Advancing Health Equity and Program Participation

Overview

Of people with diabetes, less than 5% of Medicare beneficiaries and 6.8% of privately insured people participate in DSMES within the first year of diagnosis. People with diabetes and diabetes care and education specialists (DCESs) face numerous barriers in accessing and providing DSMES services, including:

• Programmatic barriers to starting or sustaining DSMES services.
• Health care provider barriers to referral.
• Individual barriers to access and participation.

Programmatic barriers

Programmatic barriers to starting and sustaining a DSMES service include:

• Few clinical professionals in the area.
• Difficulty attracting and retaining enough participants, such as with rural populations.
• Limited or low reimbursement rates.
• Administrative or resource challenges with American Diabetes Association (ADA) recognition or Association of Diabetes Care & Education Specialists (ADCES) accreditation.
• Limited resources for administrative and marketing activities.
• Lack of support for DSMES services among health care administrators.
• Unknown impacts of health care policy, especially in reimbursement.
• Lack of reimbursement for community health workers (CHWs) assisting with DSMES services.

Health care provider barriers

Health care provider barriers to referral include:

Awareness

• Lack of knowledge and awareness about DSMES.
• Lack of perceived need.

Referral process

• Confusion about referrals.
• Complicated referral forms and paperwork.
• Previous negative experiences with referring to DSMES services.
• Lack of relationships between hospitals and community DSMES services.

Reimbursement

• Lack of health care provider reimbursement for counseling and interventions.
• Lack of health care provider understanding of reimbursement procedures.
• Concerns about insurance issues or cost to the person with diabetes.

Tips and resources

Electronic health records (EHRs) can help health care providers identify patients with diabetes and increase referrals. EHRs can help:

• Generate and track referrals.
• Identify people with diabetes who need additional follow-up.
• Close referral loops between providers and DSMES services.
• Strengthen health care provider buy-in for DSMES services by streamlining the referral process.

Develop a streamlined referral process to DSMES services:

• See Building and Strengthening Your Referral Network for tips and resources to educate health care providers and establish a referral network.

Get support in implementing DSMES services:

• Diabetes Self-Management Training (DSMT) Accreditation Program
• See Building the Business Case for DSMES and Reimbursement and Sustainability

Partner with CHWs to provide DSMES services and increase access to programs (CHWs are included in Section 1 of the ADA Standards of Care in Diabetes):

• Public Health Guidance for CHWs
• ADA Resources for CHWs, including CHW training
• ADCES blogs: Community Health Workers and Health Educators: Enhancing Diabetes Management and Prevention Efforts through Health Equity and Benefits of Including Community Health Workers (CHWs) on the Diabetes Care Team
• ADCES Practice Paper: Community Health Workers as Diabetes Paraprofessionals in DSMES and Prediabetes
• C3 Project: Resources to Understand the Full Potential of CHWs
• Engage CHWs during public health crises
• 4 ways to better support the CHW workforce

Ensure your DSMES services are accessible for communities that are underserved by health and social services:

• Translate and culturally adapt materials to other languages and ensure resources are accessible (e.g., closed captioning, subtitles)
• Refer participants to local transportation resources
• Disability and Health Inclusion Strategies
• Implementing and Evaluating Diabetes Self-Management Education and Support (DSMES) Programs for Underserved Populations/Communities
• How to Develop Products for Adults with Intellectual Developmental Disabilities and Extreme Low Literacy

Individual barriers

Individual barriers to access and participation include:

• Lack of:
  • Knowledge about DSMES services and its benefits.
  • Access to DSMES services, especially in rural areas.
  • Convenient DSMES service times or locations (e.g., evening or weekend classes).
• Unwillingness to participate in group classes.
• Competing demands for time and attention.
• Social determinants of health (SDOH) that affect ability to access and participate in DSMES services, such as lack of linguistically or culturally tailored services, family support, transportation, childcare, and adequate insurance.

Use the Health Literacy Tool to support participants

This tool contains accessible tips and tools to help you provide services to people with diabetes with various levels of health literacy or English-language proficiency. It includes:

• A glossary of plain language terms
• A visual library
• Stories and analogies
• Best practice reminders

8 ways you can support individuals in accessing DSMES services

1. Use the DSMES Promotion Playbook to raise awareness and knowledge about DSMES services in your community. The playbook offers a plain language description of DSMES services to help explain the benefits.
2. Adjust class logistics to accommodate participant schedules and communication preferences:
   1. Offer classes more frequently, on various days of the week, at more convenient times, virtually, and in different formats and lengths (e.g., multiple sessions, all-day services).
   2. Call, text, or email to follow up with participants (or potential participants) who do not attend the service or miss scheduled appointments.
3. Practice cultural competency in service delivery to meet the social, cultural, and linguistic needs of participants and communities.
   1. ADA Standards of Care in Diabetes
   2. Health Equity Guiding Principles for Inclusive Communication
   3. ADCES Resources to Address Health Equity
   4. ADA Health Equity Now Commitment and Programs
   5. Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease
   6. CDC’s Division of Nutrition, Physical Activity, and Obesity Health Equity Resources
4. Address SDOH and its role in health equity to tailor DSMES services to address how environments affect program participation.
   1. RHIhub’s Social Determinants of Health in Rural Communities Toolkit
   2. Social Determinants of Health at CDC
5. Use these assessments to spark conversations with participants about the support they need to access DSMES services by identifying their health-related social risks and needs.
   1. Agency for Healthcare Research and Quality Tools to Help Healthcare Organizations Address SDOH
   2. CMS Accountable Health Communities Health-Related Social Needs Screening Tool
   3. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)
6. Learn about your community’s social risks and needs to better recognize potential barriers participants may face in accessing DSMES services:
   1. Datasets Containing SDOH Measures
   2. County Health Rankings & Roadmaps
7. Language matters when providing diabetes care and education. Encourage health care providers to review The Use of Language in Diabetes Care and Education or Speaking the Language of Diabetes: Language Guidance for Diabetes-Related Conversations, Research, Education and Publications to ensure participants feel supported and understood in conversations.
8. Participants may need support beyond what DCESs can provide. Connect participants to local resources, from financial assistance to food pantries.
   1. Search and Connect to Social Care