In the past, DSMES services typically provided information to people with diabetes in a didactic manner and setting. However, DSMES services have been evolving in the direction of empowerment models21 that help people with diabetes more effectively self-manage their diabetes.22
This more person-centered approach strives to foster sustainable lifestyle changes. More interactive approaches are also associated with better outcomes.23 It is likely that the trend toward self-management will continue as health care resources become scarcer, and technology enables higher levels of individual engagement and more personalized self-management plans.24 As a result, implementation of DSMES services can occur in a variety of settings.
Traditional DSMES settings may include:25
- Hospital outpatient departments
- Independent clinics (Freestanding FQHCs and Independent Rural Health Clinics)
- Rural health clinics
- Patient-centered medical homes26
- Provider practices
- Public health departments
- Safety net organizations
- Federally qualified health centers
- Home health agencies
- Skilled nursing homes
- Community-based organizations
- Community centers
- Faith-based organizations
- Area Agencies on Aging (see toolkit section on Area Agencies on Aging)
- Durable medical equipment companies
- Telehealth (see toolkit section on Telehealth)
- The home of the person with diabetes
- Assisted living facilities
For Medicare reimbursement, there are settings where DSMES cannot be provided:25
- Inpatient hospital settings
- End Stage Renal Disease (ESRD) facilities
Note: The settings listed above may not all be approved places of service for Medicare reimbursement. For a fuller explanation of approved places of service, please click here pdf icon[PDF – 584 KB].
DSMES Provided in Pharmacies
The National Standards for Diabetes Self-Management Education and Support address the role of the pharmacist in the provision of DSMES. Pharmacists may serve as part of the multidisciplinary DSMES team, or they may provide DSMES directly.
Pharmacists may not directly bill CMS for the provision of DSMT. However, if the pharmacist is employed by a pharmacy that is a Medicare part B provider and provides services such as urgent care and influenza vaccines, the pharmacy may be able to bill CMS for the provision of DSMT services.
Pharmacists interested in expanding their clinical service offerings by obtaining DSMES accreditation can check out this webinar offered by the Georgia Department of Public Health to the Georgia Pharmacy Association, entitled “Opportunities in Diabetes Self-Management Education.” While this is specific to pharmacies in Georgia, it is one example of innovation in DSMES services. Click hereexternal icon to access the slide deck.
DSMES Provided in Shared Medical Appointments
Shared medical appointments (SMAs) are when “groups of patients meet over time for comprehensive care related to a chronic condition or healthcare state. SMAs usually involve both a person trained or skilled in delivering patient education or facilitating patient interaction and a practitioner with prescribing privileges. SMA sessions typically last 60 to 120 minutes, with time set aside for social integration, interactive education, and medication management to achieve improved disease outcomes.”28
SMAs are a way for providers to offer individual medical appointments in a group setting, and allow an instructor to provide lifestyle behavior change education (e.g., DSMES, MNT) for people with diabetes after the provider completes the evaluation and management visit.29
SMAs can lead to increased satisfaction, as people with diabetes may feel more comfortable in a setting where they can actively participate in their own care, learn from each other, support each other, and have more time with physicians during the medical visit. Providers and educators can further support people with diabetes by encouraging them to invite their spouses/partners, family members, and/or caregivers to the SMA.
SMAs can help enhance learning, behavior change, clinical outcomes, quality of life, cost savings, and patient satisfaction.
Shared care has many benefits:30
- Greater reach and impact
- Improved engagement among people with diabetes
- Focus on individual-centered medicine
For additional information on shared medical appointments, visit the following resources:
Shared Medical Appointments Tip Sheet pdf icon[PDF – 258 KB]external icon:
This resource provides an overview of shared medical appointments and their benefits, staff requirements, information about frequency and duration, privacy tips, and billing information.
Systematic Review on Shared Medical Appointmentsexternal icon:
This review of 17 studies compares SMA interventions with usual care, noting improvements in A1C and systolic blood pressure for SMA interventions.
Group Visit Starter Kit word icon[DOC – 315 KB]external icon:
This resource from the Group Health Cooperative is designed for health care teams who want to begin offering group visits for people with diabetes.
VA Shared Medical Appointments for Patients with Diabetes pdf icon[PDF – 4 MB]external icon:
This resource summarizes the necessary guidelines, information, tools, and resources for starting and conducting successful shared medical appointments for veterans with diabetes.
Reimbursement for Shared Medical Appointments Incorporating Diabetes Self-Management Education/Training or Diabetes Medical Nutrition Therapy pdf icon[PDF – 291 KB]external icon:
This article offers an overview of Medicare and private insurance reimbursement for SMAs.
DSMES Provided via Telehealth
Telehealth has emerged as a useful, appropriate, and acceptable DSMES delivery mode for both people with diabetes and providers. The Health Resources and Services Administrationexternal icon (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration” and clarifies that “while telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services as well.”
In other words, telehealth is an umbrella term that can mean audio and visual communication in real time. Some payers may reimburse for telehealth components such as email, telephone, or online communication (without a visual component). However, for Medicare reimbursement of DSMT, telehealth services must include audio and visual communication in real time.
In practical terms, telehealth services use a real-time audiovisual telecommunication system as a substitute for an in-person encounter between a person with diabetes and a provider located at a different site.31 Delivery of DSMES via telehealth has many benefits:31,32,33
- It is scalable.
- It is reimbursable (see the Reimbursement section of this toolkit for more information).
- It provides a way to reach more people with diabetes in less time.
- It provides an affordable way to effectively and efficiently reach underserved populations.
- It can increase access by addressing barriers such as transportation and area-specific provider shortages.
- It can be easy to engage some people with diabetes with a smartphone, app, or other technology.
- It may require less staff time for follow-up.
- It can bridge the gap between in-person visits.
There are some barriers to delivering DSMES via telehealth:31
- Not all technology is appropriate for all people with diabetes, and it is important to match technology to an individual’s age, abilities, and sensitivities.
- Telehealth may require expensive technology that a provider/setting cannot afford.
- People with diabetes may not have access to the technology.
- Telehealth may require additional training for diabetes educators, because initiating DSMES in a telehealth format is very different from what educators may be used to in face-to-face settings.
Click hereexternal icon to access a webinar presented by the Montana Diabetes Program in conjunction with the Florida Department of Health, HRSA, and the Association of Diabetes Care & Education Specialists on using telehealth to deliver DSMES.