Annual Status Report

Application Information  
Signature Statement signed by
Name:
Title:
Phone:
Reporting Period
Start Date:
End Date:
Services Information  

Standard 1 - Support for DSMES Services

Sponsoring Organization Name:

Administrative Officer:
Name:
Title:
Phone:
Fax:
Email:
Add 1:
Add 2:
City:
State:
Postal Code:

Standard 1 - Stakeholders

The DSMES service has identified external service stakeholders
The DSMES service has identified how each stakeholder may provide purposeful input and/or advocacy
The stakeholders will be reviewed/revised annually

Quality Coordinator

Contact Information:
Name:
NPI Number:
Imported Coach ID:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:

General Information (EHR / Symposium Q's)

Type of Electronic Health Record:
Epic Cerner
Centricity Chronicle
E-Clinical Works (ECW) Meditech
All Scripts Diaweb
Other:
None

Have you attended an ERP DSMES Symposium?
Has any of your staff attended an ADA ERP DSMES Symposium?
Multi Site - Site Information Complete this information once for each multi-site included in the application
Site Name and Contact Information:
Name:
Site URL:
Phone:
Fax:
Add 1:
Add 2:
City:
State:
Postal Code:
County:
Spanish:
Single Discipline:
Patients are seen in a year
Total patients seen in last 12 months:
What other services are provided in addition to DSMES?
CDC DPPE with pending Recognition CDC DPPE with full Recognition
What Can I Eat (WCIE) Insulin pump services
Continuous glucose monitoring (CGM) services Medical nutrition therapy (MNT)
Medical/clinical (including lab) Exercise facility
Foot screenings Other nutrition counseling
Intensive behavioral therapy None
Complete Recognition Standards Questionnaire
Yes No If no a reason will be required.
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.
  Outcome Target %   Actual %
Behavioral Outcome(s)
Nutritional Management
Physical Activity/Being Active
Taking medications
Monitoring
Acute complications/Problem Solving
Chronic complication/Reducing Risks
Psychosocial Adjustment/healthy Coping
Other: ______________________________
Other Participant Outcomes
A1c - % of pt that have 2 or more A1c values documented
A1c - Actual decrease in value - Example Target 1.5 and Actual 1.0. Do not include a “-“ in the box*
A1c - % of participants with decrease - Example Target is 50% and actual 75%. *
Eye Exam
Foot Exam
BP
Lipids
Quality of Life
Weight - % of pt that have 2 or more weight values documented
Weight Change - Actual decrease in value - Example Target 10(lbs) and Actual is 8(lbs) Do not include “-“ in the box. *
Weight Change - % of participants with decrease - Example Target is 50% and actual 75%. *
Patient Experience
Hospital Admissions – Due to Diabetes - Actual decrease in value
Hospital Admissions – Due to Diabetes - % of participants with decrease*
ER Visits – Due to Diabetes - Actual decrease in value
ER Visits - Due to Diabetes - % of participants with decrease *
Other: ______________________________

Multi Site - Site Information Complete this information once for each multi-site included in the application
Site Name and Contact Information:
Name:
Site URL:
Phone:
Fax:
Add 1:
Add 2:
City:
State:
Postal Code:
County:
Complete Recognition Standards Questionnaire
Yes No If no a reason will be required.
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.