Additional Sites Application - Expansion site(s)

Application Information  
Signature Statement signed by

General Information (EHR / Symposium Q's)

Type of Electronic Health Record:
Epic Cerner
Centricity Chronicle
E-Clinical Works (ECW) Meditech
All Scripts Diaweb

Have you attended an ERP DSMES Symposium?
Has any of your staff attended an ADA ERP DSMES Symposium?
Reporting Period
Start Date:
End Date:
Expansion Site - Site Information Complete this information once for each expansion site included in the application
Site Name and Contact Information:
Site URL:
Add 1:
Add 2:
Postal Code:
Site Service Area
Urban Rural Suburban
Expansion Site Information
You must be able to answer Yes to all the questions on this page.
There is evidence to show that each of the following items is the SAME at the expansion site as it is at the site from which you are expanding:
The DSMES entity has documentation of DSMES service stakeholder names and how each may provide purposeful input and/or advocacy.
The DSMES service has assessed their target oopulation’s demographics, diabetes types, DSMES preferences and needs and DSMES barriers to DSMES and compared these to the services provided to identify any gaps and develop a plan to address them.
A quality coordinator is designated to oversee the planning, implementation, and evaluation of the DSMES services at all times. The coordinator has the appropriate number of CE credits if not CDCES or BC-ADM per the standard guidelines.
Diabetes self-management education is provided by one or more team members. The team members have recent educational and experiential preparation in education and diabetes management and are a CDCES or BC-ADM.. or non-CDCES or non-BC-ADM team members have obtained regular continuing education in the field of diabetes management education and support. At least one of the professional team members is a registered nurse, dietitian, pharmacist, CDCES, or BC-ADM. Diabetes Community Care Coordinators (DCCC), previously known as Paraprofessional team members, are supervised by a professional team member and supervision is documented. There is proof of DCCC's diploma, certification, previous experience or training. DCCC must demonstrate training and competency in DSMES topics taught. DCCC must have documentation of 15 hours of diabetes or diabetes related training and competency in the DSMES topics taught before teaching and annually.
A written curriculum reflecting current evidence and practice guidelines, serves as the framework for the DSMES entity, including teaching approaches and method of evaluating learning that are interactive, participant-centered and incorporate problem solving. There is evidence of regular review and revisions as needed, at least annually, of the curriculum and/or course materials. All DSMES services must have a process to ensure that the participant's needs that are outside fo the scope of practice of the DSMES team or service are met.
An individual assessment and education plan is developed collaboratively by the participant and team members to direct the selection of appropriate educational interventions and self-management support strategies. This assessment, education plan, education intervention and education outcomes are documented in the education record.
The DSMES entity measures attainment of participant defined goals and other participant outcomes (clinical or quality of life) at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention.
The education planned or provided and at least one outcome is communicated back to the referring provider or other healthcare providers.
The DSMES entity measures at least every 6 months the effectiveness of the education and/or process and determines opportunities for improvement using a written continuous quality improvement (CQI) plan that describes and documents a systematic review of the entities' process and outcome data
The DSMES entity aggregates at least one behavioral goal and one other participant clinical or quality of life outcome at least annually.
Paper Audit Item(s) and Misc. Documentation This lists the files you may need
A formal description of CQI process and current project
Documentation of annual program review and/or plan and advisory committee activities
A copy of a de-identified patient chart showing complete education process
A copy of a full section of Program's "Nutrition" curriculum
A copy of a full section of Program's "Medication" curriculum
A copy of a full section of Program's "Goals Setting and Behavior Change" curriculum
Support Documentation