Decoding Diabetes With Dr. Bob: How To Get More People Involved in Diabetes Self-Management Education and Support

To start, what exactly is diabetes self-management education and support (DSMES)? DSMES is the ongoing process of gaining the knowledge, skills, and abilities necessary for diabetes self-care. DSMES is a process guided by evidence-based standards that incorporates the needs, goals, and life experiences of each person with diabetes. 

The importance of DSMES is clear — since most people with diabetes see their endocrinologist or primary care provider only a few times a year, effective self-management between visits is essential. Daily care relies on behaviors like monitoring glucose, taking medications, eating well, and staying active.

DSMES can serve to benefit virtually all people with diabetes, from newly diagnosed individuals just learning how to use a continuous glucose monitor (CGM) to those who have had diabetes for decades and would like ongoing support (e.g., identifying new options and strategies or managing complications). Multiple studies have shown that DSMES is associated with lower A1C values, reduced all-cause mortality risk, lower healthcare costs, lower diabetes distress, and positive coping behaviors.

With such clear benefits, one would expect DSMES uptake to be high. Despite decades-long efforts to remind clinicians to refer to DSMES, rates are still low. Moreover, the ADA Standards of Care recommend DSMES at least yearly. However, only half of adults with diabetes report ever receiving diabetes education. Another study found that even among privately insured adults newly diagnosed with diabetes whose coverage is good, only about 7% participated in DSMES in their first year after diagnosis. Even in cases where DSMES is offered to people with diabetes, many programs report high no-show rates reaching 50% in many cases. Why might this be? 

Lost in communication: What’s driving under-use of DSMES?

Having led both the Joslin Diabetes Center and the ADA, I’ve spent a lot of time thinking about why DSMES use is so low. 

It’s not so much that healthcare providers are just forgetting to refer patients to DSMES. The hurdles for clinicians to refer patients to DSMES are a major issue. Many doctors I’ve spoken to do not know where to begin finding a DSMES program for their patients. Another source of friction lies in the referral forms themselves. They typically vary by DSMES group, and if DSMES is reimbursed through Medicare, the forms require specific information that providers or schedulers may not have readily available. 

Streamlining the process through “standing orders,” which automatically refer certain patients, can save time for providers and eliminate the possibility of forgetting to offer DSMES. 

One other scenario that can be improved is hospitalist referrals. In an inpatient setting, people who are newly diagnosed or new to insulin therapy are often taught relatively quickly how to self-manage their diabetes. It’s unlikely that they will remember everything, so they usually need a follow-up appointment. However, hospital clinicians sometimes are not permitted to write DSMES referrals. Instead, the patient’s primary care provider may need to be the referring clinician, which can delay care.

Billing restrictions also create logistical challenges for healthcare systems, clinicians, and patients. Current same-day billing restrictions for DSMES sometimes prevent providers from referring patients to both a diabetes care and education specialist (DCES) – a specialized healthcare expert who works with people on managing their diabetes – and a dietitian for medical nutrition therapy on the same day, often requiring an additional appointment. 

Increasing the value of DSMES

I have heard from many providers who think that DSMES doesn’t work when their patients’ A1c is still high after one or two visits. It’s important to remember that DSMES is not a quick fix – it requires ongoing engagement and support. 

Clinicians may be hesitant to refer their patients to DSMES because they do not fundamentally understand what they offer. This can lead to unrealistic expectations (e.g., hoping that a single visit will result in dramatic A1c reduction – something even I wish I could do for my patients). Many healthcare providers also do not really understand what DMSES is and reduce it to just “education” without recognizing the many ways it can help people with diabetes problem solve.

The single most effective strategy I’ve seen for this issue is to embed these educators in primary care. The power of building trusted relationships and establishing rapport is truly underrated. I have found that embedding diabetes care and education speciliasts made all the difference for a majority of patients, based on my experience in my Patient-Centered Medical Home in Pennsylvania and through the wonderful work of my friend and colleague, Linda Siminerio, who demonstrated the efficacy of this strategy through the Pittsburgh Regional Initiative for Diabetes Education (PRIDE) Network, which focused on delivering DSMES through primary care practices.

It is worth highlighting that many educators are looking for and ready to get referrals, and almost every educator I can think of who is embedded in primary care has said that once their clinicians got to know them, the referrals just started flowing in.

Additionally, there is a lot of value that comes from clinicians forming close connections with their DCES. When providers really get to know who they are working with, they don’t just say “educators are great.” Instead, they say, “Jane really knows diabetes and makes a difference with my toughest patients.” They also get more comfortable asking them questions and realize that educators often know more about diabetes than they do.

How to improve engagement with DSMES

Even in an ideal world where there are no referral challenges for DSMES programs, the challenge remains that people with diabetes need to show up to their appointments and return for follow-ups. Many DCES have cited issues with setting up follow-up appointments. 

Embedding DSMES in primary care doesn’t just help providers – it helps patients, too. Ideally, people with diabetes want help right in the clinics they are already visiting so they can see both providers on the same day without having to travel to a different office.

Some DSMES programs are also open to the public and not tied to a specific provider. This is where ADCES, ADA, and other organizations can help provide the templates and tools to support this integration moving forward.

Another way to improve patient engagement may be to offer DSMES virtually. Survey data from the ADA found that about 75% of DSMES programs offer telemedicine, and there are more and more digital health companies filling this need.

One thing I noticed at Joslin and have heard from other colleagues is that no-show rates are much lower when patients are clear on the purpose of their visit (e.g., pump initiation, pregnancy). In the same way that setting expectations is critical among clinicians, it is also important to make sure that people are going to their DSMES appointments with clear and appropriate expectations. When referrals for DSMES are described as “general diabetes education,” no-shows are high, and I (Dr. Bob) have had many of my patients say, “I have had diabetes for 20 years. I don’t need education.”

Addressing this will first require some reframing. DSMES visits need to be framed beyond “education.” Some people with diabetes may not know that these appointments can involve problem-solving and – with standing orders in place – even medication adjustment.

I also have playfully challenged my patients to give DSMES a try and come back and tell me if they learned nothing. So far, all of my patients have gained something from DSMES. And even if they really did know all about diabetes already, they received ongoing support and encouragement, which is invaluable.

Making learning more patient-driven

One issue I often hear about and have seen for myself is that some DSMES programs are too academic (think long slide decks where patients sit and listen the entire time). 

We believe learning should be driven by the individual. Letting people decide what they want to learn also increases perceived value. One resource that can be used is a conversation map (see below), which allows people to see and choose from various topics. This has been demonstrated to be quite impactful and appears to be making a comeback with an extension to obesity through Healthy Interactions.

Concluding thoughts

At the end of the day, solving the problem that only a minority of people with diabetes receive evidence-based recommended DSMES involves addressing referral challenges among healthcare providers, reducing friction, and reshaping perceived value through strategies such as embedding educators in primary care, protocolizing referrals, and setting clear expectations. 

We truly believe that embedding more DCES where the overwhelming majority of people with diabetes receive their care (primary care offices) is going to be key. There is also a call to action for leaders at the ADA, ADCES, and CDC to continue to come together and tackle these challenges as a united front. This is how we can ensure that more people with diabetes can benefit from this proven intervention.

The information and insights in this column are adapted from an original Closer Look column, published by Close Concerns. Written by Dr. Bob and Elaine Young, this column was originally designed for clinicians, researchers, and professionals working in diabetes and obesity care and has been adapted for diaTribe audiences.

Read more installments of Decoding Diabetes With Dr. Bob here:

• Diabetes and Mental Health
• Automated Insulin Delivery
• The GLP-1 Revolution
• Automated Insulin Delivery
• Diabetes in the Digital Era