The Multidisciplinary DSMES Team

DSMES services have traditionally been provided by nurses and registered dietitians. While these health professionals are still a vital part of the education team, studies show DSMES is most effective when furnished by a multidisciplinary team.³⁴

These teams may include pharmacists and other clinicians, such as primary care physicians, specialty providers (such as endocrinologists), mental health specialists, and exercise physiologists. In addition, others can contribute to education and provide support with appropriate training in diabetes and with supervision and support. For example, community health workers (CHWs), promotores de salud, and community health representatives can provide information and behavioral support and can serve as a link to the health care system as part of DSMES.³⁴

Multidisciplinary teams work together to support the needs of the person with diabetes. Diabetes care and education specialists can be from many different disciplines, including registered nurses, registered dietitians, and pharmacists. These professionals provide the necessary self-management education for people with diabetes and serve as trainers and supervisors for CHWs, promotores de salud, and community health representatives, who can coordinate care and provide ongoing support for behavior change, among other tasks. Collaboration in providing DSMES services can enhance partnerships between primary care providers and educators, while also strengthening connections to other members of the team.¹³

The benefits of a multidisciplinary diabetes team include:¹³

• Access to multiple experts for enhanced patient education.
• Better glycemic control.
• Increased patient follow-up.
• Greater patient satisfaction.
• Lower risk for diabetes complications.
• Improved quality of life.
• Reduced hospitalizations.
• Decreased health care costs.

Members of a multidisciplinary DSMES team can include:

Pharmacist

In many communities, pharmacists are among the most accessible health care professionals. People with diabetes see a pharmacist 7 times more often than they see a primary care physician.³⁵ The National Standards for Diabetes Self-Management Education and Support specifically addresses the role of the pharmacist in providing DSMES.

Pharmacists may serve as part of the multidisciplinary DSMES team or they may provide DSMES directly. Pharmacist-led DSMES services can occur in a wide variety of settings, such as community pharmacies, clinics or provider practices, hospitals, managed care organizations, long-term care facilities, and government entities such as US Department of Veterans Affairs medical centers and Federally Qualified Health Centers.

Pharmacists interested in obtaining DSMES accreditation can view this webinar as an example of innovation in DSMES services.

For another example of pharmacies providing DSMES services, see the Tennessee Department of Health’s DSMES pharmacy initiative.

CHWs, Promotores de Salud, and Community Health Representatives

These frontline public health workers are trusted community members who possess a deep understanding of the communities they serve. They can help people with diabetes and their families learn how to manage diabetes and how to find resources in the community.

CHWs, promotores de salud, and community health representatives can serve as liaisons between health or social service agencies and communities. This relationship enables them to facilitate access to services while improving service quality and making services more culturally relevant. People in these roles are generally not professionals or clinicians, but instead are trained to build capacity in the communities they serve by increasing health knowledge and self-sufficiency through outreach, community education, informal counseling, social support, and advocacy.³⁴

CHWs, promotores de salud, and community health representatives can participate in DSMES services in numerous ways, such as:³⁷

• Helping to improve DSMES service management and efficiency by addressing barriers to care.
• Teaching a variety of DSMES topics.
• Providing follow-up education on self-management behaviors and skills.
• Performing nonclinical tasks more cost effectively than clinically trained personnel.

See these resources to learn more:
National Standards for Diabetes Self-Management Education and Support (see Standard 3)
Community Health Workers as Diabetes Paraprofessionals in DSMES and Prediabetes
Benefits of Including Community Health Workers on the Diabetes Care Team
Comparative Effectiveness of Peer Leaders and Community Health Workers in Diabetes Self-management Support: Results of a Randomized Controlled Trial

State Departments of Health

DDT funds state and local health departments to support services and activities to prevent or delay the onset of type 2 diabetes and improve health outcomes for people diagnosed with diabetes.³⁸

State health departments are critical to the success of DSMES services. According to CDC’s Emerging Practices in Diabetes series, “Because state health departments are on the front lines of coordinated chronic disease public health prevention efforts, they are exploring and testing innovative approaches that will provide critical insight and lessons learned”³⁸ on increasing access to and participation in DSMES. It is important that state health departments work with key diabetes stakeholders to address this public health need.

State health departments can work to promote existing DSMES services, or they can establish community partnerships to start new DSMES services. CDC encourages state health departments to work toward achieving greater efficiency and more significant and lasting outcomes, with the goal of increasing access to, participation in, and coverage for DSMES. A variety of activities are possible:

• Convening key stakeholders to identify DSMES barriers and create a plan to address them.
• Using strategic communication to reach people with diabetes about the importance of DSMES and its benefits.
• Using targeted marketing and social media approaches to reach providers and health care systems.
• Providing technical assistance and training on DSMES referrals and reimbursement.
• Building systems (such as those supported by electronic health records [EHRs]) to facilitate and track referrals and enhance clinical decision support.
• Linking organizations and government agencies that serve people with diabetes to health care systems with DSMES services.
• Providing support to health systems (including Federally Qualified Health Centers, community health centers, local health departments, and other safety-net organizations) to establish new DSMES services recognized by ADA or accredited by ADCES.
• Providing support to existing DSMES services to assist them in obtaining ADA recognition or ADCES accreditation.
• Obtaining a statewide umbrella license from ADA or ADCES to expand recognized or accredited DSMES services.
• Working with established DSMES services to improve sustainability.
• Sharing information on group visit models with bundled services with health care providers, staff, and DSMES service providers to maximize reimbursement.
• Providing technical assistance to DSMES service providers on appropriate billing practices to maximize reimbursement.
• Working with state employee health plans and state Medicaid agencies to extend coverage where needed.
• Working with established DSMES services to consider additional services (such as medical nutrition therapy, medication therapy management, and the National Diabetes Prevention Program’s lifestyle change program).
• Integrating DSMES services and referrals into coordinated care such as the patient-centered medical home.

State health departments can encourage health care providers to use EHRs and other systems to initiate and track referrals and enhance decision support.

They can also partner with managed care organizations (MCOs) to integrate DSMES into performance improvement plans and programs. By implementing systems and increasing partnerships to facilitate bi-directional referral between community resources and health care systems, state health departments can help drive access to and use of DSMES services.

Here are examples of DSMES programs in four state health departments:

Alaska DSMES Umbrella License
Alaska Department of Health and Social Services
Kentucky Cabinet for Health and Family Services
Kentucky Diabetes Self-Management Education and Support Programs
Michigan Department of Health and Human Services
Diabetes Prevention and Control Program
North Carolina Division of Public Health
DiabetesSmart: Diabetes Education Recognition Program

Community Partners

Community organizations may be interested in providing the infrastructure necessary to support an accredited or recognized DSMES service. Some community organizations support DSMES services by:

• Promoting DSMES to their members.
• Offering space for DSMES classes.
• Providing community health workers or peer counselors to teach classes.
• Becoming a DSMES provider.

Community-based DSMES can be held in community centers, libraries, private facilities, and faith-based institutions. By offering convenient locations, community support, and cultural relevance to participants, community-based DSMES services can help reach those who:

• May have limited access to health care.
• Have language barriers.
• May not have access to DSMES services in other traditional locations.³⁹

An additional benefit of providing DSMES in a community setting is that participants are then introduced to other programs and services offered in the community.

Area Agencies on Aging

Area Agencies on Aging (AAAs) may offer DSMES services in community settings for older adults with diabetes. Many AAAs are accredited or recognized DSMES providers, and if not, AAAs can play a role in expanding the use of other DSMES services.

Older adults with diabetes (particularly those who live in underserved communities) who are already receiving other AAA services would benefit from attending a DSMES service. Like other community health agencies that cannot bill Medicare directly, AAA can partner with Medicare Part B providers for Medicare reimbursement.²⁷