Original Application

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

Standard 2 - Population and Service Assessment

❑ Verify that there is at least annual documented evidence of an assessment of the target Population the DSMES service serves
❑ There is documentation showing DSMES Service Design and Resources relative to the population served
❑ There is documentation showing plan to address any identified barriers or gaps in service

Quality Coordinator

Contact Information:
Name:
NPI Number:
Imported Coach ID:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:
Certifications:
Credentials:
Certificates & Credentials
Certifications
❑ CDCES ID #: Exp:
❑ BC-ADM ID #: Exp:
❑ Other cert:
Credentials
❑ RN Lic. #: Exp:
❑ RD CDR #: Exp:
❑ Pharm Lic. # Exp:
❑ Exercise Physiologist Prof. Reg. #: Exp:
❑ Physician Prof. Reg. #: Exp:
❑ Physician's Assistant Prof. Reg. #: Exp:
❑ Podiatrist Prof. Reg. #: Exp:
❑ Social Worker Prof. Reg. #: Exp:
❑ Other Prof. Reg. #: Exp:
If this staff member is not a CDCES or BC-ADM
❑ There is documentation to support that this Staff member has received 15 contact hours in any one or a combination of diabetes specific topics, diabetes related topics, psychosocial topics, or educational topics within the 12 months prior to the date this application is being entered online.
Job Description
❑ Has academic preparation and/or experiential preparation in program management.
❑ Has academic preparation and/or experiential preparation in the care of persons with a chronic disease.
❑ Oversees the planning, implementation, and quality evaluation of the DSMES services at all sites.

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:
How many years has the Site offered DSMES as an ADA Recognized program?
❍ Less than 1 ❍ 1-2 ❍ 3-5
❍ 6 or more        
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
Total number of participants during reporting period
Comprehensive and/or Initial:
Post Program Instruction:
Total:
Average hours of DSMES received by participants during reporting period
Comprehensive and/or Initial:
Post Program Instruction:
Age of participants receiving DSMES during reporting period
More than 65 years of age:
45-64 years of age:
19-44 years of age:
Less than 19 years of age:
Total:
Diabetes type of participants receiving DSMES during reporting period
Pre-diabetes
0-18 years old:		   Pre-diabetes
19+ years old:
Type 1
0-18 years old:		   Type 1
19+ years old:
Type 2
0-18 years old:		   Type 2
19+ years old:
GDM:   Other:
  Total:
Race/ethnicity of participants receiving DSMES during reporting period
❑ American Indian or Alaskan Native ❑ Asian/Chinese/Japanese/ Korean/Pacific Islander
❑ Black/African American ❑ Hispanic/Chicano/Cuban/ Mexican/Puerto Rican/Latino
❑ White/Caucasian ❑ Middle Eastern
Special needs of participants receiving DSMES during reporting period
❑ Physically disabled ❑ Visually impaired
❑ Hearing impaired ❑ Low literacy
❑ English as a second language    
❑ Other:

❑ None:

Unique features of the site
❑ Print augmentation ❑ Interpreters
❑ Low literacy education tools ❑ Physical plant enhancements
❑ Transportation opportunities ❑ Allowances for cultural diversity
❑ Languages other than English    
❑ Other:
❑ None:

Site Service Area
❍ Urban ❍ Rural ❍ Suburban
Multi Site - Site Information (Continued) Complete this information once for each multi-site included in the application
Site Setting
❑ Community based ❑ Pediatric
❑ Home health ❑ RD practice
❑ Outpatient hospital based ❑ Nurse Practitioner practice
❑ Long term care facility ❑ Long-distance learning/telemedicine
❑ Pharmacy ❑ Skilled Nursing Facility
❑ Physician practice ❑ Patient Centered Medical Home
❑ Worksite health ❑ Government or public health
If Government or public health:
❑ Federally Qualified Health Clinic ❑ Veterans Administration
❑ Indian Health Services ❑ Department of Health
❑ Rural health clinic ❑ Other
❑ Military
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)
❑ Intensive behavioral therapy ❑ Medical/clinical (including lab)
❑ Exercise facility ❑ Foot screenings
❑ Other nutrition counseling ❑ None
Site DSMES method(s)
❍ 1:1 ❍ Group ❍ 1:1 and Group
Setting(s) used for DSMES - You must be able to answer Yes to at least one of the questions in this block.
❑ In person
❑ Telehealth (meeting CMS requirements)
❑ Other virtual offerings
Topics / Content You must be able to answer Yes to all the questions on this page.
❑ Diabetes Pathophysiology:
❑ Incorporating nutritional management into lifestyle
❑ Incorporating physical activity into lifestyle
❑ Using medications safely
❑ Monitoring blood glucose, interpreting and using results
❑ Prevention, detection and treatment of acute complications
❑ Prevention, detection and treatment of chronic complications
❑ Lifestyle and healthy coping
❑ Diabetes distress and support
Elements
❑ Evidence that the teaching approach is individualized, interactive, patient centered and incorporates problem solving
❑ Each topic includes objectives, methods of delivery and methods of evaluation
❑ There is a documented process for meeting DSMES participants needs that are out of scope of the DSMES team or service
❑ Documentation reflecting at least annual review/revision of the curriculum and/or supporting materials
Education records from this site You must be able to answer Yes to all the questions on this page.
❑ Documentation of a referral from a provider managing participant's diabetes if insurance requires one
❑ Documentation of comprehensive assessment of the participant's diabetes knowledge, self-management skills, diabetes- and health-related behaviors, behavior change potential, and other relevant information including medical history
❑ Documentation of baseline assessment of the DSMES service wide monitored clinical or quality of life measure
❑ Documentation of participants DSMES education plan and behavioral goals
❑ Documentation of educational interventions which include the date of intervention, content taught and the name(s) of the DSMES team members'
❑ Documentation of an evaluation of education outcomes and behavioral goals
❑ Documentation of an assessment of the DSMES service wide monitored clinical or quality of life measure after one or more DSMES encounters
❑ Documentation of communication with referring provider (if applicable) or other healthcare provider outside of the DSMES team
Continuous Quality Improvement (CQI) Process At This Site You must be able to answer Yes to all the questions on this page.
❑ There is documentation of at least one category of participant behavioral goal outcome identified and aggregated at a minimum annually
❑ There is documentation of at least one other participant clinical or quality of life outcome identified and aggregated at a minimum annually
❑ There is documentation that the DSMES Provider(s) measure or plan to measure the effectiveness of the DSMES services on an ongoing basis so the Recognized DSMES team can identify areas for improvement and adjust engagement strategies and service offerings to optimize outcomes.
❑ Opportunity for DSMES Service improvement or change.
❑ Project outcome targets
❑ Project assessment and evaluation schedule at a minimum of every 6 months
  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 - Team Member Information Complete this information once for each staff member included in the application

Note about Resource Staff and Temporary Staff: Resource staff and temporary staff are not required to obtain 15 hours of CEUs annually and should not be added to the application. Resource staff are professionals that teach less than 10% of the entire program. Instructors that fill in for permanent staff and are with the program less than 4 months are considered temporary instructors and are not required to be on the application.

Instructional Staff Members at this Site
Instructional Staff Member
Title:
Name:
Credentials:
NPI Number:
Imported Coach ID:
Title:
Email:
❑ Assistant Coordinator:
❑ Mental Health Trained:
No. of hours per month in DSMES during reporting period:
Certificates & Credentials
Certifications
❑ CDCES ID #: Exp:
❑ BC-ADM ID #: Exp:
❑ Other cert:
Credentials
❑ RN Lic. #: Exp:
❑ RD CDR #: Exp:
❑ Pharm Lic. # Exp:
❑ Exercise Physiologist Prof. Reg. #: Exp:
❑ Physician Prof. Reg. #: Exp:
❑ Physician's Assistant Prof. Reg. #: Exp:
❑ Podiatrist Prof. Reg. #: Exp:
❑ Social Worker Prof. Reg. #: Exp:
❑ Other Prof. Reg. #: Exp:
If this staff member is not a CDCES or BC-ADM
❑ There is documentation to support that this Staff member has received 15 contact hours in any one or a combination of diabetes specific topics, diabetes related topics, psychosocial topics, or educational topics within the 12 months prior to the date this application is being entered online.

Paraprofessionals at this Site

Examples are LPN, Dietary Tech, Community Health Worker, MA, Lab Technician, Yoga Instructor or a Personal Trainer.
Paraprofessional Staff Member
Name:
Credentials:
NPI Number:
Imported Coach ID:
Title:
Email:
❑ Assistant Coordinator:
❑ Mental Health Trained:
Diploma or Certification
Certificate, Diploma, or Training:
❑ Proof of training
Description:
Expiration date:
❑ Does not expire
❑ Lifestyle Coach:
❑ Lifestyle Coach Master Trainer:
Paraprofessional Information
Paraprofessional Information
No. Hours worked per Month during Reporting Period:
Hours of Diabetes Program related training:
Paraprofessional Supervised By:
Documentation
❑ There is annual documentation that the paraprofessional educator is competent in the areas of the DSMES program taught
❑ There is documentation of supervision by a professional educator
Paper Audit Item(s) and Misc. Documentation This lists the files that are required for this application
❑ Quality Coordinator's Job description and CV or Resume
❑ 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