Original Application

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:

DSMES Oversight / Planning

Standard 2 Stakeholder Input
❑ Verify that there is evidence that the established advisory system provides input at least annually for planning DSMES operations and oversight for quality of services provided by the DSMES.
❑ Verify that there is documentation that an established DSMES advisory system exists which involves external stakeholders (If the program is single discipline, at least one stakeholder must be healthcare provider of a different discipline). Verification that there is documented evidence of at least annual input from external stakeholders of the program.
Population Served:
❑ Population served assessment
❑ Program Resources relative to the population served
Methods of Oversight Involvement:
❑ Group Meetings ❑ Phone calls ❑ Email
❑ Ballots ❑ Surveys
❑ Other:

Quality Coordinator

Contact Information:
Name:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:
Certifications:
Credentials:
Cont'ing Ed:
If the Quality Coordinator is not a CDCES or BC-ADM:
❑ There is documentation to support that this Staff member has received 15 or 20 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 evaluation of the DSMES entity at all sites.

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:
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?
❑ Medical/clinical (including lab) ❑ Exercise facility
❑ Foot screenings ❑ Other nutrition counseling
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:

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:

Multi Site - Site Information (Continued) Complete this information once for each multi-site included in the application
Site Service Area
❍ Urban ❍ Rural ❍ Suburban
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
Site DSMES method(s)
❍ 1:1 ❍ Group ❍ 1:1 and Group
Continuous Quality Improvement (CQI) Process at this Site
❑ There is documentation that the DSMES Provider(s) measure or plan to measure the effectiveness of the education (and support if applicable), and look for ways to improve any identified gaps in services or service quality using a systemic review of process and outcome data.
Topics / Content
❑ Diabetes disease process and Treatment options
❑ 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
❑ Developing strategies to address psychosocial issues
❑ Developing strategies to promote health/change behavior
Elements
❑ Evidence that the teaching approach is interactive, patient centered and incorporates problem solving
❑ Methods of delivery
❑ Methods of evaluation
Education records from this site
❑ Referral from a provider managing patient's diabetes if insurance requires one
❑ A 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
❑ An education plan which includes patient-selected behavioral objectives based on the assessed needs of the participant
❑ Educational interventions which include the date of intervention, content taught and the name(s) of the Instructional Staff, or Resource Person
❑ Evaluation of progress towards/or achievement of learning and behavioral objectives and related outcomes
❑ Communication with other members of the Health Care Team, including plan for diabetes self-management support (DSMS)
  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: ______________________________

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
Name:
No. of hours per month in DSMES during reporting period:
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:
Title:
Diploma or Certification
Certificate, Diploma, or Training:
❑ Proof of training
Description:
Expiration date:
❑ Does not expire
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