There is a shortage of diabetes self-management education and support (DSMES) services across the country, in part due to a lack of support and resources needed to start and sustain an accredited DSMES program. Recognizing this need, ADCES created the DSMES Umbrella Model, which aims to expand DSMES services in underserved and/or low-volume areas where a need is identified. In this model, a sponsor (umbrella) will support the program/service (microsite) to build capacity to deliver, document, and bill for DSMES services. In addition to helping each microsite to achieve accreditation, the umbrella will also assist each microsite to maintain accreditation over time. Each microsite will serve as its own DSMES program/service but will share tools, resources, and templates with the umbrella.
To learn more about this model in action, two ADCES DSMES Umbrella Programs share their experiences, insights, and advice.
Led by Co-Quality Coordinators Marci Butcher RD, CDCES, FADCES, and Melissa House, MBA
Why Did You and Your Organization Decide to Become a DSMES Umbrella?
Developing a DSMES Umbrella Program was the logical outgrowth of the Montana Diabetes Program’s (MDP) activities to improve diabetes care and education. We’ve built an extensive diabetes network by providing a peer-mentoring program supporting individual diabetes care and education specialists and developing accredited/recognized DSMES programs.
These efforts have resulted in DSMES service expansion; however, there are still areas with limited to no access to DSMES, often affecting priority populations.
Administrative burden, cost of accreditation, staffing challenges, and burden of trying to do it alone were barriers reported by Montana DSMES programs, and participating in the umbrella structure would allow them to either start a DSMES program or to “keep their doors open.” MDP made it a priority to pursue umbrella accreditation to reach priority populations in underserved areas and to reduce the burden of program administration to increase DSMES access.
Could You Explain What the Process Looked Like to Get Prepared to Become a DSMES Umbrella Program?
MDP has experience developing accredited DSMES programs, so the knowledge and skills were there. We approached the ADCES Diabetes Education Accreditation Program (DEAP) to receive approval and assistance working through the steps for umbrella accreditation.
To gain background insight, we worked with two states that had implemented an umbrella strategy and participated in quarterly networking calls with other states to learn best practices and resources. We wish to extend our gratitude to all!
The quality coordinator (QC) role is shared between the MDP manager and DSMES consultant. A robust QC job description was developed to define roles and responsibilities. The co-QCs routinely attend ADCES webinars and networking opportunities around program management, billing, and reimbursement and share with the microsites.
A “crosswalk” document was developed, clearly outlining the National Standards, ADCES’s Interpretive Guidance, and additional criteria MDP requires to ensure sites have adequate internal support and provider champions who refer to their program.
We worked with our initial site to meet the Standards, provided support walking a patient through documentation, planned for program continuous quality improvement (CQI) and measuring outcomes, and received accreditation before pursuing other microsites. Our umbrella accreditation goal is to grow sustainable sites, whether they continue under our umbrella or “graduate” into their own accreditation.
MDP serves only as the accrediting organization and provides oversight, support, and technical assistance to each microsite under its accreditation. Each microsite has its own accreditation certificate associated with a billing NPI and does its own billing.
Could You Describe Your Process for Identifying Microsites?
MDP updated surveillance reports, mapped current diabetes burden and existing DSMES sites, conducted a provider survey, and utilized our partners to help identify where DSMES is needed. Our strong statewide diabetes network provided opportunities to identify potential sites, and interested sites inquired about the umbrella. Two existing recognized/accredited sites chose to come under our umbrella to avoid losing their programs. We currently have three hospital-outpatient-based programs, a pharmacy, a federally qualified health center (FQHC), and a private nutrition practice under the umbrella and are pursuing additional microsites.
How Did You Get Your Microsites Onboarded?
The onboarding process follows basic steps but provides for flexibility and collaboration. An initial site meeting reviews the value of DSMES, how the umbrella is structured, and expectations. An agreement is signed outlining roles and expectations.
Regular meetings are held to work through each of the Standards, provide the site with data and templates, gather needed information, and provide training on documentation and delivering DSMES. We provide structure for the CQI plan and tracking outcomes and assist with continuing education needs.
All microsites are required to use our documentation platform, Electronic Diabetes Quality Care Monitoring System. We provide ongoing technical assistance.
When the Standards are met and a patient has participated in the full DSMES cycle, the deidentified chart is reviewed by the QC and the site is added in the ADCES DEAP Dashboard.
How Are You Providing Ongoing Support for Your Microsites?
MDP continues to support our microsites through monthly peer-learning opportunities. Mentoring and peer support are key aspects of the umbrella structure.
We pay for the umbrella accreditation, microsite fees, and ADCES curriculum and provide educational materials and resources for all microsites.
We also offer guidance and technical support and outreach national resources when higher level answers are required (ie, reimbursement), provide the documentation platform, and support each program to ensure audit readiness.
Microsites value the services provided by the QC. This support enhances microsite ability to provide quality DSMES services, focus on patient care, and feel supported and part of a team.
What Are Some of the Challenges You Have Encountered?
We serve different settings, which increases access, but it is challenging to understand the complexities of each setting, including varying billing and reimbursement requirements.
Our microsites report documentation standardization and “double entry” as challenges.
Our biggest hurdle has been program closure due to staffing loss. Staffing in rural areas continues to be one of the largest barriers faced by Montana’s DSMES programs.
What Advice Would You Give Others That Are Considering Becoming a DSMES Umbrella?
Significant time and effort were spent developing a sustainable structure before submitting our application. Having an experienced QC, addressing program readiness, providing stepwise assistance in meeting the National Standards, and providing ongoing assistance and resources have facilitated our success. Planning for DSMES documentation/reporting and outlining documentation expectations ahead of time is important, as are ongoing peer support and networking.
These elements are critical to our umbrella structure, provide value, and incentivize participation. We suggest planning for instructor succession in low-volume areas. Every site is different, and being willing to be flexible and understand each organization and their patient populations is critical to successful DSMES umbrella program implementation.
Led by Quality Coordinator Lorrie Rilko, DNP, FNP, BC-ADM, CDCES
Approximately 11.4% of the adult population in Virginia have been diagnosed with diabetes, and diabetes education programs are notably scarce in the highest risk areas of the state. The Virginia Department of Health (VDH) has sponsored the Virginia DSMES Umbrella program, designed to assist underrepresented and high-risk areas in enhancing the availability and accessibility of DSMES programs. This umbrella initiative provides organizations with the resources needed to develop evidence-based diabetes education programs, navigate the accreditation process, and provide financial support as they launch their DSMES programs. Additionally, the role of the umbrella QC is to alleviate some of the administrative burden on these programs by offering ongoing support, oversight, and technical assistance.
Could You Explain What the Process Looked Like to Prepare for Becoming a DSMES Umbrella?
The VDH commissioned the Virginia Center for Diabetes Prevention and Education (VCDPE), at the University of Virginia, to establish the VA DSMES Umbrella. Our journey to achieving ADCES accreditation for our first microsite involved a comprehensive yearlong preparation process, during which we collaborated closely with an experienced DSMES umbrella QC. This critical partnership provided us with valuable insights and enhanced our capacity to support small, often solo diabetes care and education specialists.
By participating in quarterly state DSMES umbrella meetings and connecting with umbrella QCs from various states—including North Carolina, Alaska, Kentucky, Georgia, Michigan, Texas, and Montana—we were able to share best practices and learn from their experiences.
We met several times with the ADCES DEAP to gather essential information and ensure the accuracy of our data for the accreditation application. Throughout the year, VCDPE collaborated with various organizations to evaluate digital platforms that would facilitate documentation for the microsites, ensuring they always remained audit ready. We developed a comprehensive job description for the umbrella QC and clearly defined the roles and responsibilities for both the umbrella and the microsites. Finally, we attended webinars focused on DSMES billing and reimbursement. This thorough preparation has positioned us to effectively support diabetes education in Virginia.
After a landscape analysis was done, various networking channels were utilized to connect with prospective programs and engage in discussions about potential collaboration. We delivered multiple presentations to organizations, including community pharmacies, FQHCs, and free clinics. For organizations that expressed interest, we followed up to schedule meetings where we could explore the benefits of joining the umbrella program.
Our first microsite was an FQHC with a solo dietitian and certified diabetes care and education specialist who aimed to expand her medical nutrition therapy services into a comprehensive DSMES program. We are currently collaborating with another pharmacy and an additional FQHC, both of which plan to submit their accreditation applications in early 2025.
After several meetings to establish the structure of our umbrella program, the microsite and the umbrella QCs engaged in frequent planning sessions for several months. During these meetings, we meticulously navigated each step of the accreditation process. Once all necessary steps were completed, the umbrella QC submitted the accreditation application on behalf of the microsite.
We provided comprehensive support to the microsite in setting up their DSMES program. This included reviewing all required documentation for accreditation, offering education on billing and reimbursement specific to FQHCs, and collaboratively developing the site’s continuous quality improvement project, which is essential for maintaining accreditation.
To promote the new program and increase referrals, we created flyers for microsite staff and providers and a patient-focused flyer outlining the benefits of DSMES.
How are You Providing Ongoing Support to Your Microsites?
The VA DSMES umbrella program offers comprehensive ongoing support to our microsites through initiatives including:
Financial assistance: Covering the initial accreditation fee.
Documentation platform: Provide a dedicated platform for patient DSMES documentation, streamlining recordkeeping and compliance.
Clinical and behavioral oversight: Oversee metrics, offering support to ensure effective program delivery.
Guidance and support: Assist with annual status reporting, CQI, and remaining audit ready.
Targeted marketing materials: Assist with promotional and marketing materials aimed at high-risk populations to enhance outreach and engagement.
One of our most significant challenges has been identifying a documentation platform that enables the umbrella QC to effectively oversee the education process and outcomes without imposing an additional documentation burden on microsite DSMES teams. Currently, we are using ADA Chronicle Pro, which serves as an excellent solution for organizations without access to electronic health records (EHRs), such as pharmacies. However, this platform creates a duplication of documentation for sites that do have EHRs, complicating the workflow for those DSMES teams. We are actively seeking alternatives that strike a balance between oversight and efficiency to streamline the documentation process for all our microsites.
What Advice Would You Give Others Considering Becoming a DSMES Umbrella?
Before submitting the first microsite’s accreditation application, the VA DSMES umbrella program invested significant time in preparation. We believe this groundwork was crucial for the program’s success and contributed to a smoother initiation process.
It’s also important to recognize that each microsite may demonstrate varying levels of readiness for initiating and implementing a DSMES program. Because there is no onesize-fits-all solution for the support needed, it is essential to tailor assistance to address the unique needs of each microsite, which will lead to more effective and successful implementation.
If you would like to learn more about the ADCES DSMES Umbrella Model or are interested in becoming a sponsor, please email deap@adces.org.