Dashboard Data Measure: % adults with diabetes and A1c >9 who were referred to DSMES, MNT, or Lifestyle Program in the last 2 years.
Engaging people with diabetes in care, healthy lifestyle, and improving self-efficacy are important in improving A1c levels. Three critical interventions are known to improve engagement, lifestyle, and self-efficacy: 1) Diabetes Self-Management Education and Support (DSMES), 2) medical nutrition therapy (MNT), and 3) effective communication. Interventions discussed in other sections can also improve self-efficacy and engagement such as outreach, community health worker approaches, and individual and group visits.
D1: Diabetes Self-Management Education and Support (DSMES)
Diabetes is a chronic disease that requires a person with diabetes to make many daily self-management decisions and perform complex care activities. DSMES helps support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team. DSMES has been shown to improve A1C levels by about 0.5% and improve quality of life while reducing hypoglycemia, hospital admissions, depressive symptoms, and health care costs.36-37 There are four critical times to consider referral of people with diabetes to self-management including: 1) at diagnosis, 2) annually when reassessing a person’s needs, 3) when new complicating factors arise which influence self-care, and 4) when transitions in care occur.
D1.1: 2021: Diabetes Self-Management Education Covered by all Ohio Medicaid & MyCare Ohio Managed Care Plans
Comparison table of DSMES and MNT.
D1.2: Diabetes Self-Management Education and Support: Provider Use and Patient Benefits
This Cardi-OH document describes why, when, and how physicians can use DSMES to benefit patients with diabetes.
D1.3: Ask Your Doctor to Order Diabetes Self-Management Education and Support
DSMES is a program for people with diabetes to gain the knowledge, skills, and confidence necessary to make behavior changes in order to better control their diabetes.
D1.4: Find an Accredited Diabetes Self-Management Education and Support Program in Your Area
This website allows you to search for an ADCES-accredited DSMES program near you.
D1.5: Diabetes Self-Management Education and Support (DSMES) Toolkit
The CDC provides a DSMES toolkit to help organizations start a program.
D1.6: ADCES Practice Resources
The American Association of Diabetes Educators DEAP program guides interested professionals in how to start an accredited DSMES program.
D1.7: Certified Diabetes Care and Education Specialist (CDCES) Designation
The national certification board for the CDCES credential gives guidance on how to become a certified diabetes educator.
D2: Medical Nutrition Therapy (MNT)
MNT is one way to facilitate effective weight management, carbohydrate counting, or meal planning. MNT interventions provided by registered dietitians is effective for improving A1c, with absolute decreases up to 2.0% (in type 2 diabetes) at 3 to 6 months.38 Diabetes focused MNT should be provided by a registered dietitian nutritionist/registered dietitian (RDN), preferably one who has comprehensive knowledge and experience in diabetes care. Ongoing MNT support is helpful in maintaining glycemic improvements. When initiating mealtime insulin, consistent carbohydrates help reduce the risk of hypoglycemia. Food insecurity & health literacy and numeracy can be assessed and facilitated by an individualized meal plan using food models or the plate method.39 Referral to MNT should be considered at the same intervals that one would consider referral to Diabetes Self Management Education and Support (DSMES).
D2.1: 2021: Diabetes Self-Management Education Covered by all Ohio Medicaid & MyCare Ohio Managed Care Plans
Comparison table of DSMES and MNT.
D3: Effective Communication
Example Data Measure (not on Dashboard): Patient experience scores.
Beyond improving patient experience, improving communication skills has shown promising results on patient outcomes (such as A1C control) among diverse populations.40-44 Sharing and discussing the articles and links below with staff and providers at your clinic over time is useful in emphasizing effective communication. If your practice is interested in communication skill-building workshops, please reach out to your QI coach who can facilitate these workshops with your practice.
D3a: General Communication Practices of Physicians with High Patient-Satisfaction Ratings
Enhancing patient experience builds trust and engagement in care. In Resource D3a.1 below, the following provider strategies were associated with higher patient satisfaction scores:
D3a.1: Communication Practices of Physicians With High Patient-Satisfaction Ratings
This Kaiser Permanente article by Tallman et al. describes the following provider strategies that were associated with higher patient satisfaction scores, including focusing on the patient's agenda, drawing out the story, demonstrating understanding, providing detailed explanation, and completing the patient's agenda.
D3b: Health Literacy
Poor health literacy is a stronger predictor of a person’s health than age, income, employment status, education level, and race.
D3b.1: Talking with Your Team About Health Literacy
The Cardi-OH slides can be shared in a 20 to 30-minute session with your practice team. The slides show a short 5-minute American Medical Association health literacy video (https://youtu.be/ubPkdpGHWAQ?si=_Ogt7NQx6239SAa0), discusses ways to address health literacy, and encourages discussion among your care team about how you can identify and address health literacy in your practice.
D3b.2: AHRQ Health Literacy Universal Precautions Toolkit
This toolkit can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
D3c: Motivational Interviewing
People’s lifestyle and behaviors have an important impact on their health and quality of life,45 and this is particularly relevant for adults with diabetes. A systematic review from 2013 found an overall statistically significant, modest advantage for motivational interviewing over comparison interventions, including traditional advice giving. The technique was found to be effective in a number of studies looking at adherence to medical advice, for example around self-monitoring of blood glucose and food intake and increasing levels of physical activity.46 In simple terms, motivational interviewing is designed to encourage people with diabetes to talk themselves into making a change.47 Both resources below are quick guides with example statements or role play on how to use the principles of motivational interviewing for busy primary care teams.
D3c.1: Principles of Motivational Interviewing
Learn about principles of Motivational Interviewing (MI) as an approach to guide behavior change in patients. Cardi-OH’s presentation includes a fictional patient case study and role play to demonstrate how to use select MI skills in clinical practice.
D3c.2: Clinicians Pocket Guide on Motivational Interviewing
A Cardi-OH resource to support clinicians’ use of motivational interviewing when counseling patients.
D3d: Culturally and Linguistically Appropriate Care
Culturally and linguistically appropriate care are a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
D3d.1: Think Cultural Health
Training resources are available on this website, a comprehensive clearinghouse of materials around the National Cultural and Linguistically Appropriate Services (CLAS) Standards, effective cross-cultural communication, and cultural humility.
D3e: Implicit Bias
Implicit bias refers to the attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner. Implicit bias has been shown to impact decision making in health care where some groups are offered less treatment options or less evidence-based care.48-50 Take the implicit bias test to increase your awareness of your biases. Standardized protocols assist in reducing implicit bias and are described in Key Driver B. Another example is using a diabetes treatment protocol (Key Driver A2, Resource A2.1) which can also help standardize care, thereby reducing the impact of implicit bias. Resource D3e.1 below describes eight additional ways to mitigate implicit bias.
D3e.1: Eight Tactics to Identify and Reduce Your Implicit Biases
QuickTips, a blog from FPM Journal, provides eight tactics to mitigate implicit bias through introspection, mindfulness, perspective-taking, slowing down, individualizing care, checking your messaging, ensuring a culture of equity at your institution, and recognizing that this is a lifelong process.