabetes care includes a systematic approach with adequate coverage of the essential components of DSME as summarised by the ADA’s standards of medical care 2017. Refer to Table II.

Table II :  Components of DSME as per ADA standards of medical care

Healthy lifestyle choices (healthy eating, physical activity, tobacco cessation, weight management, and effective strategies for coping with stress)
Disease self-management (taking and managing medications and, when clinically appropriate, self-monitoring of glucose and blood pressure)
Prevention of diabetes complications (self-monitoring of foot health; active participation in screening for eye, foot, and renal complications; and immunisations)
Identification of self-management problems and development of strategies to solve those problems, including self-selected behavioural goal setting


EFFICACY OF DSME

DSME improves haemoglobin A1c (A1c) by up to 1%.1,2 It is proven to be cost-effective due to the reduction in hospital admissions and lifetime cost of diabetes complications.16,17,18,19 A summary of the clinical, behavioural and psychological areas of diabetes that are positively impacted on are listed in Table III.1,5,14

THE ROLE OF TECHNOLOGY IN DSME/S

The internet, web-based education, cell phones, emails, automatic reminders and telephonic education are effective and efficient ways of providing DSME.5,20 These modalities provide away to overcome barriers such as distance as well as the resource limitations in terms of sufficient certified DE’s.20

Table III: Benefits of DSME

Improved glycaemic control
Reduction in total health care cost
Enhancing knowledge
Self-care behaviour and self-efficacy enhanced
Likelihood of lifestyle adherence and weight maintenance
Risk identification of cardiovascular events and risk factors
Improves quality of life and healthy coping


REMUNERATION & REIMBURSEMENT FOR DSME

Healthcare professionals who provide structured DSME in a format approved by DESSA and SEMDSA must be reimbursed by third-party payers as it is a core component of diabetes management, and has the potential to improve outcomes and reduce costs.14 Reimbursement should follow recommendations as per NHRPL guidelines and should be updated annually.

Conclusion

Adequate and ongoing DSME is an integral component of diabetes care. It should use evidence-based strategies and promote the practical application of knowledge.

Authors: Razana Allie, Hamish van Wyk, Ankia Coetzee and Lourentia van Wyk.
Editors: Zaheer Bayat and Aslam Amod.

References

  1. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, Maryniuk MD, Siminerio L, Vivian E. Diabetes self-management education and support in type2 diabetes a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator. 2015 Aug 1;41(4):417-30.
  2. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient education and counseling. 2016 Jun 30;99(6):926-43.
  3. Pani LN, Nathan DM, Grant RW. Clinical predictors of disease progression and medication initiation in untreated patients with type 2 diabetes and A1C less than 7%. Diabetes Care. 2008 Mar 1;31(3):386-90.
  4. Levetan C. Adding a daily dosage of diabetes wisdom to your prescription.Diabetes Spectrum. 2001 Aug 1;14(3):163-7.
  5. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee.Canadian Diabetes Association 2013 Clinical Practice Guidelines for thePrevention and Management of Diabetes in Canada. Self-ManagementEducation. Canadian Journal of Diabetes 2013;37 (suppl 1):S26-S30
  6. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, Fisher E, Hanson L, KentD, Kolb L, McLaughlin S. National standards for diabetes self-management education and support. The Diabetes Educator. 2012 Sep; 38 (5):619-29.
  7. American Diabetes Association. 1. Promoting Health and Reducing Disparities inPopulations. Diabetes Care. 2017 Jan 1;40 (Supplement 1):S6-10.
  8. American Association of Diabetes Educators. AADE guidelines for the practice of diabetes self-management education and training (DSME/T). The DiabetesEducator. 2009 Nov 1;35 (3 suppl):85S-107S.
  9. Lorig K, Ritter PL, Villa F, Piette JD. Spanish diabetes self\-management with and without automated telephone reinforcement. Diabetes Care. 2008 Mar1;31(3):408-14.
  10. Lorig K, Ritter PL, Villa FJ, Armas J. Community-based peer-led diabetes self-management a randomized trial. The Diabetes Educator. 2009 Jul1;35(4):641-51.
  11. Smith SM, Paul G, Kelly A, Whitford DL, O’Shea E, O’Dowd T. Peer support for patients with type 2 diabetes: cluster randomised controlled trial. Bmj. 2011 Feb15;342:d715.
  12. Babamoto KS, Sey KA, Camilleri AJ, Karlan VJ, Catalasan J, Morisky DE. Improving diabetes care and health measures among hispanics using community health workers: results from a randomized controlled trial. Health Education & Behavior. 2009 Feb;36(1):113-26.
  13. Mash B, Levitt N, Steyn K, Zwarenstein M, Rollnick S. Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial. BMC family practice. 2012 Dec24;13(1):126.
  14. American Diabetes Association. 4. Lifestyle Management. Diabetes Care. 2017Jan 1;40 (Supplement 1):S33-43.
  15. Funnell MM, Bootle S, Stuckey HL. The diabetes attitudes, wishes and needs second study. Clinical Diabetes. 2015;33:32-36.
  16. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes care. 2013 Oct 1;36(10):2960-7.
  17. Duncan I, Ahmed T, Li QE, Stetson B, Ruggiero L, Burton K, Rosenthal D, Fitzner K.Assessing the value of the diabetes educator. The Diabetes Educator. 2011 Sep1;37(5):638-57.
  18. Robbins JM, Thatcher GE, Webb DA, Valdmanis VG. Nutritionist visits, diabetes classes, and hospitalization rates and charges. Diabetes care. 2008 Apr1;31(4):655-60.
  19. Brown HS, Wilson KJ, Pagán JA, Arcari CM, Martinez M, Smith K, Reininger B.Cost-effectiveness analysis of a community health worker intervention for low-income Hispanic adults with diabetes. Prev Chronic Dis. 2012 Aug 1;9:E140.
  20. Pereira K, Phillips B, Johnson C, Vorderstrasse A. Internet delivered diabetes self-management education: a review. Diabetes technology & therapeutics. 2015 Jan 1;17(1):55-63.
  21. Dudley JD. The diabetes educator’s role in teaching the diabetic patient.Diabetes Care. 1980 Jan 1;3(1):127-33.
NeoHealth® ID 18734 · updated 10/26/2021