Overcoming Barriers to Referral and Treatment

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Although DSMES services have 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 the number of people with diabetes who receive DSMES services, 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 adequate volume (e.g., rural populations)
  • Program participants with limited financial resources
  • Limited reimbursement/low reimbursement rates
  • Administrative or resource challenges associated with starting and maintaining a DSMES service recognized by the American Diabetes Association or accredited by the Association of Diabetes Care & Education Specialists
  • Limited resources for administrative and marketing activities
  • Lack of support for DSMES among healthcare administrators
  • Unknowns associated with the impact of healthcare policy
  • Lack of reimbursement for community health workers assisting with DSMES

Resources included in the Building the Business Case and Reimbursement/Sustainability sections of this toolkit can help provide tools and resources to address the above barriers.

Provider Barriers

Provider-level barriers to referral include:19

  • Lack of knowledge about DSMES
  • Lack of awareness about local DSMES services
  • Lack of availability of local DSMES services
  • Lack of a perceived need to refer to DSMES services (e.g., diabetes education offered in a provider’s practice)
  • Confusion about referrals
  • Daunting referral form 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

Using technology can help healthcare providers identify their patients with diabetes and increase referrals to DSMES. Healthcare providers can use functions of the electronic health record (EHR) to identify people with diabetes who can benefit from 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 toolkit.

Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report of the American Diabetes Association, the Association of Diabetes Care and Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Associationpdf iconexternal icon
This report outlines the benefits of DSMES, defines four critical times to provide and modify DSMES (see Figure 1), proposes how to locate DSMES related resources, and discusses potential solutions to access and utilization barriers.

Association of Diabetes Care & Education Specialists: Tips for Reaching Prescribersexternal icon:
This tool helps educators convey to providers the value of diabetes education.

Association of Diabetes Care & Education Specialists: Why Refer for Diabetes Educationexternal icon:
This link provides reasons to make a referral as well as a link to a referral form.

Centers for Medicare & Medicaid Services (CMS) Referral Requirements pdf icon[PDF – 107 KB]external icon:
This resource details CMS requirements and instructions for DSMES referrals.

Centers for Disease Control and Prevention: Approaches to Increase Access to and Participation in DSMES pdf icon[PDF – 550 KB]:
This report describes the work of three states (Florida, Mississippi, and Tennessee) to increase access to and participation in DSMES through targeted outreach, partnership, technical assistance, grant opportunities, and reimbursement initiatives.

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, and/or staff18
  • Lack of insurance or prohibitive cost and/or copayment
  • Lack of family support
  • Competing demands for time and attention
  • Lack of transportation or childcare

Diabetes educators can address an individual’s barriers and increase utilization of DSMES services using some of the following strategies:

  • Offer classes on various days of the week and at convenient times.
  • Offer classes of differing formats and duration (e.g., multiple-session formats, all-day services).
  • Increase frequency of class offerings.
  • Improve follow-up efforts for participants (or potential participants) who do not attend the service or miss scheduled appointments, such as reminder phone calls and letters.
  • Conduct projects to test solutions to barriers.

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

Together 2 Goal® Campaign Toolkitexternal icon:
This resource identifies DSMES barriers and provides tools to address each barrier.

Motivational Interviewing: Do’s and Don’tsexternal icon
This National Institute of Diabetes and Digestive and Kidney Diseases (NIH) resource provides tips on using motivational interviewing with persons with diabetes to engage them in self-management.

Diabetes Self-Management Education and Support (DSMES) Technical Assistance Guide:
Developed by the CDC, this tool is designed to assist state health departments and their partners in planning and implementing activities to increase use DSMES programs, focusing on access, health care provider referrals, and reimbursement. This tool identifies four key drivers that influence DSMES access: 1) availability of DSMES services, 2) payers and payment mechanisms, 3) referral policies and practices and 4) people with diabetes being willing to participate in DSMES services.

Page last reviewed: February 4, 2021