When to Refer Patients for Diabetes Education: New Guidance

Margaret A. Powers, PhD, RD, CDCES; Mark Harmel, MPH


June 23, 2020

This transcript has been edited for clarity.

The 2020 Diabetes Self-management Education and Support (DSMES) consensus report is a summary of the current evidence on the value and benefits of diabetes self-management education services.

Diabetes is a complex disease. Every day, people with diabetes have to make complicated, intricate decisions. How are they to learn what to do? Clinicians typically have very little time to spend with any patient, let alone to find out when patients exercise or what they eat, to teach them how to do blood glucose monitoring and interpret the data, to teach how to check their feet — there are so many things. Diabetes education services provide that type of support.

Can you tell us about the group that came together to create this report?

For the 2020 report, we had seven national health organizations participating. We expanded the group from the 2015 paper, which had three organizations. We felt it was important to bring the perspective of clinicians into the paper. What do they want? What do they recommend? What do they find valuable? What is the language that they use? So we had nurse practitioners, physician assistants, family physicians, and pharmacists at the table debating, discussing, looking at the evidence, and determining the words that should be used.

The clinician perspective was especially important because that is the target audience for the paper. We know that educators recognize the value that we bring and we read the research, and we need to be sure that we're talking to the clinicians in the language that's important to them.

When do people need diabetes self-management education?

We've identified four critical times when diabetes self-management education and support are critical to helping people live well with diabetes. Those times are at diagnosis, annually or when target goals are not being met, when complicating factors occur, and when transitions in care and life occur. These are moments in people's lives that can raise havoc in daily self-management decisions.

For example, a complicating factor might be somebody breaking a foot. That's going to interfere with that individual's activity. They may not be able to move as much, or maybe they are able to move but they now have a different activity that can influence their medication regimen. It can influence the food that they eat. It can influence when they should be checking their blood sugar. So, somebody needs to help pull all that together, and that's when we highly recommend a referral to a diabetes education specialist.

What is the current rate of referrals to diabetes education specialists? Are they higher at diagnosis?

One of the critical times is at diagnosis, and sometimes people will think, Well, of course. But the interesting thing is that there are very low referral rates to diabetes education services at diagnosis. In the Medicare population alone, only 5% of Medicare patients are referred to diabetes education during the first year of having diabetes. And that number is similar to those with private insurance.

So the referrals are not being made, or there might be a referral and the patient is not getting to the service for some reason. There may be a barrier, maybe there's not a program nearby, or maybe they think, Oh, I can learn this myself. I don't need to go see anybody.

What are some of the benefits of diabetes self-management education?

Part of this consensus report is highlighting the value and the benefits of diabetes self-management education. It's highly referenced so that when clinicians read it, they see the evidence that those who attend diabetes education services actually lower their A1c, they have fewer hospital admissions, they have fewer readmissions, they have fewer emergency department visits, they have improved quality of life, they feel more empowered to take care of their diabetes, they have less diabetes distress, and they do better at making decisions about physical activity and nutrition. Those are all the things we want people to do in the home environment, and we can help people do that, but it's critical that the clinicians make the referral to diabetes education services. It's like making a prescription.

In fact, in the consensus report, we actually compared the benefits of DSMES to metformin. We compared the efficacy of metformin and its benefits to those of DSMES, and they're very comparable. But what is striking is the behavioral and psychosocial benefits of someone participating in diabetes education services. That's not what you get from medication therapy. So there's an added value, a different value to the diabetes education services that you don't get from a very clinical area in a short amount of time.

What do you hope happens with this report now that it's released?

Powers: Our overall goal is to increase access to and utilization of diabetes education services. We know that the benefits are there, and we know that we can help people make those daily decisions in diabetes self-management. It ultimately improves health outcomes; it improves quality of life, and it reduces overall healthcare costs. That's our ultimate goal. It's helping the person with diabetes make the right decisions for them.

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