June 09, 2020, 04:15 pm Michael Devitt – Family physicians play an essential role in the care of patients with diabetes. It has been reported that FPs and other primary care clinicians deliver clinical care to at least 90% of people with type 2 diabetes, and this percentage is likely to increase over time. Given these numbers, along with CDC estimates that show more than 122 million Americans currently have diabetes or prediabetes, it is crucial that FPs are aware of all resources available to effectively manage patients with this condition.
A key component of diabetes care is diabetes self-management and education support, or DSMES, which empowers patients to select methods of care that best match their specific needs. To increase awareness of DSMES, the AAFP has joined with several other health care and diabetes organizations to release a consensus report on its use in adults with type 2 diabetes. The report offers FPs and other clinicians a wealth of guidance on the most effective ways to provide DSMES to patients and help them gain access to DSMES services.
The report's main objectives are to improve clinical care and education services for those with diabetes, improve the overall health of individuals and populations, and reduce per capita health care costs associated with diabetes.
To achieve these goals, the report focuses on four aspects of DSMES.
Benefits of education and support. The report notes that DSMES produces various clinical, psychosocial and behavioral benefits. Clinical benefits include reductions in hemoglobin A1c levels, diabetes-related complications and all-cause mortality. Patients who participate in DSMES programs also demonstrate improvements in self-efficacy and empowerment, increased healthy coping skills and decreased diabetes-related distress, along with improvements in behavioral outcomes such as increased healthy meal planning and physical activity levels.
"DSMES improves quality of life and health outcomes and is cost-effective," the report states. "All members of the health care team and health systems should promote the benefits, emphasize the value, and support participation in initial and ongoing DSMES for all people with diabetes."
Critical times to refer patients. The report recommends that clinicians refer patients to DSMES and promote or facilitate patient participation in DSMES programs at four critical times: at the initial diagnosis of diabetes; annually and/or when the patient does not meet treatment targets; when complicating factors that may affect self-management (such as diagnosis of other health conditions) occur; and when transitions in life and/or care (such as retirement or hospitalization) occur.
Locating resources. Although DSMES has traditionally involved formal classes offered at a hospital or health care facility, changes in the provision of diabetes care and the evolving needs of patients have resulted in DSMES services being provided in a number of nontraditional settings ranging from pharmacies and faith-based organizations to home-based programs.
The report recommends that clinicians and health systems take such changes into account. Accordingly, health care professionals should increase their awareness of and access to nontraditional DSMES services, which will allow patients to choose the programs that work best for them.
"A variety of DSMES approaches and settings need to be presented and discussed with people with diabetes, thus enabling self-selection of a method that best meets their specific needs," the report states. In particular, the potential for technology-based services such as web-based programs, mobile applications and online peer support groups to help patients manage their diabetes should be recognized.
Identifying and addressing barriers. Despite the effectiveness of DSMES, CDC research has shown that less than 7% of privately insured individuals with newly diagnosed type 2 diabetes participate in such services within 12 months of being diagnosed.
A variety of barriers prevent patients with diabetes from receiving the services they need, the report notes. Some of these barriers are rooted in lack of access to DSMES services or inadequate administrative leadership support; in other instances, clinicians may not be aware of the availability of these services or have difficulty understanding the referral process.
"In order to reduce barriers, a focus on processes that streamline referral practices must be implemented and supported systemwide," the report recommends. "Once this major barrier is addressed, the diabetes care and education specialist can be invaluable in addressing other barriers that the person may have. Without this, it will be increasingly difficult to access DSMES services, particularly in rural and underserved communities. With focus and effort, the challenges can be addressed and benefits realized."
In addition to these aspects, the report addresses two related topics.
First, it notes that medical nutrition therapy has been shown to prevent, delay or treat many complications associated with diabetes. As such, MNT is considered an integral component of quality diabetes care and should be incorporated into a patient's overall care plan.
The report also notes that DSMES not only improves health outcomes but is cost-effective. In light of the benefits it provides, the report recommends that clinicians, health care teams, health systems, payers and policymakers facilitate reimbursement processes and other means of financial support for DSMES services.
Beulette Hooks, M.D., staff and lead physician for the Victory Team Family Medical Home at Martin Army Community Hospital, Fort Benning, Ga., told AAFP News that the Academy of Nutrition and Dietetics, American Diabetes Association and Association of Diabetes Care & Education Specialists invited the Academy to participate in developing the consensus report.
"They had written a report in 2015 that most physician groups had not read and they wanted to include the voice of physicians in the 2020 report," explained Hooks, who is listed as a co-author on the current report.
Noting that FPs play a vital role in educating patients on the benefits of DSMES, Hooks said it also was important for clinicians to grasp the team aspect of diabetes care.
"DSMES can help improve outcomes for people with diabetes, reduce costs and help to slow the epidemic of diabetes," she noted.
"I hope family physicians will increase the use of DSMES/diabetes educators in their practices, letting their (patients) know that we are a team that can get their diabetes under better control," Hooks continued. Because family physicians have limited time with patients, she added, engaging a diabetes educator as a partner can help empower patients to manage their diabetes.
Hooks noted that her practice has a diabetes educator on staff who works with patients in both individualized and small group settings.
"She makes sure the patient with diabetes knows that she is there to help with their treatment and is not there to take the place of their physician," Hooks said. "Our patients are helped by the way we work together to get their diabetes under control. Some patients like the small groups, while others prefer the one-on-one time they can get."
Hooks also emphasized that FPs should routinely reinforce the benefits of DSMES services, especially among patients who do not regularly use those services.
"Diabetes self-management is not a one-and-done thing," she said, noting the report's contention that at least four critical times to provide and/or modify DSMES exist. "DSMES is an underutilized resource for both Medicare beneficiaries and individuals with private health insurance."
Finally, Hooks pointed to a comprehensive collection of other AAFP diabetes resources for both physicians and patients that are highlighted in the Patient Care section of the Academy's website.