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The Diabetes Educatorhttp://tde.sagepub.com/National Standards for Diabetes Self-Management Education and SupportLinda Haas, Melinda Maryniuk, Joni Beck, Carla E. Cox, Paulina Duker, Laura Edwards, Ed Fisher, Lenita Hanson, Daniel Kent,Leslie Kolb, Sue McLaughlin, Eric Orzeck, John D. Piette, Andrew S. Rhinehart, Russell Rothman, Sara Sklaroff, Donna Tomkyand Gretchen YoussefThe Diabetes Educator 2012 38: 619DOI: 10.1177/0145721712455997The online version of this article can be found d by:http://www.sagepublications.comOn behalf of:American Association of Diabetes EducatorsAdditional services and information for The Diabetes Educator can be found at:Email Alerts: http://tde.sagepub.com/cgi/alertsSubscriptions: http://tde.sagepub.com/subscriptionsReprints: ions: http://www.sagepub.com/journalsPermissions.nav Version of Record - Sep 20, 2012What is This?Downloaded from tde.sagepub.com at American Association of Diabetes Educators on October 19, 2012

National Standards619National Standards forDiabetes Self-ManagementEducation and SupportTask Force Members:By the most recent estimates, 18.8 million people inthe United States have been diagnosed with diabetes, andan additional 7 million are believed to be living withundiagnosed diabetes. At the same time, 79 million people are estimated to have blood glucose levels in theprediabetes range. Thus, more than 100 million Americansare at risk of developing the devastating complications ofdiabetes.1Diabetes self-management education (DSME) is acritical element of care for all people with diabetes and isnecessary to prevent or delay the complications of diabetes.2-6 Elements of DSME related to lifestyle change arealso essential for people with prediabetes, as part ofefforts to prevent the disease.7,8 The National Standardsfor Diabetes Self-Management Education are designed todefine quality DSME and support and to assist diabeteseducators in providing evidence-based education andself-management support. The standards are applicableto educators in solo practice as well as those in largemulticenter programs—and everyone in between. Thereare many good models for the provision of diabetes education and support. The standards do not endorse any oneapproach but rather seek to delineate the commonalitiesamong effective and excellent self-management education strategies. These are the standards used in the fieldfor recognition and accreditation. They also serve as aguide for nonaccredited and nonrecognized providersand programs.Because of the dynamic nature of health care anddiabetes-related research, the standards are reviewed andrevised approximately every 5 years by key stakeholdersand experts within the diabetes education community. Inthe fall of 2011, a task force was jointly convened by theLinda Haas, PhC, RN, CDE (Chair)Melinda Maryniuk, MED, RD, CDE (Chair)Joni Beck, PharmD, CDE, BC-ADMCarla E. Cox, PhD, RD, CDE, CSSDPaulina Duker, MPH, RN, BC-ADM, CDELaura Edwards, RN, MPAEd Fisher, PhDLenita Hanson, MD, CDE, FACE, FACPDaniel Kent, PharmD, BS, CDELeslie Kolb, RN, BSN, MBASue McLaughlin, BS, RD, CDE, CPTEric Orzeck, MD, FACE, CDEJohn D. Piette, PhDAndrew S. Rhinehart, MD, FACP, CDERussell Rothman, MD, MPPSara SklaroffDonna Tomky, MSN, RN, C-NP, CDE, FAADEGretchen Youssef, MS, RD, CDEVA Puget Sound Health Care System Hospital and Specialty Medicine, Seattle, Washington; JoslinDiabetes Center, Boston, Massachusetts; University of Oklahoma Health Sciences Center, Collegeof Medicine, Edmond, Oklahoma; Western Montana Clinic, Missoula, Montana; American DiabetesAssociation, Alexandria, Virginia; Center for Healthy North Carolina, Apex, North Carolina;Department of Health Behavior and Health Education, Gillings School of Global Public Health,University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Ultracare Endocrine andDiabetes Consultants, Venice, Florida; Group Health Central Specialty Clinic, Seattle, Washington;American Association of Diabetes Educators, Chicago, Illinois; On Site Health and Wellness, LLC,Omaha, Nebraska; Endocrinology Associates, Houston, Texas; Center for Global Health, VA Centerfor Clinical Management Research; University of Michigan Health System, Ann Arbor, Michigan;Johnston Memorial Diabetes Care Center, Abingdon, Virginia; Center for Health ServicesResearch, Vanderbilt University Medical Center, Nashville, Tennessee; Writer and person withdiabetes, Washington, DC; Department of Endocrinology and Diabetes, ABQ Health Partners,Albuquerque, New Mexico; MedStar Diabetes Institute, MedStar Health, Washington, DCCorrespondence to Leslie E. Kolb, RN, BSN, MBA, Director of Accreditation and QualityInitiatives, American Association of Diabetes Educators, 200 West Madison, Suite 800, Chicago,IL 60606 ([email protected]); and Paulina N. Duker, MPH, RN, BC-ADM, CDE, Vice President,Diabetes Education and Clinical Programs, American Diabetes Association, 1701 NorthBeauregard Street, Alexandria, VA 22311 ([email protected]).Acknowledgments: Linda Haas and Melinda Maryniuk were co-chairs of the Task Force. LeslieE. Kolb, RN, BSN, MBA, and Paulina N. Duker, MPH, RN, BC-ADM, worked on behalf of AADEand ADA, respectively, coordinating the effort on this document. Sara Sklaroff was the medicalwriter.DOI: 10.1177/0145721712455997 2012 The Author(s)Haas et alDownloaded from tde.sagepub.com at American Association of Diabetes Educators on October 19, 2012

The Diabetes EDUCATOR620American Association of Diabetes Educators (AADE)and the American Diabetes Association. Members of thetask force included experts from the areas of publichealth, underserved populations including rural primarycare and other rural health services, individual practice,large urban specialty practice, and urban hospitals. Theyalso included people with diabetes, diabetes researchers,certified diabetes educators, registered nurses, registereddietitians, physicians, pharmacists, and a psychologist.The task force was charged with reviewing the currentNational Standards for Diabetes Self-ManagementEducation for their appropriateness, relevance, and scientific basis and updating them based on the available evidence and expert consensus.The task force made the decision to change the nameof the standards from the National Standards for DiabetesSelf-Management Education to the National Standardsfor Diabetes Self-Management Education and Support.This name change is intended to codify the significanceof ongoing support for people with diabetes, particularlyto encourage behavior change and the maintenance ofhealthy diabetes-related behaviors and to address psychosocial concerns. Given that self-management doesnot stop when a patient leaves the educator’s office, selfmanagement support must be an ongoing process.Although the term diabetes is used predominantly, thestandards should be understood to apply to the educationand support of people with prediabetes. Currently, thereare significant barriers to the provision of education andsupport to those with prediabetes. And yet, the strategiesfor supporting successful behavior change and the healthybehaviors recommended for people with prediabetes arelargely identical to those for people with diabetes. As barriers to care are overcome, providers of DSME and diabetes self-management support (DSMS), given their trainingand experience, are particularly well equipped to assistpeople with prediabetes in developing and maintainingbehaviors that can prevent or delay the onset of diabetes.Many people with diabetes have or are at risk fordeveloping comorbidities, including heart disease, lipidabnormalities, nerve damage, hypertension, and depression. In addition, the diagnosis, progression, and dailywork of managing the disease can take a major emotionaltoll on people with diabetes that makes self-care evenmore difficult.9 The standards encourage providers ofDSME and DSMS to address the entire panorama of eachparticipant’s clinical profile. Regular communicationamong the members of participants’ health care teams isessential to ensure high-quality, effective education andsupport for people with diabetes and prediabetes.In the course of its work on the standards, the taskforce identified areas in which there is currently an insufficient amount of research. In particular, there are 3 areasfor which the task force recommends additional research:1. What is the influence of organizational structure on theeffectiveness of the provision of DSME?2. What is the impact of using a structured curriculum inDSME?3. What training should be required for those community, lay,or peer workers without training in health or diabetes whoare to participate in the provision of DSME and provideDSMS?Finally, the standards emphasize that the person withdiabetes is at the center of the entire diabetes educationand support process. It is people with diabetes who dothe hard work of managing their condition, day in andday out. The educator’s role, first and foremost, is tomake that work easier.10DefinitionsDiabetes self-management education: the ongoingprocess of facilitating the knowledge, skill, and abilitynecessary for prediabetes and diabetes self-care. Thisprocess incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and isguided by evidence-based standards. The overall objectives of DSME are to support informed decision making,self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinicaloutcomes, health status, and quality of life.Diabetes self-management support: activities thatassist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to managehis or her condition on an ongoing basis beyond or outside of formal self-management training. The type ofsupport provided can be behavioral, educational, psychosocial, or clinical.11-15Standard 1Internal StructureThe provider(s) of DSME will document an organizational structure, mission statement, and goals. Forthose providers working within a larger organization,Volume 38, Number 5, September/October 2012Downloaded from tde.sagepub.com at American Association of Diabetes Educators on October 19, 2012

National Standards621that organization will recognize and support qualityDSME as an integral component of diabetes care.Documentation of an organizational structure, missionstatement, and goals can lead to efficient and effectiveprovision of DSME and DSMS. In the business literature,case studies and case report investigations of successfulmanagement strategies emphasize the importance ofclear goals and objectives, defined relationships androles, and managerial support. Business and health policyexperts and organizations emphasize written commitments, policies, support, and the importance of outcomesreporting to maintain ongoing support or commitment.16,17Documentation of an organizational structure thatdelineates channels of communication and representsinstitutional commitment to the educational entity iscritical for success. According to the Joint Commissionon Accreditation of Healthcare Organizations, this typeof documentation is equally important for small andlarge health care organizations.18 Health care and business experts overwhelmingly agree that documentationof the process of providing services is a critical factor inclear communication and provides a solid basis fromwhich to deliver quality diabetes education. In 2010, thejoint commission published the Disease-Specific CareCertification Manual, which outlines standards and performance measurements for chronic care programs anddisease management services, including “supportingself-management.”18Standard 2External InputThe provider(s) of DSME will seek ongoing input fromexternal stakeholders and experts to promote programquality.For individual and group providers of DSME andDSMS, external input is vital to maintain an up-to-date,effective program. Broad participation of communitystakeholders, including people with diabetes, health professionals, and community interest groups, will increasethe program’s knowledge of the local population andallow the provider to better serve the community. Often,but not always, this external input is best achieved by theestablishment of a formal advisory board. The DSMEand DSMS provider(s) must have a documented plan forseeking outside input and acting on it.The goal of external input and discussion in the program planning process is to foster ideas that will enhancethe quality of the DSME and/or DSMS being providedwhile building bridges to key stakeholders.19 The result iseffective, dynamic DSME that is patient centered, moreresponsive to consumer-identified needs and the needs ofthe community, more culturally relevant, and moreappealing to consumers.17,19,20Standard 3AccessThe provider(s) of DSME will determine whom toserve, how best to deliver diabetes education to thatpopulation, and what resources can provide ongoingsupport for that population.Currently, the majority of people with diabetes andprediabetes do not receive any structured diabetes education.19,20 While there are many barriers to DSME, onecrucial issue is access.21 Providers of DSME can helpaddress this issue by doing the following.* Clarifying the specific population to be served.Understanding the community, service area, orregional demographics is crucial to ensuring that as manypeople as possible are being reached, including thosewho do not frequently attend clinical appointments.9,17,22-24* Determining that population’s self-managementeducation and support needs.Different individuals, their families, and communitiesneed different types of education and support.25 The provider of DSME needs to work to ensure that the necessary education alternatives are available.25-27 This meansunderstanding the population’s demographic characteristics, such as ethnic/cultural

DSME and DSMS to address the entire panorama of each participant’s clinical profile. Regular communication among the members of participants’ health care teams is essential to ensure high-quality, effective education and support for people with diabetes and prediabetes. In the course of its work on the standards, the task force identified areas in which there is currently an insuf-ficient .