Overcoming Barriers to Referral and Treatment

Despite well-documented benefits, less than 5% of Medicare beneficiaries with diabetes and 6.8% of privately insured people with diabetes in the United States participate in DSMES services within the first year of diagnosis.²^,³ To increase that number, it is important to identify and address barriers at multiple levels, including programmatic barriers to starting or sustaining DSMES services, provider barriers to referral, and barriers to access and participation.

Programmatic Barriers

Programmatic barriers to starting and sustaining a DSMES service include:¹⁸

Limited clinical professionals in the area.
Difficulty attaining or maintaining enough participants (e.g., rural populations).
Program participants with limited financial resources.
Limited reimbursement or low reimbursement rates.
Administrative or resource challenges associated with American Diabetes Association recognition or Association of Diabetes Care & Education Specialists accreditation.
Limited resources for administrative and marketing activities.
Lack of support for DSMES among health care administrators.
Unknowns associated with the impact of health care policy.
Lack of reimbursement for community health workers assisting with DSMES.

Building the Business Case for DSMES and Reimbursement and Sustainability provide tools and resources to address these barriers.

Provider Barriers

Provider barriers to referral include:¹⁹

Lack of knowledge about DSMES.
Lack of awareness about local DSMES services.
Lack of a perceived need (e.g., diabetes education offered in a provider’s practice).
Confusion about referrals.
Daunting referral forms and paperwork.
Lack of provider reimbursement for counseling and interventions.
Lack of provider understanding of reimbursement procedures.
Concerns about insurance issues or cost to the person with diabetes.
Previous negative experiences with referring to DSMES services.
Lack of relationships between hospitals and community DSMES services.

Technology such as electronic health records (EHRs) can help health care providers identify patients with diabetes and increase referrals to DSMES. EHRs can be used to:

Generate and track referrals.
Identify people with diabetes in need of additional follow-up.
Close referral loops between providers and DSMES services.
Strengthen provider buy-in for DSMES by streamlining the referral process.

The following resources can help address provider barriers and develop a streamlined referral process to DSMES services. For additional resources, visit the Educating Providers and Establishing a Referral Network sections of the DSMES Toolkit.

Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report

Association of Diabetes Care & Education Specialists: Why Refer for Diabetes Education

Diabetes Self-Management Training (DSMT) Accreditation Program

Centers for Disease Control and Prevention: Approaches to Increase Access to and Participation in DSMES

Individual Barriers

Individual barriers to access and participation include:¹⁹

Lack of knowledge about DSMES services.
Lack of knowledge about the benefits of DSMES services.
Lack of access to DSMES services, especially in rural areas.
Inconvenient DSMES service times or locations (e.g., lack of evening or weekend classes).
Unwillingness to participate in group classes.
Lack of linguistically or culturally tailored services, curricula, or staff.¹⁸
Lack of insurance or insurance with high costs or copayments.
Lack of family support.
Competing demands for time and attention.
Lack of transportation or childcare.

Diabetes care and education specialists can address individual barriers and increase DSMES participation using some of the following strategies:

Offer classes on various days of the week and at convenient times.
Offer classes in different formats and lengths (e.g., multiple sessions, all-day services).
Increase frequency of class offerings.
Use reminder phone calls, texts, or email to follow up with participants (or potential participants) who do not attend the service or miss scheduled appointments.

The following resources provide additional information to help DSMES services address barriers to participation:

Together 2 Goal® Campaign Toolkit

Motivational Interviewing: Do’s and Don’ts

Diabetes Self-Management Education and Support (DSMES) Technical Assistance Guide