Annual Status Report

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

Sponsoring Organization

Sponsoring Organization Name:

Administrative Officer:
Name:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:

Quality Coordinator

Contact Information:
Name:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:

General Information

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

Multi Site - Site Information Complete this information once for each multi-site included in the application
Site Name and Contact Information:
Name:
Phone:
Fax:
Add 1:
Add 2:
Spanish:
Single Discipline:
Patients are seen in a year
Total patients seen in last 12 months:
  Outcome Target %   Actual %
Behavioral Outcome(s)
❑ Nutritional Management/Healthy Eating
❑ Physical Activity/Being Active
❑ Taking medications
❑ Monitoring
❑ Preventing, detecting, treating acute complications/Problem Solving
❑ Preventing, detecting, treating chronic complication/Reducing Risks
❑ Psychosocial Adjustment/healthy Coping
❑ Other: ______________________________
Other Participant Outcomes
❑ A1c
❑ Eye Exam
❑ Foot Exam
❑ BP
❑ Lipids
❑ Quality of Life
❑ Weight Change
❑ Patient Experience
❑ Other: ______________________________
Recognition Standards
❑ The DSMES entity has documentation of it's organizational structure, mission statement, and goals, and recognizes and supports quality DSMES as an integral component of diabetes care.
❑ The DSMES entity has documentation that an established DSMES advisory system exists which involves external stakeholders. There is documented evidence of at least annual input from external stakeholders of the program. (If the program is single discipline, at least one external stakeholder must be a healthcare provider of a different discipline.)
❑ The DSMES entity has assessed the diabetes educational needs of the population it serves and addressed how to meet those needs if applicable.
❑ A coordinator is designated to oversee the planning, implementation and evaluation of diabetes self-management education. The coordinator has academic or experiential preparation in chronic disease care and education and in program management. The coordinator has appropriate number of CE credits if not CDCES or BC-ADM.
❑ Diabetes self-management education is provided by one or more instructors. The instructors have recent educational and experiential preparation in education and diabetes management or are a Certified Diabetes Educator. All non-CDCES or non-BC-ADM instructor(s) have obtained regular continuing education in the field of diabetes management and education. At least one of the instructors is a registered nurse, dietitian, pharmacist or a CDCES/BC-ADM. For single discipline programs a mechanism is in place to ensure that the participant's needs are met, if those needs are outside the instructors' scope of practice and expertise. Paraprofessionals are supervised by a professional instructor and supervision is documented. There is proof of Paraprofessional's diploma, certification, or training. Paraprofessionals must demonstrate training or competency in program topics taught. There must be documentation of 15 hours of diabetes or diabetes related training 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, patient-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 by DSMES instructor(s).
❑ An individual assessment and education plan is developed collaboratively by the participant and instructor(s) to direct the selection of appropriate educational interventions and self-management support strategies. This assessment and education plan and the intervention and follow-up with outcomes assessment are documented in the education record.
❑ A personalized follow-up plan for on-going self management support is developed collaboratively by the participant and instructor(s). The patient's outcomes and goals, and the plan for on-going self management support are communicated with other healthcare team members.
❑ The DSMES entity measures attainment of patient-defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention.
❑ The DSMES entity measures the effectiveness of the education 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
Expansion Site - Site Information Complete this information once for each expansion site included in the application
Site Name and Contact Information:
Name:
Phone:
Fax:
Add 1:
Add 2:
 
Recognition Standards
❑ The DSMES entity has documentation of it's organizational structure, mission statement, and goals, and recognizes and supports quality DSMES as an integral component of diabetes care.
❑ The DSMES entity has documentation that an established DSMES advisory system exists which involves external stakeholders. There is documented evidence of at least annual input from external stakeholders of the program. (If the program is single discipline, at least one external stakeholder must be a healthcare provider of a different discipline.)
❑ The DSMES entity has assessed the diabetes educational needs of the population it serves and addressed how to meet those needs if applicable.
❑ A coordinator is designated to oversee the planning, implementation and evaluation of diabetes self-management education. The coordinator has academic or experiential preparation in chronic disease care and education and in program management. The coordinator has appropriate number of CE credits if not CDCES or BC-ADM.
❑ Diabetes self-management education is provided by one or more instructors. The instructors have recent educational and experiential preparation in education and diabetes management or are a Certified Diabetes Educator. All non-CDCES or non-BC-ADM instructor(s) have obtained regular continuing education in the field of diabetes management and education. At least one of the instructors is a registered nurse, dietitian, pharmacist or a CDCES/BC-ADM. For single discipline programs a mechanism is in place to ensure that the participant's needs are met, if those needs are outside the instructors' scope of practice and expertise. Paraprofessionals are supervised by a professional instructor and supervision is documented. There is proof of Paraprofessional's diploma, certification, or training. Paraprofessionals must demonstrate training or competency in program topics taught. There must be documentation of 15 hours of diabetes or diabetes related training 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, patient-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 by DSMES instructor(s).
❑ An individual assessment and education plan is developed collaboratively by the participant and instructor(s) to direct the selection of appropriate educational interventions and self-management support strategies. This assessment and education plan and the intervention and follow-up with outcomes assessment are documented in the education record.
❑ A personalized follow-up plan for on-going self management support is developed collaboratively by the participant and instructor(s). The patient's outcomes and goals, and the plan for on-going self management support are communicated with other healthcare team members.
❑ The DSMES entity measures attainment of patient-defined goals and patient outcomes at regular intervals using appropriate measurement techniques to evaluate the effectiveness of the educational intervention.
❑ The DSMES entity measures the effectiveness of the education 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