Advocacy Tool-Kit

Advocacy Tool-Kit: Type 2 Diabetic Self-Management, Education, and Support Deficit
Morgan J. Trokey III
Missouri State University
Advocacy Tool Kit: Type 2 Diabetic Self-Management, Education, and Support Deficit
Table of Contents
White Paper: Type 2 Diabetic Self-Management, Education, and Support Deficit3
Talking Points and FAQs
Sample Documents
Advocacy Agenda
White Paper: Type 2 Diabetic Self-Management, Education, and Support Deficit
Problem
Nearly 30 million Americans are living with diabetes with prevalence rates steady and in some areas increasing American Diabetic Association (ADA). (2017). Another 86 million are living with prediabetes, a health condition that increases a person’s risk of developing Type 2 diabetes and other health problem and 90% of them are unaware that they are prediabetic ADA. (2017). Without intervention, one?third of individuals with prediabetes will develop Type 2 diabetes within five years. It has been projected that one in three individuals will develop type 2 diabetes by 2050 Boyle et al., (2010). The risk factors for prediabetes and Type 2 diabetes are similar and for the most part preventable with lifestyle changes.

Diabetic self-management education and support (DSMES) has been shown to be cost-effective by reducing hospital admissions and readmissions, as well as estimated lifetime health care costs related to a lower risk for complications Healy (2013). Given that the cost of diabetes in the U.S. in 2012 was reported to be $245 billion and indirect costs for employers are above $65 billion in lost productivity, DSMES offers an opportunity to decrease these costs ADA. (2013). The U.S. health care system will be unable to afford the costs of care unless incidence rates and diabetes-related complications are reduced. Powers The purpose of this paper is to enhance utilization of individualized diabetic self-management, education and ongoing support to decrease health care costs of diabetes and its comorbidities which will ultimately improve patient outcomes dealing with the chronic care of diabetes.

Significance of the Issue
Health inequalities related to diabetes and its complications are well documented and are heavily influenced by social determinants of health. Social determinants of health are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide. While a comprehensive strategy to reduce diabetes-related health inequalities in populations has not been formally studied, general recommendations from other chronic disease models. Social determinants of health are not always recognized and often go undiscussed in the clinical encounter. Patel, M (2016).
A study by Piette et al. (2016) found that among patients with chronic illnesses, two-thirds of those who reported not taking medications as prescribed due to cost never shared this with their physician. Creating tools to screen for social determinants of health may help overcome structural barriers and communication gaps between patients and providers Patel (2016).
DSMES is associated with an increased use of primary care and preventive services and less frequent use of acute care and inpatient hospital services. Patients who participate in DSMES are more likely to follow best practice treatment recommendations, particularly among the Medicare population, and have lower Medicare and insurance claim costs. Despite these benefits, reports indicate that only 5–7% of individuals eligible for DSMES through Medicare or a private insurance plan receive it. This low participation may be due to lack of referral or other identified barriers such as logistical issues and the lack of a perceived benefit. Thus, identifying participants patients’ needs during individualized DSMES implementation can greatly improve outcomes and cut medical costs. Piette, J. D., Heisler, M., & Wagner, T. H. (2004)
History of the Issue
Historically, DSMES has been provided through a formal program where patients and family members participate in an outpatient service conducted at a hospital or health facility. In keeping with evolving health care delivery systems and in meeting the needs of primary care, DSMES is now being incorporated into office practices, medical homes, and accountable care organizations. Receiving DSMES in alternative and convenient settings, such as community health centers and pharmacies, and through technology-based programs is becoming more available. Marcolino, et al.(2013).
The Affordable Care Act has resulted in increased access to care for many individuals with diabetes with an emphasis on health promotion and disease prevention. As mandated by the Affordable Care Act, improving the health of a population, overall quality and patient experience of care, and per capita cost must be included in implementation. As health care systems and practices adapt to the changing landscape of healthcare, it will be important to integrate traditional disease-specific metrics with measures of patient experience, as well as cost, in assessing the quality of diabetes care. Myerson, R., & Laiteerapong, N. (2016). Health care professionals, educators, and people with diabetes are advocating for more and better management options. Educators and providers must grow with the technology and tools available to better serve participants and patients. The DSMES standards are updated every 5 years by a Standards Revision Task Force convened by the American Diabetic Association to review and incorporate the latest research. The number of people with type 2 diabetes who receive DSMES, despite its proven benefits, is low. Only 6.8% of individuals with newly diagnosed type 2 diabetes with private health insurance participated in DSMES within 12 months of diagnosis. Furthermore, only 4% of Medicare participants received DSMES. Barriers are associated with several factors, including the health system, the individual health care professional, community resources, and the individual with diabetes. Barriers can include a misunderstanding of the necessity and effectiveness of DSMES, confusion regarding when and how to make referrals, lack of access to DSMES services, and patient psychosocial and behavioral factors. Provider misconceptions that can limit access to DSMES include a misunderstanding of reimbursement issues and the misconception that one or a few initial education visits are adequate to provide patients with the skills needed for lifelong self-management. Lack of or poor reimbursement for DSMES also can hamper patients’ participation. Even when DSMES programs are operating at peak service, they often struggle to cover costs making it easy to eliminate programs despite their wider influence on reducing costs and improving health outcomes. Lau,et al., (2015).Special Interest Group Positions
The providers of DSMES services will seek ongoing input from valued stakeholders and experts to promote quality and enhance participant utilization. The purpose of seeking stakeholder input in the ongoing planning process is to gather information and foster ideas that will improve the utilization, quality, measurable outcomes, and sustainability of the DSMES services ADA 2017. Stakeholders can be identified from DSMES participants, referring practitioners, and community-based groups that support DSMES who provide input to promote value, quality, access, and increased utilization ADA 2017. Social determinants related to the population served will be used to guide stakeholder selection and facilitate the connection between the DSMES services, the participant population, the health care providers, and the community ADA 2017.
Stakeholders must remain focused on reimbursement qualification with Medicare policy and should focus efforts in evidence driven guidance. In the end, it relies heavily upon the patient. Legislation can be influenced by advocacy for further funding and support for DSMES implication. Emphasis on a goal of lowered overall health care funds at the expense of more upfront initial costs encountered with DSMES implementation ADA 2017.
Recommendations and Solutions
Providers are encouraged to consider the burden of treatment and the patient’s level of confidence and self-efficacy for management behaviors as well as the level of social and family support when providing DSMES. Providers are encouraged to consider the impact that language has on building therapeutic relationships and to choose positive, strength-based words and phrases that put people first. Patient performance of self-management behaviors as well as psychosocial factors impacting the person’s self-management should be monitored. Ongoing DSMES helps people with diabetes to maintain effective self-management throughout a lifetime of diabetes as they face new challenges and as advances in treatment become available ADA 2017.
DSMES is associated with improved diabetes knowledge and self-care behaviors, lower A1C, lower self-reported weight, improved quality of life, reduced all-cause mortality risk, healthy coping, and reduced health care costs ADA 2017. Better outcomes were reported for DSMES interventions that were over 10 hours in total duration, included ongoing support, were culturally and age appropriate, were tailored to individual needs and preferences, and addressed psychosocial issues and incorporated behavioral strategies ADA 2017. Technology enabled diabetes self-management solutions improve A1C most effectively when there is two-way communication between the patient and the health care team, individualized feedback, use of patient-generated health data, and education ADA 2017. DSMES is associated with an increased use of primary care and preventive services and less frequent use of acute care and inpatient hospital services Healy (2013). Easy to use, validated screening tools for some social determinants of health exist and could facilitate discussion around factors that significantly impact treatment during the clinical encounter Patel, (2016).

Patients who participate in DSMES are more likely to follow best practice treatment recommendations, particularly among the Medicare population, and have lower Medicare and insurance claim costs. Despite these benefits, reports indicate that only 5–7% of individuals eligible for DSMES through Medicare or a private insurance plan receive it. This low participation may be due to lack of referral or other identified barriers such as logistical issues and the lack of a perceived benefit. Thus, in addition to educating referring providers about the benefits of DSMES and the critical times to refer, alternative and innovative models of DSMES delivery need to be explored and evaluated. He et al., (2016).
Conclusion
The main goal of DSMES is to facilitate the knowledge, skills, and abilities necessary for optimal diabetes self-care and incorporate the needs, goals, and life experiences of the person with diabetes ADA. (2017). The objectives of DSMES are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the healthcare team to improve clinical outcomes, health status, and quality of life in a cost-effective manner ADA. (2017). Through early implementation of DSMES services along with strong ongoing support from providers and stakeholders, diabetic prevalence and cost can be significantly decreased.
References
Marcolino, M. S., Maia, J. X., Alkmim, M. B., Boersma, E., ; Ribeiro, A. L. (2013). Telemedicine Application in the Care of Diabetes Patients: Systematic Review and Meta-Analysis. PLoS ONE,8(11). doi:10.1371/journal.pone.0079246.

Piette, J. D., Heisler, M., ; Wagner, T. H. (2004). Cost-Related Medication Underuse Among Chronically III Adults: The Treatments People Forgo, How Often, and Who Is at Risk. American Journal of Public Health, 94(10), 1782-1787. doi:10.2105/ajph.94.10.1782.

Patel, M. R., Piette, J. D., Resnicow, K., Kowalski-Dobson, T., ; Heisler, M. (2016). Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults with Diabetes. Medical Care, 54(8), 796-803. doi:10.1097/mlr.0000000000000565