S144 Diabetes Care Volume 37, Supplement 1, January 2014

National Standards for Diabetes Linda Haas, PHC, RN, CDE (Chair);1
Melinda Maryniuk, MEd, RD, CDE (Chair);2
Self-Management Education Joni Beck, PharmD, CDE, BC-ADM;3
Carla E. Cox, PhD, RD, CDE, CSSD;4
and Support Paulina Duker, MPH, RN, BC-ADM, CDE;5
Laura Edwards, RN, MPA;6 Edwin B. Fisher,
PhD;7 Lenita Hanson, MD, CDE, FACE, FACP;8
By the most recent estimates, 18.8 million people in the U.S. have been diagnosed
Daniel Kent, PharmD, BS, CDE;9 Leslie Kolb,
with diabetes and an additional 7 million are believed to be living with undiagnosed
RN, BSN, MBA;10 Sue McLaughlin, BS, RD,
diabetes. At the same time, 79 million people are estimated to have blood glucose
CDE, CPT;11 Eric Orzeck, MD, FACE, CDE;12
levels in the range of prediabetes or categories of increased risk for diabetes. Thus,
John D. Piette, PhD;13 Andrew S. Rhinehart,
more than 100 million Americans are at risk for developing the devastating
complications of diabetes (1). MD, FACP, CDE;14 Russell Rothman, MD,
MPP;15 Sara Sklaroff; 16 Donna Tomky, MSN,
Diabetes self-management education (DSME) is a critical element of care for all RN, C-NP, CDE, FAADE;17 and
people with diabetes and those at risk for developing the disease. It is necessary in
Gretchen Youssef, MS, RD, CDE;18 on behalf
NATIONAL STANDARDS

order to prevent or delay the complications of diabetes (26) and has elements
of the 2012 Standards Revision Task Force
related to lifestyle changes that are also essential for individuals with prediabetes as
part of efforts to prevent the disease (7,8). The National Standards for Diabetes Self-
Management Education are designed to dene quality DSME and support and to
assist diabetes educators in providing evidence-based education and self- 1
VA Puget Sound Health Care System Hospital and
management support. The Standards are applicable to educators in solo practice as Specialty Medicine, Seattle, WA
2
Joslin Diabetes Center, Boston, MA
well as those in large multicenter programsdand everyone in between. There are 3
Pediatric Diabetes and Endocrinology, The
many good models for the provision of diabetes education and support. The University of Oklahoma Health Sciences Center
College of Medicine, Edmond, OK
Standards do not endorse any one approach, but rather seek to delineate the 4
Western Montana Clinic, Missoula, MT
5
commonalities among effective and excellent self-management education Diabetes Education/Clinical Programs, American
Diabetes Association, Alexandria, VA
strategies. These are the standards used in the eld for recognition and 6
Center for Healthy North Carolina, Apex, NC
7
accreditation. They also serve as a guide for nonaccredited and nonrecognized Peers for Progress, American Academy of Family
providers and programs. Physicians Foundation and Department of Health
Behavior, Gillings School of Global Public Health,
Because of the dynamic nature of health care and diabetes-related research, the The University of North Carolina at Chapel Hill,
Chapel Hill, NC
Standards are reviewed and revised approximately every 5 years by key 8
Ultracare Endocrine and Diabetes Consultants,
stakeholders and experts within the diabetes education community. In the fall of Venice, FL
9
Group Health Central Specialty Clinic, Seattle, WA
2011, a Task Force was jointly convened by the American Association of Diabetes 10
Diabetes Education Accreditation Program,
Educators (AADE) and the American Diabetes Association (ADA). Members of the American Association of Diabetes Educators,
Chicago, IL
Task Force included experts from the areas of public health, underserved 11
On Site Health and Wellness, LLC, Omaha, NE
12
populations including rural primary care and other rural health services, individual Endocrinology Associates, Main Medical Plaza,
practices, large urban specialty practices, and urban hospitals. They also included Houston, TX
13
VA Center for Clinical Management Research and
individuals with diabetes, diabetes researchers, certied diabetes educators, the University of Michigan Health System, Ann
registered nurses, registered dietitians, physicians, pharmacists, and a psychologist. Arbor, MI
14
Johnston Memorial Diabetes Care Center,
The Task Force was charged with reviewing the current National Standards for Abingdon, VA
15
Diabetes Self-Management Education for their appropriateness, relevance, and Center for Health Services Research, Vanderbilt
University Medical Center, Nashville, TN
scientic basis and updating them based on the available evidence and expert 16
Technical Writer, Washington, DC
17
consensus. Department of Endocrinology and Diabetes, ABQ
Health Partners, Albuquerque, NM
18
The Task Force made the decision to change the name of the Standards from the MedStar Diabetes Institute/MedStar Health,
National Standards for Diabetes Self-Management Education to the National Washington, DC
Standards for Diabetes Self-Management Education and Support. This name Corresponding authors: Linda Haas,
[email protected], and Melinda Maryniuk,
change is intended to codify the signicance of ongoing support for people with
[email protected].
diabetes and those at risk for developing the disease, particularly to encourage
DOI: 10.2337/dc14-S144
behavior change, the maintenance of healthy diabetes-related behaviors, and to
The previous version of this article National
address psychosocial concerns. Given that self-management does not stop when a
Standards for Diabetes Self-Management
patient leaves the educators ofce, self-management support must be an ongoing Education was published in Diabetes Care
process. 2007;30:16301637. This version received nal
approval in July 2012.
Although the term diabetes is used predominantly, the Standards should also be
understood to apply to the education and support of people with prediabetes. 2014 by the American Diabetes Association.
See http://creativecommons.org/licenses/by-
Currently, there are signicant barriers to the provision of education and support to nc-nd/3.0/ for details.
care.diabetesjournals.org National Standards S145

those with prediabetes. And yet, the Finally, the Standards emphasize that organizations emphasize written
strategies for supporting successful the person with diabetes is at the commitments, policies, support, and the
behavior change and the healthy center of the entire diabetes education importance of outcomes reporting to
behaviors recommended for people and support process. It is the maintain ongoing support or
with prediabetes are largely identical to individuals with diabetes who do the commitment (16,17).
those for individuals with diabetes. As hard work of managing their condition, Documentation of an organizational
barriers to care are overcome, providers day in and day out. The educators role, structure that delineates channels of
of DSME and diabetes self-management rst and foremost, is to make that work communication and represents
support (DSMS), given their training and easier (10). institutional commitment to the
experience, are particularly well educational entity is critical for success.
equipped to assist individuals with According to The Joint Commission, this
DEFINITIONS
prediabetes in developing and type of documentation is equally
maintaining behaviors that can prevent DSME: The ongoing process of
important for both small and large
facilitating the knowledge, skill, and
or delay the onset of diabetes. health care organizations (18). Health
ability necessary for prediabetes and
Many people with diabetes have or are care and business experts
diabetes self-care. This process
at risk for developing comorbidities, overwhelmingly agree that
incorporates the needs, goals, and life
including both diabetes-related documentation of the process of
experiences of the person with
complications and conditions (e.g., providing services is a critical factor in
diabetes or prediabetes and is guided
clear communication and provides a
heart disease, lipid abnormalities, nerve by evidence-based standards. The
solid basis from which to deliver quality
damage, hypertension, and depression) overall objectives of DSME are to
diabetes education. In 2010, The Joint
and other medical problems that may support informed decision making,
Commission published the Disease-
interfere with self-care (e.g., self-care behaviors, problem solving,
Specic Care Certication Manual,
emphysema, arthritis, and alcoholism). and active collaboration with the
which outlines standards and
In addition, the diagnosis, progression, health care team and to improve
performance measurements for chronic
and daily work of managing the disease clinical outcomes, health status, and
care programs and disease management
can take a major emotional toll on quality of life.
services, including Supporting Self-
people with diabetes that makes self- Management (18).
DSMS: Activities that assist the person
care even more difcult (9). The
with prediabetes or diabetes in
Standards encourage providers of DSME STANDARD 2
implementing and sustaining the
and DSMS to address the entire behaviors needed to manage his or her External Input
panorama of each participants clinical condition on an ongoing basis beyond The provider(s) of DSME will seek
prole. Regular communication among or outside of formal self-management ongoing input from external
the members of participants health training. The type of support provided stakeholders and experts in order to
care teams is essential to ensure high- can be behavioral, educational, promote program quality.
quality, effective education and support psychosocial, or clinical (1115). For both individual and group providers
for people with diabetes and of DSME and DSMS, external input is
prediabetes. STANDARD 1 vital to maintaining an up-to-date,
In the course of its work on the Internal Structure effective program. Broad participation
Standards, the Task Force identied The provider(s) of DSME will document of community stakeholders, including
areas in which there is currently an an organizational structure, mission individuals with diabetes, health
insufcient amount of research. In statement, and goals. For those professionals, and community interest
particular, there are three areas in providers working within a larger groups, will increase the programs
which the Task Force recommends organization, that organization will knowledge of the local population and
additional research: recognize and support quality DSME as allow the provider to better serve the
an integral component of diabetes community. Often, but not always, this
1. What is the inuence of care. external input is best achieved by the
organizational structure on the Documentation of an organizational establishment of a formal advisory
effectiveness of the provision of structure, mission statement, and goals board. The DSME and DSMS provider(s)
DSME and DSMS? can lead to efcient and effective must have a documented plan for
2. What is the impact of using a provision of DSME and DSMS. In the seeking outside input and acting on it.
structured curriculum in DSME? business literature, case studies and The goal of external input and discussion
3. What training should be required for case report investigations of successful in the program planning process is to
those community, lay, or peer management strategies emphasize the foster ideas that will enhance the quality
workers without training in health or importance of clear goals and of the DSME and/or DSMS being
diabetes who are to participate in objectives, dened relationships and provided, while building bridges to key
the provision of DSME and to provide roles, and managerial support. Business stakeholders (19). The result is effective,
DSMS? and health policy experts and dynamic DSME that is patient centered,
S146 National Standards Diabetes Care Volume 37, Supplement 1, January 2014

more responsive to consumer-identied and the lack of encouragement from Historically, nurses and dietitians were the
needs and the needs of the community, other health providers to seek diabetes main providers of diabetes education
more culturally relevant, and more education (35,36). (3,4,6064). In recent years, the role of
appealing to consumers (17,19,20). the diabetes educator has expanded to
STANDARD 4 other disciplines, particularly pharmacists
STANDARD 3
Program Coordination (6567). Reviews comparing the
Access A coordinator will be designated to effectiveness of different disciplines for
The provider(s) of DSME will determine oversee the DSME program. The education have not identied clear
who to serve, how best to deliver coordinator will have oversight differences in the quality of services
diabetes education to that population, responsibility for the planning, delivered by different professionals (35).
and what resources can provide ongoing implementation, and evaluation of However, the literature favors the
support for that population. education services. registered nurse, registered dietitian, and
Currently, the majority of people with Coordination is essential to ensure that pharmacist serving both as the key
diabetes and prediabetes do not receive quality diabetes self-management primary instructors for diabetes education
any structured diabetes education education and support is delivered and as members of the multidisciplinary
(19,20). While there are many barriers through an organized, systematic team responsible for designing the
to DSME, one crucial issue is access (21). process (37,38). As the eld of DSME curriculum and assisting in the delivery of
Providers of DSME can help address this continues to evolve, the coordinator DSME (17,68). Expert consensus
issue by: plays a pivotal role in ensuring supports the need for specialized diabetes
accountability and continuity in the and educational training beyond
c Clarifying the specic population to academic preparation for the primary
education program (3941). The
be served. Understanding the coordinators role may be viewed as instructors on the diabetes team (69
community, service area, or that of coordinating the program (or 72). Professionals serving as instructors
regional demographics is crucial to education process) and/or as supporting must document appropriate continuing
ensuring that as many people as the coordination of the many aspects of education or comparable activities to
possible are being reached, including self-management in the continuum of ensure their continuing competence to
those who do not frequently attend diabetes and related conditions when serve in their instructional, training, and
clinical appointments (9,17,2224). feasible (4249). This oversight includes oversight roles (73).
c Determining that populations self- designing an education program or Reecting the evolving health care
management education and support service that helps the participant access environment, a number of studies have
needs. Different individuals, their needed resources and assists him or her endorsed a multidisciplinary team
families, and communities need in navigating the health care system approach to diabetes care, education,
different types of education and (37,5055). and support. The disciplines that may be
support (25). The provider(s) of DSME
The individual serving as the coordinator involved include, but are not limited to,
and DSMS needs to work to ensure
will have knowledge of the lifelong physicians, psychologists and other
that the necessary education
process of managing a chronic disease mental health specialists, physical
alternatives are available (2527).
and facilitating behavior change, in activity specialists (including physical
This means understanding the
addition to experience with program therapists, occupational therapists, and
populations demographic
and/or clinical management (5659). In exercise physiologists), optometrists,
characteristics, such as ethnic/
some cases, particularly in solo or other and podiatrists (68,74,75). More
cultural background, sex, and age, as
small practices, the coordinator may recently, health educators (e.g.,
well as levels of formal education,
also provide DSME and/or DSMS. Certied Health Education Specialists
literacy, and numeracy (2831). It
and Certied Medical Assistants), case
may also entail identifying resources
STANDARD 5 managers, lay health and community
outside of the providers practice that
workers (7683), and peer counselors or
can assist in the ongoing support of Instructional Staff
the participant. One or more instructors will provide DSME educators (84,85) have been shown to
c Identifying access issues and working and, when applicable, DSMS. At least one contribute effectively as part of the
to overcome them. It is essential to of the instructors responsible for designing DSME team and in providing DSMS. While
determine factors that prevent and planning DSME and DSMS will be a DSME and DSMS are often provided
individuals with diabetes from registered nurse, registered dietitian, or within the framework of a collaborative
receiving self-management education pharmacist with training and experience and integrated team approach, it is crucial
and support. The assessment process pertinent to DSME, or another that the individual with diabetes is
includes the identication of these professional with certication in diabetes viewed as central to the team and that he
barriers to access (3234). These care and education, such as a CDE or BC- or she takes an active role.
barriers may include the ADM. Other health workers can contribute Certication as a diabetes educator
socioeconomic or cultural factors to DSME and provide DSMS with (CDE) by the National Certication
mentioned above, as well as, for appropriate training in diabetes and with Board for Diabetes Educators (NCBDE) is
example, health insurance shortfalls supervision and support. one way a health professional can
care.diabetesjournals.org National Standards S147

demonstrate mastery of a specic body research endorses the inclusion of change and addressing psychosocial
of knowledge, and this certication has practical problem-solving approaches, concerns (114,115).
become an accepted credential in the collaborative care, psychosocial issues,
diabetes community (86). An additional behavior change, and strategies to STANDARD 7
credential that indicates specialized sustain self-management efforts Individualization
training beyond basic preparation is (12,13,19,74,86,98101). The diabetes self-management,
board certication in Advanced education, and support needs of each
The following core topics are commonly
Diabetes Management (BC-ADM) participant will be assessed by one or
part of the curriculum taught in
offered by the AADE, which is available more instructors. The participant and
for nurses, dietitians, pharmacists, comprehensive programs that have
demonstrated successful outcomes instructor(s) will then together develop
physicians, and physician assistants an individualized education and support
(68,74,87). (2,3,5,91,102104):
plan focused on behavior change.
Individuals who serve as lay health and c Describing the diabetes disease Research has demonstrated the
community workers and peer process and treatment options importance of individualizing diabetes
counselors or educators may contribute c Incorporating nutritional education to each participants needs
to the provision of DSME instruction and management into lifestyle (116). The assessment process is used to
provide DSMS if they have received c Incorporating physical activity into identify what those needs are and to
training in diabetes management, the lifestyle facilitate the selection of appropriate
teaching of self-management skills, c Using medication(s) safely and for educational and behavioral interventions
group facilitation, and emotional maximum therapeutic effectiveness and self-management support strategies,
support. For these individuals, a system c Monitoring blood glucose and other guided by evidence (2,63,116118). The
must be in place that ensures parameters and interpreting and assessment must garner information
supervision of the services they provide using the results for self- about the individuals medical history,
by a diabetes educator or other health management decision making age, cultural inuences, health beliefs and
care professional and professional back- c Preventing, detecting, and treating attitudes, diabetes knowledge, diabetes
up to address clinical problems or acute complications self-management skills and behaviors,
questions beyond their training (8890). c Preventing, detecting, and treating emotional response to diabetes,
For services outside the expertise of any chronic complications readiness to learn, literacy level (including
provider(s) of DSME and DSMS, a c Developing personal strategies to health literacy and numeracy), physical
mechanism must be in place to ensure address psychosocial issues and limitations, family support, and nancial
that the individual with diabetes is concerns status (11,106,108,117,119128).
connected with appropriately trained c Developing personal strategies to The education and support plan that the
and credentialed providers. promote health and behavior change participant and instructor(s) develop
STANDARD 6 will be rooted in evidence-based
While the content areas listed above approaches to effective health
Curriculum provide a solid outline for a diabetes
A written curriculum reecting current communication and education while
education and support curriculum, it is taking into consideration participant
evidence and practice guidelines, with
crucial that the content be tailored to barriers, abilities, and expectations. The
criteria for evaluating outcomes, will
match each individuals needs and be instructor will use clear health
serve as the framework for the provision
adapted as necessary for age, type of communication principles, avoiding
of DSME. The needs of the individual
participant will determine which parts of diabetes (including prediabetes and jargon, making information culturally
the curriculum will be provided to that diabetes in pregnancy), cultural factors, relevant, using language- and literacy-
individual. health literacy and numeracy, and appropriate education materials, and
comorbidities (14,105108). The using interpreter services when
Individuals with prediabetes and indicated (107,129131). Evidence-
content areas will be able to be adapted
diabetes and their families and based communication strategies such as
for all practice settings.
caregivers have much to learn to collaborative goal setting, motivational
become effective self-managers of their Approaches to education that are
interviewing, cognitive behavior change
condition. DSME can provide this interactive and patient centered have
strategies, problem solving, self-efcacy
education via an up-to-date, evidence- been shown to be effective (12,13,109
enhancement, and relapse prevention
based, and exible curriculum (8,91). 112). Also crucial is the development of strategies are also effective (101,132
The curriculum is a coordinated set of action-oriented behavioral goals and 134). Periodic reassessment can
courses and educational experiences. It objectives (1214,113). Creative, determine whether there is need for
also species learning outcomes and patient-centered, experience-based additional or different interventions and
effective teaching strategies (92,93). delivery methodsdbeyond the mere future reassessment (6,72,134137).
The curriculum must be dynamic and acquisition of knowledgedare effective A variety of assessment modalities,
reect current evidence and practice for supporting informed decision including telephone follow-up and other
guidelines (9397). Recent education making and meaningful behavior information technologies (e.g., Web based,
S148 National Standards Diabetes Care Volume 37, Supplement 1, January 2014

text messaging, or automated phone calls), benet from working with a nurse case intervention(s), using appropriate
may augment face-to-face assessments manager (6,86,146). Case management measurement techniques.
(72,87,138141). for DSMS can include reminders about Effective diabetes self-management can
The assessment and education plan, needed follow-up care and tests, be a signicant contributor to long-
intervention, and outcomes will be medication management, education, term, positive health outcomes. The
documented in the education/health behavioral goal setting, psychosocial provider(s) of DSME and DSMS will
record. Documentation of participant support, and connection to community assess each participants personal self-
encounters will guide the education resources. management goals and his or her
process, provide evidence of The effectiveness of providing DSMS progress toward those goals (151,152).
communication among instructional through disease management The AADE Outcome Standards for
staff and other members of the programs, trained peers and community Diabetes Education specify behavior
participants health care team, prevent health workers, community-based change as the key outcome and
duplication of services, and programs, information technology, provide a useful framework for
demonstrate adherence to guidelines ongoing education, support groups, and assessment and documentation. The
(117,135,142,143). Providing medical nutrition therapy has also been AADE7 lists seven essential factors:
information to other members of the established (711,86,8890,142,147 physical activity, healthy eating, taking
participants health care team through 150). medication, monitoring blood glucose,
documentation of educational While the primary responsibility for diabetes self-carerelated problem
objectives and personal behavioral goals diabetes education belongs to the solving, reducing risks of acute and
increases the likelihood that all the provider(s) of DSME, participants chronic complications, and psychosocial
members will work in collaboration benet by receiving reinforcement of aspects of living with diabetes
(86,143). Evidence suggests that the content and behavioral goals from their (93,153,154). Differences in behaviors,
development of standardized entire health care team (135). health beliefs, and culture as well as
procedures for documentation, training Additionally, many patients receive their emotional response to diabetes
health professionals to document DSMS through their primary care can have a signicant impact on how
appropriately, and the use of structured provider. Thus, communication among participants understand their illness and
standardized forms based on current the team regarding the patients engage in self-management. DSME
practice guidelines can improve educational outcomes, goals, and DSMS providers who account for these
documentation and may ultimately plan is essential to ensure that people differences when collaborating with
improve quality of care (135,143145). with diabetes receive support that participants on the design of
meets their needs and is reinforced and personalized DSME or DSMS programs
STANDARD 8
consistent among the health care team can improve participant outcomes
Ongoing Support members. (147,148).
The participant and instructor(s) will
together develop a personalized follow- Because self-management takes place Assessments of participant outcomes
up plan for ongoing self-management in participants daily lives and not in must occur at appropriate intervals. The
support. The participants outcomes and clinical or educational settings, interval depends on the nature of the
goals and the plan for ongoing self- patients will be assisted to formulate a outcome itself and the time frame
management support will be plan to nd community-based specied based on the participants
communicated to other members of the resources that may support their personal goals. For some areas, the
health care team. ongoing diabetes self-management. indicators, measures, and time frames
Ideally, DSME and DSMS providers will will be based on guidelines from
While DSME is necessary and effective, work with participants to identify such professional organizations or
it does not in itself guarantee a lifetime services and, when possible, track government agencies.
of effective diabetes self-care (113). those that have been effective with
Initial improvements in participants STANDARD 10
patients, while communicating with
metabolic and other outcomes have providers of community-based Quality Improvement
been found to diminish after resources in order to better integrate The provider(s) of DSME will measure
approximately 6 months (3). To sustain them into patients overall care and the effectiveness of the education and
the level of self-management needed to ongoing support. support and look for ways to improve
effectively manage prediabetes and any identied gaps in services or service
diabetes over the long term, most STANDARD 9 quality using a systematic review of
participants need ongoing DSMS (15). Patient Progress
process and outcome data.
The type of support provided can be The provider(s) of DSME and DSMS will Diabetes education must be responsive
behavioral, educational, psychosocial, monitor whether participants are to advances in knowledge, treatment
or clinical (1114). A variety of achieving their personal diabetes self- strategies, education strategies, and
strategies are available for providing management goals and other psychosocial interventions, as well as
DSMS both within and outside the outcome(s) as a way to evaluate the consumer trends and the changing
DSME organization. Some patients effectiveness of the educational health care environment. By measuring
care.diabetesjournals.org National Standards S149

and monitoring both process and for adults with type 2 diabetes: a meta- 15. Fjeldsoe BS, Marshall AL, Miller YD.
outcome data on an ongoing basis, analysis of the effect on glycemic control. Behavior change interventions delivered
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in Youth Study. Diabetes Care 2009;32
acknowledges Paulina Duker, ADA Staff 11. Anderson RM, Funnell MM, Nwankwo R, (Suppl. 2):S102S111
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