DSME Accreditation Allows Pharmacists to Help Patients Self-Manage Diabetes, Enjoy The Foods They Love

Travis Wolff, PharmD, BCACP, the CEO and founder of PharmFurther and director of CPESN Medical Billing Special Purpose Effort in Sapulpa, Oklahoma, joins Pharmacy Times to discuss diabetes self-management education (DSME), an accreditation that pharmacists can get which allows them to educate patients with diabetes on how to manage symptoms and bill Medicare without needing provider status. Wolff dives into the 7 self-care behaviors associated with DSME, an NCPA resource that teaches pharmacists the most efficient way to get DSME accreditation.

Moreso, February is American Heart Month and it's important to remember that there is a significant link between diabetes and cardiovascular risk. Wolff dives into the overlap between diabetes and risk of cardiovascular disease, and discusses how DSME can be beneficial for higher-risk patients.

Travis Wolff, PharmD, BCACP: My name is Travis Wolff, I'm coming to you as the CEO and founder of PharmFurther. We work with community pharmacies in a space where we're able to implement clinical opportunities into a traditional dispensing workflow.

Some of our more notable work in coaching pharmacies coast-to-coast has been our diabetes self-management education accreditation bootcamp, which we teach with the National Community Pharmacists Association (NCPA). We are proud to say that we have presented that to all the states as well as Puerto Rico and the Virgin Islands because they can bill Medicare; that is a statute that allows for Centers for Medicare and Medicaid Services (CMS) billing opportunities for pharmacies so that you don't have to have provider status as a pharmacist.

PT Staff: Can you please go into this? What is Diabetes self-management education?

Travis Wolff, PharmD, BCACP: Yes, so let's talk about acronyms first, Erin, because I think that people get stuck when they go look things up. So there's DSME, which is diabetes self-management education. There's DSMT, where the T stands for training, and there's DSMES, which is education and specialist services (you have several different words with the S usually). [For] the person with diabetes, we're trying to teach them how to self-manage their disease state.

There's a lot that happens in other healthcare forms and different settings that help [patients] to manage the more technical stuff, but we want [patients] to be able to self-manage. There is an accreditation process— you can choose to be accredited through the Association of Diabetes Care & Education Specialists (ADCES) or American Diabetes Association (ADA)—those are the 2 accrediting bodies recognized by CMS.

DSME is a statute that was passed by Medicare, and so that's where we get a tremendous opportunity—every Medicare patient under that statute is available to get 10 hours of initial DSME. The first 1 or 2 [hours] of that is a 1:1 office visit, just like a medical practice would do. The other 8 or 9 hours, depending on how the patient has needs because an individualized approach is much, much desired right now and very much pushed by the accrediting agencies, should be in a group setting. The reimbursement follows that because they are trying to encourage that peer-to-peer learning, but they can also learn a lot of self-management skills, like where they're buying the bread with the low carbs and the high fiber, and what they do when they go to Thanksgiving (what types of foods they must avoid, what do they like to eat).

We've really evolved from the traditional diabetes educator that was very much in the “Don't eat this, don't eat that, only eat 45 to 60 grams of carbs at every meal, etc…”. [With the old model], we're setting them up for failure and a strenuous regimen that they could not meet. We've done a great job as we've moved to evolve it to be an individualized approach, where we really focus on what is important to that patient in their culture, in their community and the foods they eat.

[Now] I would ask you (if you are newly diagnosed or if you're struggling to manage previously diagnosed diabetes) what types of foods are important to you, and let's teach you how much of that you can eat (what's the portion size, things that you would need to avoid or cut back in and that same meal).

The other big thing we've done a good job [with] is kind of individualizing goals as well. So now we need to have a new algorithm where we're focusing on goals that are specific to [the patients’] other disease states and their age. So, we can consider those other risk factors. And that's all part of it.

The DSME is built around 7 self-care behaviors. I know we're getting ready to celebrate cardiovascular month and so, when we look at that the 7 self-care behaviors, there's a ton of overlap [about] how we can really help persons with diabetes that also are at high risk for cardiovascular disease. [Among] those 7 self-care behaviors (we can dive in as deep as you want on this, I can talk about this all day) healthy eating is 1 [of them]. This of course [has] lots of overlap with cardiovascular disease. Being active [is number 2] and it again overlaps [with CVD] and there is great, great opportunity there.

Monitoring (number 3) is a big one. So on the diabetes-front, we would talk about correct use of your glucometer when to check your blood glucose levels. Also in the monitoring, we want them to learn how to take action, right? “What do I do when my blood pressure my blood sugar is high or when it's low.”

So the overlap there with cardiovascular [health], as we go to celebrate that this month and try to really get the prevention message out there, is how it's 1 thing to stick your finger and have blood involved and try to make decisions, but I feel like a blood pressure monitor is so much more available and easier to use. And we really don't take advantage of that. So monitoring could be a great impact pharmacists can have on helping people be aware of their blood pressure [which can be beneficial for diabetes and cardiovascular management].

I also find that we don't always get that message where it needs to be. I feel like a lot of patients have ended up in a crisis down the road (whether it's immediate or long-term) because they were on blood pressure medicine (so they were on the radar) but even though we had continuous measurements out of range, the medication was never adjusted or changed [and] the lifestyle was never addressed. I think pharmacists can have a great effect on that through the DSME program because, if you take a blood pressure in your pharmacy and then you are now making a recommendation to the doctor, it kind of comes out of left field because pharmacists are still trying to get our seat at the table with DSME.

Part of the accreditation is continuity-of-care and proving that your communication patterns to the doctor happen in the education. So now there's a formal relationship as if you're another provider because we must get a referral from that provider to actually see and bill for the time that we're helping the patient. So now they're referred out and we now have a provider-to-provider relationship. When [a pharmacist] sends communication after the first office visit with the patient, this is part of the accreditation (and everyone else should be doing this too). [This way] we can tell the physician “Here are the things we found in the office visit that we think the patient really needs help on, and here's what we're going to focus on. Please tell me if there's something else that we missed that you have seen that we should also focus on.”

Here's the beauty. When [the patient] is present for their 1-on-1 or for their group class, we should be triaging them, just like a doctor's office— we should be taking their blood pressure and their weight (at minimum) and we report these values and our progress reports for our accreditation every year. S

In this process, if I take someone's blood pressure and it's out of range— and if it is out of range more than once (we're following the algorithm of 1 to 3 times)— we have a natural progression to formally send the recommendation [for adjusting or changing a medication] as a diabetes educator, a right to tell the doctor “I found this blood pressure out of range.”

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And blood pressure is so easy for pharmacists; even if you don't have prescribing rights, what you can do is ask for reasonable request from the doctor. At minimum, you can increase the dose of what they're already on. And people don't realize that all electronic prescriptions have a tab somewhere in that remittance data that shows the blood pressure last taken and the date and the doctor's office. If we are getting that data anyway, why wouldn't we also follow up on that, and now we have a formal way? I think it's a great opportunity.

So monitoring (number 3) and taking medication is number 4. We also talked through cardiovascular disease prevention when taking medication. The last 3 self-care behaviors taught in DSME are problem-solving— I think that's a great one, right? We can do a lot of great, great good in diabetes and in cardiovascular outcomes, too. There are some problem-solving issues where we might need nitro or we might be in a hypertensive urgency, or “What do I do if I have weighed myself and I have heart failure and I'm I gained 7 pounds overnight?”That's totally problem-solving. There's a lot of overlap for cardiovascular outcomes with diabetic diabetes—

Reducing risk is the number 6 self-care behavior. Obviously, that is huge overlap with cardiovascular disease. Most of our cardiovascular disease should be prevention as and try to be proactive as opposed to reactive. And then healthy coping healthy coping is the other one (number 7). Obviously with COVID-19 and everything else we have going on in the world, depression is a big risk for everybody at this point, and now we lay on [a patient] who's getting reprimanded in a physician-type setting because their blood sugar is unmanaged, or their blood pressure is unmanaged. [While] a lot of that is lifestyle, a lot of that is hereditary too.