Encountering struggles with your diabetes control will happen. You can't plan for every situation you may face. However, learning from struggles and developing plans for dealing with problems in the future will help you be successful. Having diabetes puts you are a higher risk for developing other health problems.

Understanding the risks is the first step towards reducing your chances of diabetes-related complications. Diabetes can not only affect you physically, but emotionally as well.

A call to action for all health care systems and organizations is to engage needed resources and to effectively and efficiently manage and address this expensive epidemic affecting health outcomes.

We must address barriers that result in therapeutic inertia created by health policy, health systems, providers, people with diabetes, and the environment, including social determinants of health 10 , which encompass the conditions in which people live, work, learn, and play Rather than being overwhelmed and nonattentive to this crisis, all stakeholders must be creative and responsive to the needs of all involved and make it their priority.

This Consensus Report is an update of the joint position statement on DSMES The panel of experts authoring this report includes representatives from the three national organizations that jointly published the original article ADA, American Association of Diabetes Educators [AADE], and Academy of Nutrition and Dietetics , and, in an effort to widen the reach and stakeholder input, the American Academy of Family Physicians, American Academy of PAs, American Association of Nurse Practitioners, American Pharmacists Association, and a patient advocate were invited to participate.

At the beginning of the writing process all members of the expert panel participated in two surveys related to the joint position statement and its impact and the desired future use of this Consensus Report: one survey from their perspective and one completed while interviewing colleagues.

The expert panel agreed on the direction for this Consensus Report, established writing teams to author the various sections of the report, and reviewed the entire updated manuscript after each step. An outside market research company was used to conduct the literature search and was paid using ADA funds.

Monthly calls were held between March and December , with additional e-mail and web-based collaboration. Two in-person meetings were conducted to provide organization to the process, establish the review process, reach consensus on the content and key definitions see Table 2 , and discuss and deliberate the recommendations.

Once the draft was completed, the structured peer review process was implemented and the report was sent to two additional representatives from each of the seven participating organizations. A final draft was completed and submitted to all seven national organizations for final review and approval.

The recommendations are the informed, expert consensus of the seven contributing organizations. The benefits of DSMES are multifaceted and include clinical, psychosocial, and behavioral outcomes benefits. Key clinical benefits are improved hemoglobin A 1c A1C with reductions that are additive to lifestyle and drug therapy 13 — Based on recent data 13 , 14 , 16 , DSMES results in an average A1C reduction of 0.

DSMES improves quality of life 15 , 21 — 23 and promotes lifestyle behaviors including healthful meal planning and engagement in regular physical activity In addition, participation in DSMES services shows enhancement of self-efficacy and empowerment 25 , increased healthy coping 26 , and decreased diabetes-related distress These improvements clearly affirm the importance and benefits of utilizing DSMES and justify efforts to facilitate participation as a necessary part of quality diabetes care.

Table 3 highlights the multiple and varied benefits that make DSMES services a critical component of quality diabetes care and compares its effects to metformin therapy metformin therapy Evidence supports that better health outcomes are associated with an increased amount of time spent with a diabetes care and education specialist 13 , 28 , People with diabetes who completed more than 10 h of DSMES over the course of 6—12 months and those who participated on an ongoing basis were found to have significant reductions in mortality 20 and A1C average absolute reduction of 0.

Research shows that those who participate in diabetes education are more likely to use best practices and have lower health care costs 28 , Even though outpatient and pharmacy costs are higher for those who use diabetes education, t hese costs are offset by lower acute care costs DSMES is cost-effective by reducing emergency department visits, hospital admissions, and hospital readmissions 28 , 30 — The cost of diabetes in the U.

The cost of care for people with diabetes accounts for about one in four health care dollars spent in the U. The U. health care system cannot sustain the costs of care associated with the increasing incidence of diabetes and diabetes-related complications. DSMES offers a pathway to decrease these costs and improve outcomes.

DSMES improves quality of life and health outcomes and is cost-effective. 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 see Table 4.

Summary of DSMES benefits to discuss with people with diabetes 15 — 28 , 30 — 33 , 40 , 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 Evolving health care delivery systems, primary care needs, and the needs of people with diabetes have resulted in the incorporation of DSMES services into additional and nontraditional settings such as those located within patient-centered medical homes, community health centers, pharmacies, and accountable care organizations ACOs , as well as faith-based organizations and home settings.

Technology-based services including web-based programs, telehealth, mobile applications, and remote monitoring enable and promote increased access and connectivity for ongoing management and support Recent health care concerns are rapidly expanding the use of these services, especially telehealth.

In conjunction with formal DSMES, online peer support communities are growing in popularity. Involvement in these groups can be a beneficial adjunct to learning, serving as an option for ongoing diabetes peer support 36 , 37 Supplementary Table 1.

Creative, person-centered approaches to meet individual needs that consider various learning preferences, literacy, numeracy, language, culture, physical challenges, scheduling challenges, social determinants of health, and financial challenges should be widely available.

It is important to ensure access in communities at highest risk for diabetes, such as racial and ethnic minorities and underserved communities. Office-based health care teams without in-house resources can partner with local diabetes care and education specialists within their community to explore opportunities to reach people with diabetes and overcome some barriers to participation at the point of care If the office-based care team assumes responsibility for providing diabetes education and support, every effort should be made to ensure they receive up-to-date training in diabetes care and education and utilize the details in Tables 5 and 6.

Sample questions to guide a person-centered assessment Regardless of the DSMES approach or setting, personalized and comprehensive methods are necessary to promote effective self-management required for day-to-day living with diabetes. Effective delivery involves expertise in clinical, educational, psychosocial, and behavioral diabetes care 39 , It is essential for the referring provider to mutually establish personal treatment plans and clinical goals with the person with diabetes and communicate these to the DSMES team.

Ongoing communication and support of recommendations and progress toward goals between the person with diabetes, education team, referring provider, and other members of the health care team are critical.

A person-centered approach to DSMES beginning at diagnosis of diabetes provides the foundation for current and future decisions. Diabetes self-management is not a static process and requires ongoing assessment and modification, as identified by the four critical times see Fig.

Initial and ongoing DSMES helps the person overcome barriers and cope with the enduring and changing demands throughout the continuum of diabetes treatment and life transitions. Providers and other members of the immediate health care team have an important role in providing education and ongoing support for self-management needs.

New behaviors can be difficult to maintain and require reinforcement at a minimum of every 6 months In addition to the providers, the care team may include diabetes care and education specialists DCES ; registered dietitian nutritionists RDNs ; nutrition and dietetics technicians, registered NDTRs ; nurse educators; care managers; pharmacists; exercise and rehabilitation specialists; and behavioral or mental health care providers.

In addition, others have a role in helping to sustain the benefits gained from DSMES, including community health workers, nurses, care managers, trained peers, home health care service workers, social workers, and mental health counselors and other support people e.

Professional associations may help identify specific services in the local area such as the Visiting Nurse Association and block nurse programs see Supplementary Table 1. Family members and peers are an underutilized resource for ongoing support and often struggle with how to best provide help 47 , Including family members in the DSMES process can help facilitate their involvement 49 — Such support people can be especially helpful and serve as cultural navigators in health care systems and as liaisons to the community Community programs such as healthy cooking classes, walking groups, peer support communities, and faith-based groups may lend support for implementing healthy behavior changes, promoting emotional health, and meeting personal health goals Health care providers need to be aware of the DSMES resources in their health system and communities and make appropriate referrals.

Although these four critical times are listed, it is important to recognize diabetes is a chronic disease that progresses over time and requires vigilant care to meet changing physiologic needs and goals The existing treatment plan may become ineffective due to changing situations that can arise at any time.

Such situations include progression of the disease, changes in personal goals, unmet targets, major life changes, or new barriers identified when assessing social determinants of health. It is prudent to be proactive when changes are identified or emerging. Additional support from the entire care team and referral to DSMES are appropriate responses to any of these needs.

Quality ongoing, routine diabetes care includes continuous assessment, ongoing education and learning, self-management planning, and ongoing support.

The AADE7 Self-Care Behaviors provide the overarching framework for identifying key components of education and support The seven self-care behaviors are healthy coping, healthy eating, being active, taking medication, monitoring, reducing risks, and problem solving.

Mastery of skills and behaviors related to each of these areas requires practice and experience. Often, a series of ongoing education and support visits are necessary to allow participants the time to practice new skills and behaviors, to develop problem-solving skills, and to improve their ability and self-efficacy to set and reach personal self-management goals Care and education plans at each of the four critical times focus on the needs and personal goals of the individual.

Therefore, the plan should be based on personal experiences that are relevant to self-management and applicable to personal goals, treatment targets, and objectives and acknowledge that adults possess expertise about their own lives Tables 5 and 6 serve as checklists to ensure clinical teams and health systems offer necessary diabetes services factors that indicate DSMES needs and what DSMES provides.

Overview of MNT: an evidence-based application of the nutrition care process provided by the RDN 1 , 40 , 69 — Note: The Academy of Nutrition and Dietetics recognizes the use of registered dietitian RD and registered dietitian nutritionist RDN. RD and RDN can only be used by those credentialed by the Commission on Dietetic Registration.

For an individual and family, the diagnosis of diabetes is often overwhelming 58 , 59 , with fears, anger, myths, and personal, family, and life circumstances influencing this reaction.

Immediate care addresses these concerns through listening, providing emotional support, and answering questions. Providers typically first set the stage for a lifetime chronic condition that requires focus, hope, and resources to manage on a daily basis.

A person-centered approach at diagnosis is essential for establishing rapport and developing a personal and feasible treatment plan. Despite the wide range of knowledge and skills that are required to self-manage diabetes, caution should be taken to not confound the overwhelming nature of the diagnosis but to determine what the person needs from the care team at this time to safely navigate self-management during the first days and weeks.

Responses to such questions as shown in Table 7 also see Tables 5 and 6 guide and set direction for each person. Immediate referral to DSMES services establishes a personal education and support plan and highlights the value of initial and ongoing education.

Initial DSMES at diagnosis typically includes a series of visits or contacts to build on clinical, psychosocial, and behavioral needs. See Table 6 for suggested content. These team members are critical at all four critical times.

Important discussions at diagnosis include the natural history of type 2 diabetes, what the journey will involve in terms of lifestyle and possibly medication, and acknowledgment that a range of emotional responses is common. Diabetes is largely self-managed and care management involves trial and error.

The role of the health care team is to provide information and discuss effective strategies to reach chosen treatment targets and goals. The many tasks of self-management are not easy, yet worth the effort 61 see benefits associated with dsmes. The health care team and others support the adoption and maintenance of daily self-management tasks 8 , 40 , as many people with diabetes find sustaining these behaviors difficult.

They need to identify education and other needs expeditiously in order to address the nuances of self-management and highlight the value of ongoing education.

Table 6 provides details of DSMES at this critical time. Annual assessment of knowledge, skills, and behaviors is necessary for those who achieve diabetes treatment targets and personal goals as well as for those who do not.

Primary care visits for people with diabetes typically occur every 3—6 months These visits are opportunities to assess all areas of self-management, including laboratory results, and a review of behavioral changes and coping strategies, problem-solving skills, strengths and challenges of living with diabetes, use of technology, questions about medication therapy and lifestyle changes, and other environmental factors that might impact self-management It is challenging for primary care providers to address all assessments during a visit, which points to the need to utilize established DSMES resources and champion new ones to meet these needs, ensuring personal goals are met.

See Table 5 for indications for referral. Possible barriers to achieving treatment goals, such as financial and psychosocial issues, life stresses, diabetes-related distress, fears, side effects of medications, misinformation, cultural barriers, or misperceptions, should be assessed and addressed.

People with diabetes are sometimes unwilling or embarrassed to discuss these problems unless specifically asked 62 , Frequent DSMES visits may be needed when the individual is starting a new diabetes medication such as insulin 64 , is experiencing unexplained hypoglycemia or hyperglycemia, has worsening clinical indicators, or has unmet goals.

Importantly, diabetes care and education specialists are charged with communicating the revised plan to the referring provider and assisting the person with diabetes in implementing the new treatment plan. The identification of diabetes-related complications or other individual factors that may influence self-management should be considered a critical indicator of the need for DSMES that requires immediate attention and adequate resources.

The diagnosis of other health conditions often makes management more complex and adds additional tasks onto daily management. DSMES addresses the integration of multiple medical conditions into overall care with a focus on maintaining or appropriately adjusting medication, meal plans, and physical activity levels to maximize outcomes and quality of life.

In addition to the need to adjust or learn new self-management skills, effective coping, defined as a positive attitude toward diabetes and self-management, positive relationships with others, and enhanced quality of life are addressed in DSMES services 16 , The progression of diabetes can increase the emotional and treatment burden of diabetes and distress 65 , It has a greater impact on behavioral and metabolic outcomes than does depression Diabetes-related distress is responsive to intervention, including DSMES-focused interventions 68 and family support However, additional mental health resources are generally required to address severe diabetes-related distress, clinical depression, and anxiety It is important to recognize the psychological issues related to diabetes and prescribe treatment as appropriate.

Throughout the life span many factors such as aging, living situation, schedule changes, or health insurance coverage may require a re-evaluation of diabetes treatment and self-management needs see Tables 5 and 6.

They may also include life milestones: marriage, divorce, becoming a parent, moving, death of a loved one, starting or completing college, loss of employment, starting a new job, retirement, and other life circumstances.

Changing health care providers can also be a time at which additional support is needed. DSMES affords important benefits to people with diabetes during transitions in life and care. Providing input into the development of practical and realistic self-management and treatment plans can be an effective asset for successful navigation of changing situations.

The health care provider can make a referral to a diabetes care and education specialist to add input to the transition plan, provide education and problem solving, and support successful transitions.

The goal is to minimize disruptions in therapy during any transition, while addressing clinical, psychosocial, and behavioral needs. Additionally, MNT helps prevent, delay, or treat other complications commonly found with diabetes such as hypertension, cardiovascular disease, renal disease, celiac disease, and gastroparesis.

MNT is integral to quality diabetes care and should be incorporated into the overall care plan, medication plan, and DSMES plan on an ongoing basis 1 , 40 , 69 — 72 Table 8. Although basic nutrition content is covered as part of DSMES, people with diabetes need both initial and ongoing MNT and DSMES; referrals to both can be made through many electronic health records as well as through hard copy or faxed referral methods see Supplementary Table 1 for specific resources.

Everyday decisions about what to eat must be driven by evidence and personal, cultural, religious, economic, and other preferences and needs 69 — The entire health care team should provide consistent messages and recommendations regarding nutrition therapy and its importance as a foundation for quality diabetes care based on national recommendations Despite the proven value and effectiveness of DSMES, a looming threat to its success is low utilization due to a variety of barriers.

In order to reduce barriers, a focus on processes that streamline referral practices must be implemented and supported system wide. 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.

The Centers for Disease Control and Prevention reported that only 6. This low initial participation in DSMES was also reported in a recent AADE practice survey, with most people engaging in a diabetes program diagnosed for more than a year These low numbers are seen even in areas where cost is less of a barrier because of national health insurance.

Analysis of National Health Service data in the U. This highlights the need to identify and utilize resources that address all barriers including those related to health systems, health care providers, participants, and the environment. In addition, efforts are being made by national organizations to correct the identified access and utilization barriers.

Health system or programmatic barriers include lack of administrative leadership support, limited numbers of diabetes care and education specialists, geographic location, limited or lack of access to services, referral to DSMES services not effectively embedded in the health system service structure, limited resources for marketing, and limited or low reimbursement rates DSMES services should be designed and delivered with input from the target population and critically evaluated to ensure they are patient-centered.

Despite the value and proven benefits of these services, barriers within the benefit design of Medicare and other insurance programs limit access.

Using Medicare as an example, some of these barriers include the following: hours allowed in the first year the benefit is used and subsequent years are predefined and not based on individual needs; a referral is required and must be made by the primary provider managing diabetes; there is a requirement of diabetes diagnosis using methods other than A1C; and costly copays and deductibles apply.

A person cannot have Medicare DSMES and MNT visits either face to face or through telehealth on the same day, thus requiring separate days to receive both of these valuable services and possibly delaying questions, education, and support. Referrals may also be limited by unconscious or implicit bias, which perpetuates health care disparities and leads to therapeutic inertia.

To address these barriers, providers can meet with those currently providing DSMES services in their area to better understand the benefits, access, and referral processes and to develop collaborative partnerships.

Participant-related barriers include logistical factors such as cost, timing, transportation, and medical status 34 , 77 , 78 , For those who avail themselves of DSMES services, few complete their planned education due to such factors. Underutilization of services may be because of a lack of understanding or knowledge of the benefits, cultural factors, a desire to keep diabetes private due to perceived stigma and shame, lack of family support, and perceptions that the standard program did not meet their needs and is not relevant for their life, and the referring providers may not emphasize the value and benefits of initial and ongoing DSMES 34 , 79 , 80 , We acknowledge the rights, interests, priorities, and concerns of all Indigenous Peoples - First Nations, Métis, and Inuit - respecting and acknowledging their distinct cultures, histories, rights, laws, and governments.

Provincial Standards: Supporting Students with Type 1 Diabetes in the School Setting PDF Normes provinciales relatives au soutien offert en milieu scolaire aux élèves atteints de diabète de type 1 PDF Standards, services and supports are based on best practice developed by Child Health BC: Diabetes Care in the School Settings: Evidence-Informed Key Components, Care Elements and Competencies Learn about keeping student records and medical alerts: Permanent Student Record Instructions Planning with Parents Work closely with parents to provide the support their child's needs — especially in an emergency situation.

Expand All Collapse All. Start building a support plan for each child by having parents complete the following form: The Diabetes Support Plan and Medical Alert Information Form PDF Formulaire - Plan de gestion du diabète PDF.

Assist parents with notifying Nursing Support Services of children that need assistance with monitoring glucose levels or administering insulin: Nursing Support Services. HealthLinkBC Access information about this disease in children and find out what to do in an emergency.