Renewal 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:

DSME Oversight / Planning

DSME Advisory System:
Verify that there is evidence that the established advisory system provides input at least annually for planning DSME operations and oversight for quality of services provided by the DSME.
Verify that there is documentation that an established DSME 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:

Program Coordinator

Contact Information:
Name:
Title:
Email:
Phone:
Fax:
Add 1:
Add 2:
Certifications:
Credentials:
Cont'ing Ed:
If the Program Coordinator is not a CDE 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 DSME entity at all sites.
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 this site offered DSME?
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 DSME?
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 DSME received by participants during reporting period
Comprehensive and/or Initial:
Post Program Instruction:
Age of participants receiving DSME 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 DSME 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 DSME 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 DSME 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 DSME method(s)
1:1 Group 1:1 and Group
Continuous Quality Improvement (CQI) Process at this Site
There is documentation that the DSME 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 Satisfaction
Other: ______________________________

Multi Site - Staff 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 DSME during reporting period:
Certifications
CDE 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 CDE 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
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:
Service Area
What is the service area around this site considered:
Urban Rural Suburban
Expansion Site Information
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:
Curriculum
At least one instructor who is RN, RD or pharmacist
Instructors who have the academic credentials to sit for the CDE exam
Instructors are CDE, BC-ADM or have CEU's in the past 12 months
Continuous Quality Improvement Process and Current Project
Policies and Procedures
Educational Chart Forms
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