The Multidisciplinary DSMES Team
DSMES has traditionally been provided by nurses and 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
There are many health care providers who can support people with diabetes as part of a multidisciplinary team. These teams may include pharmacists and other clinicians such as physicians, specialty providers, mental health specialists, and exercise physiologists. In addition, other health workers can contribute to education and provide support with appropriate training in diabetes and with supervision and support. For example, lay health and/or community health workers can provide information and behavioral support and can serve as a link to the healthcare system as part of DSMES.34
Multidisciplinary teams work together to support the needs of the person with diabetes. Diabetes educators can be from many different disciplines, including registered nurses, registered dietitians, pharmacists, and others. These educators provide the necessary self-management education for people with diabetes and serve as trainers and supervisors for community health and lay health workers. Community health workers can coordinate care and provide ongoing support for behavior change, among other tasks. Collaboration in DSMES teams can enhance partnerships between primary care providers and educators, while also strengthening connections to community health and lay health workers.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 healthcare costs
The descriptions below address a few of the many possible members of a multidisciplinary DSMES team.
In many communities, pharmacists are among the most accessible healthcare professionals. People with diabetes see a pharmacist seven times more often than they see a primary care physician.35 The National Standards for Diabetes Self-Management Education and Support specifically address the role of the pharmacist in the provision of DSMES.
Pharmacists may have varying roles in DSMES, as they 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/provider practices, hospitals, managed care organizations, long-term care facilities, and government entities such as Department of Veterans Affairs medical centers and federally qualified health centers.
Pharmacists interested in expanding their clinical service offerings by obtaining DSMES accreditation can check out this webinar offered by the Georgia Department of Public Healthexternal icon. While this is specific to pharmacies in Georgia, it is one example of innovation in DSMES services.
For another example of pharmacies providing DSMES services, click here pdf icon[PDF – 550 KB] to learn more about the Tennessee Department of Health’s DSMES pharmacy initiative.
Paraprofessionals and Peer Leaders
Standard 5 of the 2017 National Standards for Diabetes Self-Management Education and Supportexternal icon allows for support from paraprofessionals, including peer leaders and community health workers, as long as they receive supervision from clinical staff. Paraprofessionals can play a very important role by providing education and emotional support between appointments, which is often the time when people with diabetes have questions and concerns. Both the American Association of Diabetes Educators and the American Diabetes Association recognize that paraprofessionals can contribute to and assist diabetes educators with the delivery of DSMES.
Community Health Workers
Community health workers (CHWs) are frontline public health workers who typically are trusted community members and 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 can serve as liaisons between health or social service agencies and communities. This liaison relationship enables CHWs to facilitate access to services while improving service quality and making services more culturally relevant. CHWs are not generally professionals or clinicians, but instead are trained to build individual and community capacity by “increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.”34
CHWs can participate in DSMES in numerous ways, such as:37
- Helping to improve DSMES service management and efficiency
- Teaching a variety of DSMES topics
- Providing follow-up education to people with diabetes on self-management behaviors and skills
- Performing important non-clinical tasks more cost-effectively than clinically trained personnel
To learn more about the role of community health workers in DSMES, view The National Standards for Diabetes Self-Management Education and Support pdf icon[PDF – 707 KB]external icon (Standard 5), and the American Association of Diabetes Educators practice synopsis on Community Health Workers in Diabetes Management and Prevention pdf icon[PDF – 218 KB]external icon.
The following resources support the role of paraprofessionals in DSMES:
Comparative Effectiveness of Peer Leaders and Community Health Workers in Diabetes Self-Management Support: Results of a Randomized Controlled Trialexternal icon:
This study compares peer leaders and community health workers in a telephone outreach intervention to assess their role in sustaining improvements in hemoglobin A1c levels after a DSMES service.
Competencies for Diabetes Educators and Diabetes Paraprofessionals pdf icon[PDF – 341 KB]external icon: This report delineates the roles and responsibilities of diabetes educators and paraprofessionals, suggests career paths for diabetes educators and paraprofessionals, and clarifies the contributions that can be made by both in different settings.
State Departments of Health
CDC’s Division of Diabetes Translation (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 the 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 cultivate relationships and establish innovative 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 healthcare systems.
- Providing technical assistance and training on DSMES referrals and reimbursement.
- Building systems (such as those supported by electronic health records) to facilitate and track referrals and enhance clinical decision support.
- Linking organizations and government agencies that serve people with diabetes to healthcare 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 AADE.
- Providing support to existing DSMES services to assist them in obtaining ADA recognition or AADE accreditation.
- Obtaining a statewide umbrella license from ADA or AADE for the state health department to facilitate expansion of recognized or accredited DSMES services.
- Working with established DSMES services to improve sustainability.
- Sharing information on group visit models with bundled services with healthcare 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 Homeexternal icon
State health departments can encourage healthcare providers to utilize EHRs and other systems to initiate and track referrals and enhance decision support.
They can also work toward the integration of DSMES services and referrals into coordinated care (e.g., patient centered medical homes), and 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 healthcare systems, state health departments can help drive access to and utilization of DSMES services.
Here are examples of DSMES programs in four state health departments. Click each link to learn more.
Kentucky Cabinet for Health and Family Services:
Kentucky Diabetes Self-Management Education and Support Programsexternal icon
Michigan Department of Health and Human Services:
Michigan DSME Impactexternal icon
Mississippi State Department of Health:
Diabetes Self-Management Programexternal icon
North Carolina Division of Public Health:
DiabetesSmart: Diabetes Education Recognition Programexternal icon
Community organizations may be interested in collaborating to provide the infrastructure necessary to support an accredited or recognized DSMES service. Some community organizations support accredited or recognized DSMES services by promoting DSMES to their members; offering space for DSMES; providing community health workers or peer counselors to teach classes; or even becoming a provider of accredited or recognized DSMES services.
Community-based DSMES can be held in locations such as 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, or may not have access to DSMES services in other traditional locations.39 An additional benefit of holding 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 (AAA) may offer DSMES services in some community settings for older adults with diabetes. Many AAAs are accredited/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 services from AAA would benefit from also attending a DSMES service. Like other community health agencies that cannot bill Medicare directly, AAA can partner with Medicare Part B providers to enhance sustainability through Medicare reimbursement.27
The National Council on Aging provides helpful information for AAAs on their websiteexternal icon. NCOA’s Community-Integrated Healthcare Toolkit includes an overview of DSMT as well as many tip sheets and samples. See “Make it Happen” for the Diabetes Reimbursement details they have outlined.
The Georgia Department of Health has a Sample Policy and Procedure Manual pdf icon[PDF – 1 MB] for Agencies on Aging DSMES services.