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MODULE 12. ADA and AADE Diabetes Programs in the Community Pharmacy Setting: Basic Concepts for Pharmacists

INTRODUCTION

Diabetes is a complex, multi-organ chronic disease that requires continuous medical care and education. It is imperative for health care professionals (HCPs) to understand that risk-reduction strategies associated with diabetes go well beyond glycemic control. Continuous diabetes self-management education and support (DSMES) are necessary for the prevention and/or delay of acute and chronic complications associated with diabetes.1,2 Each January the American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes, 1 which has been referred to as the Go-To reference guide for HCPs who practice in and care for people with diabetes. It provides clinicians, patients, researchers, and payers with the components of diabetes care, general treatment goals, and tools to evaluate quality of care. Although the clinical management of the patient is most commonly reviewed and referenced, diabetes self-management education and support (DSMES) remains the cornerstone of therapy.1,2 Keep in mind that the patient’s self-management does not stop after the health care visit, but is an ongoing, lifetime process. Clinicians must realize that patients spend less than 5% of their lives in medical offices/clinics/pharmacies. Therefore, the majority of time patients spend managing their diabetes is done on their own.2

A key element of the Standards of Medical Care in Diabetes supports patient referral to a DSMES program to facilitate the knowledge, skills, and ability necessary for diabetes self-care.1 Two main accrediting bodies for DSMES programs are the ADA and the American Association of Diabetes Educators (AADE).3,4 Historically, most accredited/recognized programs were located in institutional health systems and individual physician’s offices. Over the past 2 decades, however, there has been an increase in the number of independent and chain community pharmacies that have established ADA- or AADE-accredited/recognized DSMES programs. Per the ADA, current research supports nurses, dietitians, and pharmacists as providers of DSMES who may also develop curriculum.1,5

As the role of the pharmacist continues to evolve and expand, focusing on team-based, patient-centered care, community pharmacies strive to obtain accreditation/recognition for DMSES programs. This allows pharmacists to practice at the top of their training, providing optimal therapeutic and self-management for patients with diabetes in an accessible, convenient location. In addition, accredited/recognized programs will allow the pharmacy to bill for reimbursement of DSMES services.3,4

DSMES

There are several terms that are commonly used in the literature to describe diabetes self-management, including education, training, and/or support. In this article, the term diabetes self-management education/support or, more likely, DSMES will be used because it is the most current representation of the patient-centered process accepted by experts in the field.

By definition, DSMES is an evidence-based intervention that facilitates the knowledge, skills, and ability necessary for people with prediabetes or diabetes to optimize their self-management of diabetes and its related conditions.1,2 This process incorporates patients’ individual needs, goals, and life experiences. The overall objectives of DSMES are to assist patients so they are able to make informed decisions and incorporate self-care behaviors, as well as adopt problem-solving skills through active collaboration with their health care team to improve clinical outcomes, health status, and quality of life.6 This includes activities that assist the person with prediabetes or diabetes in implementing and sustaining the health behaviors needed to manage his or her condition on an ongoing (lifetime) basis beyond and outside of formal training and classes.1,7

DSMES is a critical element of care for people with prediabetes or diabetes. It is necessary to prevent or delay the complications related to diabetes and has elements related to lifestyle changes that are also essential for those with prediabetes as part of the effort to prevent the progression to diabetes. The National Standards for Diabetes Self-Management Education and Support are designed to define quality DSMES and assist HCPs with providing evidence-based education and self-management support.2

These standards are applicable to educators/instructors in various practice settings, including community pharmacies, and are used for programs seeking accreditation/recognition. The standards also serve as a guide for non-accredited/recognized programs.

There are 10 standards for DSMES programs and this model will help guide interested HCPs and health care systems when envisioning, developing, implementing, and monitoring their programs.

STANDARD 1: INTERNAL STRUCTURE

One of the first steps in establishing a DSMES program is to develop an organizational structure, mission statement, and program goals that support effective provision of DSMES. The 2017 National Standards state that defined leadership is required to remove any service-related obstacles and to find resources to advance DSMES services. 2

STANDARD 2: STAKEHOLDER INPUT

In an effort to provide quality assurance, DSMES programs are required to seek ongoing input from valued stakeholders and experts to promote quality and enhance participant utilization.2 The goal is to gather information from stakeholders and foster ideas that will improve the utilization, quality, outcomes, and sustainability of the DSMES services provided.2 The advisory board is the ideal resource for ensuring program effectiveness and excellence. Social determinants related to the population that will be served by the program should guide stakeholder selection. Involving such individuals on the team can help facilitate connection of potential participants with DSMES services. 8,9

STANDARD 3: EVALUATION OF POPULATION SERVED

Knowledge of the population that the program will serve and the best format for delivery are essential to the curriculum’s success. Many people with prediabetes or diabetes do not even realize there are structured educational programs available to help them with the management of their diabetes.10 In addition, access to these programs can be challenging for many people.11-13 Considerations in program design must include the populations’ demographics, such as ethnic/cultural background, sex, age, level of formal education, health literacy, and health numeracy.14

Patients commonly experience lengthy wait times (e.g., more than 3 months) when attempting to secure an open seat in an outpatient health-system program. This consideration has led many patients to neglect or forget to enroll, thereby never receiving any structured guidance in the self-management of their disease. Pharmacies are an ideal venue to help close this gap and well-established DSMES programs can offer group and individual visits to meet the needs of patients. Easy access to a pharmacist in-between scheduled DSMES appointments can allow for optimal continuity of care. Pharmacy programs should have a referral list of other HCPs or resources readily available for patients in need. This list may include dietitians, primary care providers, endocrinologists, podiatrists, ophthalmologists, retina specialists, dentists, behavioral and mental health specialists, physical therapists, etc.

STANDARD 4: QUALITY COORDINATOR OVERSEEING DSMES SERVICES

Every DSMES program must have a coordinator overseeing the program.2 The quality coordinator is responsible for all components of DSMES, including evidence-based practice, service design, evaluation, and continuous quality improvement. 2 As diabetes education and care evolve, the quality coordinator ensures that the program adapts to change, and is thus charged with collecting and evaluating data to identify gaps in DSMES and provide feedback on the performance of DSMES services to team members, referring practitioners, and the organization.2 Theoretically, the coordinator should be an expert in the field of diabetes and its related conditions, and will need to have an understanding of the process of identifying, analyzing, and communicating quality data. Though it is not mandatory, the coordinator may often be a Certified Diabetes Educator (CDE) or board certified in advanced diabetes management (BC-ADM). In many pharmacy programs, the coordinator also serves on the advisory board and as the DSMES provider/educator at one or more community pharmacy locations within the company.

STANDARD 5: DSMES TEAM

Per the 2017 National Standards, “at least one of the team members responsible for facilitating DSMES services will be a registered nurse, registered dietitian nutritionist, or pharmacist with training and experience pertinent to DSMES or be another health care professional holding certifications as a diabetes educator (CDE) or Board Certification in Advanced Diabetes Management (BC-ADM).”2 In addition, other health care workers or professionals can also contribute to the DSMES program provided they receive appropriate training in DSMES and have oversight and support from an individual meeting the requirements noted above. For example, a pharmacy technician may assist with scheduling patient appointments, blood-glucose-monitor training, and billing for services.

In an ideal program, the instructional staff is an inter-professional team, which includes a pharmacist, a nurse, and a dietitian, at a minimum.3,4 In many programs, though, especially those that are pharmacy-based, the team is small and may only have 1 or 2 HCP educators/instructors.15 

Literature supports the inter-professional team approach, with pharmacists, nurses, and dietitians collaboratively designing the curricula to be used as well as offering education and care for patients.2,16 The expert consensus also supports postgraduate training in diabetes for HCPs entering this field.16,17 Many HCP college/school curricula provide basic knowledge and training in diabetes, which is insufficient for DSMES programs. But this additive training is essential for the delivery of a quality program, with certification being a method that can assist pharmacists in demonstrating their mastery of the disease. The National Certification Board of Diabetes Educators (NCBDE) oversees the process for CDEs whereas the AADE furnishes the BC-ADM examination.2 Pharmacists – as well as other HCPs – are eligible for both credentials, although they appear to be underutilized in the field of diabetes, accounting for less than 10% of CDEs in the United States. It is not mandatory for pharmacists to be certified to be employed as educators/instructors in DSMES programs. However, these pharmacists have to complete postgraduate training in diabetes education and care, such as an intensive continuing education program to advance their knowledge and skills.

STANDARD 6: CURRICULUM

The DSMES curriculum should all be current and reflect evidence-based guidelines, with criteria for evaluating outcomes. 2 Also, the curricula should be tailored to the needs of each patient being educated individually. The Standards recommend the inclusion of practical problem solving approaches within the program that address psychosocial issues, behavior change, and strategies to sustain self-management efforts. 2

Over the years, several standardized curricula have been developed and published and are available to purchase for DSMES programs. However, some DSMES program teams prefer to create their own curriculum. In either case, the curriculum should include key courses with specific learning objectives that utilize effective teaching strategies.18 The following core content areas have demonstrated successful outcomes and must be reviewed to determine which are applicable to each participant: 2

  • diabetes pathophysiology and treatment options
  • healthy eating
  • physical activity
  • medication usage
  • monitoring and using patient-generated health data (PGHD)
  • preventing, detecting, and treating acute and chronic complications
  • healthy coping with psychosocial issues and concerns
  • problem solving

In addition to the core curriculum, many programs will add topics to enhance the personalized approach to patient care and education. The Standards recommend that participants also be educated about navigating the health care system, learning self-advocacy, and receive e-health education. 2 In all cases, the topics and teaching steps should be tailored to the individual patient, inclusive of age, type of diabetes, cultural factors, and health literacy/numeracy. Many community pharmacy DSMES programs will have educational materials available for patients outside the formal sessions. For example, if a patient enrolled in the pharmacy DSMES program is picking up a prescription for a skin irritation, the DSMES pharmacist educator/instructor may provide verbal and written education regarding diabetes and skin care during that point-of-care consultation.

STANDARD 7: INDIVIDUALIZATION

Individualized treatment and self-management plans are necessary for optimal health and wellness outcomes. For most people with diabetes, health behavioral change is essential to self-management.19 There is no one-size-fits-all approach to managing diabetes. The AADE developed 7 self-care behaviors known as the AADE7, which are recognized as guiding principles for DSMES program participants.20 These include the following:

  • Healthy eating
  • Being active
  • Monitoring
  • Taking medication
  • Problem solving
  • Healthy coping
  • Reducing risk

DSMES program educators/instructors must work with each patient on an individualized basis to create an education and support plan that is specialized for that person. While individualized, it is important to note that DSMES can be provided in both individual and group settings. The plan should include health behavioral changes that the patient has identified as important to him or her and are ready (motivated) to be set in motion.17-19 Pharmacists should embrace motivational interviewing skills and techniques to help assess patients’ readiness for change, identify potential barriers, and develop an approach to overcome obstructions and/or ambivalence. The key is for patients to problem-solve themselves and create their own behavioral change plans that will fit into their daily lives.

Successful health behavioral change will require monitoring along with follow up visits.2,21 This will allow educators/instructors to reassess their patients’ progress and work with them to adopt other interventions, if needed. With the technologic advancements, pharmacists have the ability to follow up with patients through a variety of modalities, such as telephone appointments, web-based sessions, and text messaging as well as the traditional, face-to-face (in-person) appointments.21,22

All assessment, educational, and interventional plans must be documented in the patients’ health records to allow for optimal follow-up, especially between multiple instructors or locations. For example, if a patient is enrolled in a DSMES program at a pharmacy that offers education at 2 different locations and the patient attends individual or group sessions at both places, all educators/instructors are required to thoroughly document patient assessment, planning, and progress. Providing documentation of the patients’ plan and progress to other health care team members is also warranted, thereby allowing for the entire medical team to be on the same page in offering collaborative support for the patient.

STANDARD 8: ONGOING SUPPORT

The key to a successful and personalized diabetes education and care plan is ongoing support. Ongoing support is defined within the Standards as “resources that help the participant implement and sustain the ongoing skills, knowledge, and behavior changes needed to manage their condition.”2 Although patients do not spend an extensive amount of time with their health care team, it is important for these individuals to understand that their team is highly supportive and willing to work with them in managing their diabetes in the long-term. Therefore, consistent, frequent communication among the team’s members and the patient is necessary to achieve the best possible health outcomes.23

Recent studies suggest that most patients’ initial health and behavioral improvements begin to diminish after 6 months.3 For that reason, long-term strategies are necessary and DSMES programs have to furnish education and care well beyond the initial training sessions. Over time, the type of DSMES may change, so programs should include behavioral, educational, psychosocial, and clinical services to address the individual’s evolving needs.18 Pharmacists are a unique community-based resource for patients to utilize for continued care and support.

STANDARD 9: PARTICIPANT PROGRESS

Monitoring progress to assess whether participants are achieving their personal self-management goals and meeting clinical and other health outcomes is a critical method of evaluating the DSMES programs’ usefulness and efficacy. Differences in behaviors, health beliefs, culture, and emotional responses can impact how patients perceive, understand, and engage in self-managing their diabetes.2 Therefore, the time needed to achieve personal goals will vary from patient to patient. Importantly, DSMES providers should utilize and rely on behavior change goal-setting strategies to help participants realize and meet their personal targets.24 Follow-up intervals and teaching/learning strategies must be adapted to account for these differences. It is common that frequent follow-ups and shorter time intervals between visits are required in the beginning of diabetes education and care, but the intervals may lengthen as the patient becomes more confident and achieves his or her personal and clinical goals.2 Although third-party payment structures may govern the frequency of DSMES visits, community pharmacists are uniquely positioned to assist patients who are between formal sessions because of their accessibility, especially if patients use the DSMES pharmacy for their prescriptions or other services as well.

STANDARD 10: QUALITY IMPROVEMENT

The DSMES program quality coordinator will routinely measure the impact and effectiveness of the DSMES services and identify areas for improvement by conducting a systematic evaluation of process and outcome data.2 The program must also adapt to advances in knowledge, education, and care along with trends in the changing health care environment.2,25 The Institute for Healthcare Improvement suggests the following 3 key questions to guide improvement26:

  • What are we trying to accomplish?
  • How will we know a change is an improvement?
  • What changes can we make that will result in an improvement?

Many programs will develop their own quality improvement assessment tool, such as patient surveys, prescriber questionnaires, and educator/instructor performance evaluations.

Once the areas for improvement have been identified, a reasonable and measurable timeline for implementation should be documented and followed to the finish line.

STANDARDS OF MEDICAL CARE IN DIABETES RECOMMENDATIONS FOR DSMES

The 2019 Standards of Medical Care in Diabetes includes recommendations and discussion regarding the importance of DSME within several sections of the document. 1 Topics include, but are not limited to, DSMES, nutrition, physical activity, smoking cessation, immunizations, psychosocial care, and medication management.1 A referral by prescribers to DSMES services is highly suggested and necessary for programs to bill for services. The 2019 Standards of Medical Care in Diabetes recommendations regarding DSMES include1:

  • “In accordance with the national standards for diabetes self-management education and support, all people with diabetes should participate in diabetes self-management education to facilitate the knowledge, skill, and ability necessary for diabetes self-care. Diabetes self-management support is additionally recommended to assist with implementing and sustaining skills and behaviors needed for ongoing self-management.”
  • “There are four critical times to evaluate the need for diabetes self-management education and support: at diagnosis, annually, when complicating factors arise, and when transitions in care occur.”
  • “Clinical outcomes, health status, and quality of life are key goals of diabetes self-management education and support that should be measured as part of routine care.”
  • “Diabetes self-management education and support should be patient-centered, may be given in group or individual settings or using technology, and should be communicated with the entire diabetes care team.”
  • “Because diabetes self-management education and support can improve outcomes and reduce costs, adequate reimbursement by third-party payers is recommended.”

THE CHRONIC CARE MODEL

Over the past few decades, diabetes care has evolved from provider-driven management to a team-based approach, with the patient as the team’s most significant member. With the infusion of the Chronic Care Model (CCM), a more patient-engaged focus supports the framework for improving the quality of diabetes care.28 As the pharmacist’s role expands to include more direct patient care responsibilities, pharmacists have to be aware of their roles within the CCM and how they will interface with community pharmacy DSMES programs. There are 6 core elements of the CCM, which include21,27:

  1. Delivery system design.
    This is a proactive, chronic-care (as opposed to reactive, acute care), team-based avenue to health care. Health, wellness, and prevention services can help reduce such chronic diseases as diabetes and their related conditions and complications.
  2. Self-management support system.
    As mentioned earlier, patients spend minimal time with their health care team during the overall life span. By including the patient (and his or her family and/or caregivers) in the therapy-plan decision-making process, that individual takes an active role in his or her health and well-being, thereby resulting in greater adherence and improved long-term outcomes.
  3. Decision support.
    Treatment and care plans have to be developed and implemented using current evidence-based, effective-care guidelines.
  4. Clinical-information systems.
    Through the use of registries or electronic medical records, HCPs can identify people at risk and implement prevention, health, and wellness pathways that provide population-specific and patient-specific support.
  5. Community resources and policies.
    Partnerships within and outside the health care system allow for greater outreach to all communities, including those at high risk for suboptimal health and disease. Implementation of awareness, education, and prevention programs as well as access to care and support can improve healthy lifestyles and effectively prevent or reduce chronic diseases/conditions.
  6. Health care systems.
    Proper and appropriate use of coordinated team-based care through a quality-oriented culture can improve overall health care and lessen costs.

Redefining the roles of the health care delivery team and promoting self-management on the patient’s part are fundamental to successful implementation of the CCM. Collaborative inter-professional teams are best suited to provide care for people with chronic diseases/conditions and to facilitate their self-management.21,28 The foundation of successful diabetes management includes ongoing (long-term) individualized lifestyle and behavioral changes, patient commitment, assessment of the person’s level of understanding about the disease, and his or her level of preparedness for self-management.

ACCREDITATION/RECOGNITION

As previously mentioned, the AADE and ADA are 2 main accrediting organizations for DSMES programs. The Centers for Medicare and Medicaid (CMS) will provide reimbursement to DSMES programs for Medicare beneficiaries under certain conditions.29 In addition, many other health insurers cover and reimburse accredited/recognized programs as well, so pharmacists have to know that this payment is fee for service and not affiliated with prescription coverage, which is separate and distinct. Often, patients will have their prescriptions filled at a different pharmacy from where they receive their DSMES service because of third-party-plan dictates. However, patients can choose their DSMES program provider granted the patient has a prescriber referral.

CMS benefits cover29:

  • Up to 10 hours of diabetes-related education/training within a consecutive 12-month period following the submission of the first claim for the benefit. This includes 1 hour for either group or individual sessions and/or 9 hours for group-only sessions.
    • All 10 hours can be provided individually if the following conditions are met:
      • No group class is available for two months or longer from the date on the referral
      • The referring provider indicates on the referral that the beneficiary has one or more barriers to group learning; examples are: reduced vision, reduced hearing, reduced cognition, language barrier, non-ambulatory
      • The referring provider indicates on the referral that the beneficiary needs additional insulin training
  • Up to 2 hours of follow-up sessions each year after the initial 12-month cycle.
  • The sessions may be completed in increments of no less than 30-minutes.

The following are considered approved places of service for DSMES services29:

  • Hospital outpatient department
  • Critical access hospital
  • Private physician practice
  • Registered dietitian (RD) practice
  • Independent clinic
  • Federally qualified health center (FQHC)
  • Rural health clinic (RHC)
  • Home health agency
  • Skilled nursing facility (SNF)
  • Pharmacy
  • Durable medical equipment (DME) company

Pharmacies that have multiple stores providing DSMES services would receive a CMS provider number for each individual site, with reimbursement going to that facility.

The process for obtaining accreditation from the ADA or the AADE is similar, but there are several notable variations. The titles for the programs are the Education Recognition Program (ERP – 10th ed.) for the ADA and the Diabetes Education Accreditation Program (DEAP) for the AADE. Both accreditation organizations use the National Standards for Diabetes Self-Management Education 2017 as their source for guiding standards.3,4 Please refer to the website for each program to access the most current information about application processes and fees. 3,4 

ADA Education Recognition Program: https://professional.diabetes.org/diabetes-education

AADE Diabetes Education Accreditation Program (DEAP): https://www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap)

Once a pharmacy program achieves recognition, the certificate of accreditation/recognition and the National Provider Identification (NPI) must be submitted to the local CMS provider enrollment department. Once received and processed, the pharmacy is officially recognized by the CMS for DSMES program services under Medicare Part B. If the pharmacy already has an NPI for Part D, a different form (CMS-855B) is required for submission to become a Part B provider.

Prescribers must refer patients for DSMES. Therefore, the community pharmacy program must receive a referral from the prescriber for the patient to submit a third-party claim for reimbursement. The pharmacy program, however, can also accept self-payment directly from patients who do not have a referral. To generate DSMES business, the pharmacy and/or pharmacists have to market their services to local physicians and nonphysician prescribers so patients can be referred to the pharmacy program. Pharmacists may schedule appointments with prescribers and their staff for the sole purpose of informing them of the pharmacy DSMES program. Providing an information packet inclusive of the pharmacy services offered and sample referral forms can be beneficial and increase referrals. The referral order must include the following:29

  • a statement of need for DSMES for a patient with a diagnosis of prediabetes or diabetes
  • a plan of care and length of time that DSMES services are required
  • expected health outcomes
  • barriers that would require individual (as opposed to group) sessions
  • the signature of the treating prescriber

DSMES teams should refer to current Healthcare Common Procedure Coding System (HCPCS) information when billing for services.

STAR RATINGS

As the United States health care system evolves, there is a move toward rewarding positive outcomes while reducing or eliminating unnecessary services. Implementing strategies to measure costs associated with quality outcomes such as patient health and wellness are being utilized through various quality metrics systems. The score then states the amount reimbursed to the health plan providers, health systems, and other HCPs and health-related programs, including pharmacists and pharmacies. The CMS’s goal is to provide services that achieve consensus-based performance measures at an affordable cost.30 For an in-depth review of star ratings and how they may impact your DSMES program, please review the module on MTM Star Ratings within this series.

CONCLUSION

The role of the community pharmacist is moving toward a greater focus on patient-centered education and care. Given the significant societal burden imposed by diabetes, pharmacists have to take action in educating and supporting patients with the self-management of their disease. Instruction and patient care in diabetes are essential to improve disease outcomes and decrease complications. Studies on pharmacist-implemented diabetes programs have shown a positive effect on clinical, humanistic, and economic outcomes. Community pharmacists are uniquely positioned to develop and implement DSMES programs, allowing for improved access to care, delivering optimal patient treatment, taking an active role on the health care team, and performing competently at the level for which they have been trained.

REFERENCES

  1. American Diabetes Association. Standards of medical care in diabetes–2019. Diabetes Care. 2019;42(Suppl. 1):S1-S193.
  2. Beck J, Greenwood DA, Blanton L, et al. 2017 national standards for diabetes self-management education and support. Diabetes Educ. 2017;43(5):449-464.
  3. American Diabetes Association Education Recognition Program. 10th ed. www.professional.diabetes.org/diabetes-education. Accessed April 14, 2019.
  4. American Association of Diabetes Educators. DEAP (Diabetes Education Accreditation Program) FAQs. www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap). Accessed April 14, 2019.
  5. van Eikenhorst L, Taxis K, van Dijk L, de Gier H. Pharmacist-led self-management interventions to improve diabetes outcomes. A systematic literature review and meta-analysis. Front Pharmacol. 2017;8:891.
  6. Cochran J, Conn VS. Meta-analysis of quality of life outcomes following diabetes self-management training. Diabetes Educ.2008;34(5):815-823.
  7. Ratner RE; Diabetes Prevention Program Research. An update on the Diabetes Prevention Program. Endocr Pract. 2006;12(Suppl 1):20-24.
  8. Lawn S, Battersby M, Lindner H, et al. What skills do primary health care professionals need to provide effective self-management support? Seeking consumer perspectives. Aust J Prim Health. 2009;15(1):37.
  9. Garg A, Boynton-Jarrett R, Dworkin P. Avoiding the unintended consequences of screening for social determinants of health. JAMA. 2016;316(8):813-814.
  10. Siminerio LM, Piatt GA, Emerson S, et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ.2006;32(2):253-260.
  11. Boren S, Fitzner K, Panhalkar P, Specker J. Costs and benefits associated with diabetes education: a review of the literature. Diabetes Educ. 2009;35(1):72-96.
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  13. Rutledge S, Masalovich S, Blacher R, Saunders M. Diabetes self-management education programs in nonmetropolitan counties – United States, 2016. MMWR Surveill Summ. 2017;66(SS-10):1-6.
  14. Peyrot M, Rubin RR, Funnell MM, Siminerio LM. Access to diabetes self-management education: results of national surveys of patients, educators, and physicians. Diabetes Educ.2009;35(2):246-263.
  15. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash).2003;43(2):173-184.
  16. American Association of Diabetes Educators. The Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. http://www.diabetesed.net/page/_files/Standards-of-Practice-ADA-2011.PDF. Published 2011. Accessed April 15, 2019.
  17. American Association of Diabetes Educators (AADE). AADE guidelines for the practice of diabetes self-management education and training (DSME/T). Diabetes Educ.2009;35(suppl 3):85S-107S.
  18. Funnell MM, Nwankwo R, Gillard ML, et al. Implementing an empowerment-based diabetes self-management education program. Diabetes Educ.2005;31(1):53-61.
  19. American Association of Diabetes Educators (AADE). AADE position statement. Individualization of diabetes self-management education. Diabetes Educ.2007;33(1):45-49.
  20. Austin MM. Diabetes educators: partners in diabetes care and management.Endocr Pract. 2006;12 Suppl 1:138-141.
  21. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood).2009;28(1):75-85.
  22. Walker EA, Shmukler C, Ullman R, et al. Results of a successful telephonic intervention to improve diabetes control in urban adults: a randomized trial. Diabetes Care. 2011;34(1):2-7.
  23. Mulcahy K, Maryniuk M, Peeples M, et al. Diabetes self-management education core outcomes measures. Diabetes Educ.2003;29(5):768-788.
  24. Boger E, Ellis J, Latter S, et al. Self-management and self-management support outcomes: a systematic review and mixed research synthesis of stakeholder views. PLoS One. 2015;10(7):e0130990.
  25. American Association of Diabetes Educators. Standards for outcomes measurement of diabetes self-management education. Diabetes Educ. 2003;29(5):804, 808-810, 813-816.
  26. Institute for Healthcare Improvement. Science of improvement: how to improve. www.ihi.org/knowledge/Pages/Howtoimprove/ScienceofimprovementHowtoimprove.aspx. Accessed April 14, 2019.
  27. American Association of Diabetes Educators (AADE); Siminerio LM, Drab SR, Gabbay RA, et al. AADE. Diabetes Educators: implementing the chronic care model, Diabetes Educ. 2008;34(3):451-456.
  28. Renders CM, Valk GD, Griffin SJ, et al. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care.2001;24(10):1821-1833.
  29. Centers for Disease Control and Prevention. Medicare reimbursement guidelines for DSMT. https://www.cdc.gov/diabetes/dsmes-toolkit/reimbursement/medicare.html. Accessed April 14, 2019.
  30. Centers for Medicare and Medicaid Services. Roadmap for implementing value driven healthcare in the traditional Medicare fee-for-service program. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/VBPRoadmap_OEA_1-16_508.pdf. Published 2008. Accessed April 15, 2019.

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