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1 LEARNING OBJECTIVES DIABETES PREVENTION AND DSMES IN VIRGINIA: AN OPPORTUNITY FOR PHARMACISTS ANNE WOLF, MS,RD & ANNA PEOPLES, PHARM D Define prediabetes, the burden and progression to diabetes Understand the evidence behind effectiveness of lifestyle change for diabetes prevention Provide tools and resources that support diabetes prevention in a pharmacist s practice Describe Diabetes Self-Management and Support (DSMES) Demonstrate measurable self-care behaviors of diabetes Demonstrate proper documentation practices necessary for DSME and reimbursement WHAT IS PREDIABETES Prediabetes is a condition in which blood glucose or hemoglobin A1c (HbA1C) levels are higher than normal but not high enough to be classified as diabetes DIABETES PREVENTION ANNE WOLF, MS,RD VIRGINIA CENTER FOR DIABETES PREVENTION & EDUCATION DEFINITION BY TYPE OF TEST WHY IS PREDIABETES IMPORTANT? BURDEN 30.3 million with Diabetes 84.1 million with Prediabetes 33.9% of population 9 out of 10 don t know they have it Centers for Disease Control. National Diabetes Statistic Report,

2 Diabetes Incidence per 100 Person-Years Diabetes Incidence per 100 Person-Years BURDEN OF PREDIABETES IN VIRGINIA WHY IS PREDIABETES SO IMPORTANT? 2.1 million Virginians have Prediabetes $1.1 million direct cost in x number of ambulatory visits -diabetes 1.5 x number of hypertension visits Population with prediabetes is heterogeneous and those at the higher end of the prediabetes spectrum have a higher risk of developing type 2 diabetes WHY IS PREDIABETES SO IMPORTANT? DIABETES IS PREVENTABLE Lifestyle management is the cornerstone of all prevention efforts Weight loss: 5-7% Increase physical activity to at least 150 minutes per week Healthy eating pattern with reduced calories INTENSIVE LIFESTYLE INTERVENTION EFFECTIVELY PREVENTS PROGRESSION FROM IGT TO TYPE 2 DIABETES Diabetes Prevention Program (N=3234) 58% % Intensive lifestyle intervention* (n=1079) Metformin 850mg BID (n=1073) Placebo (n=1082) DPP Research Group. N Engl J Med. 2002;346: LIFESTYLE INTERVENTION MORE EFFECTIVELY PREVENTS DIABETES AS POPULATIONS AGE % 6.2 Diabetes Prevention Program (N=3234) 59% % 10- YEAR INCIDENCE OF TYPE 2 DIABETES Placebo Metformin Lifestyle DPP Outcomes Study (N=2766) Lifestyle Age (years) Years DPP Research Group. N Engl J Med. 2002;346: DPP Research Group. Lancet. 2009;374:

3 % Weight Loss RESEARCH EFFECTIVELY TRANSLATED TO COMMUNITY FIVE STEPS TO HELP PREVENT TYPE 2 DIABETES months 1 Year 1. Create Awareness 2. Identify Patients with Prediabetes Educate At-Risk Patients 4. Refer Patients to Evidence-based Diabetes Prevention Programs 0 DPP YMCA DEPLOY YMCA RAPID Weight Watchers Montana HELP PD AADE NDPP Canary Health Omada Alive PD 5. Follow up on Weight Loss Progress In-person Group Digital/ Human Digital/ Automated Adapted from Institute for Clinical and Economic Review, and DiBenedetto JC, et al. The Diabetes Educator Online doi: / STEP 1. CREATE AWARENESS AVAILABLE MATERIAL FOR PATIENTS Among Patients Hang educational posters in office Provide educational handouts Diabetes-self- assessment tests Engage & collaborate in community & church health events Among Clinicians Raise awareness among colleagues and clinicians Evidence-based diabetes prevention Importance of screen & refer Material Available: Diabetes STAT Toolkit STEP 2. IDENTIFY AT-RISK PATIENTS Prospectively Diabetes risk assessment in waiting area Retrospectively Query in EHR BMI* > 25 (> 23 kg/m 2 for Asian Americans), and Blood glucose/hba1c levels in prediabetes range, or History of Gestational Diabetes STEP 3. EDUCATE AT-RISK PATIENTS Focus on four key messages Prediabetes is a serious condition Prediabetes is treatable Losing 5-7% of your body weight is the goal for diabetes prevention pounds for someone who weighs 200 pounds Increasing physical activity and eating healthier foods are key to weight loss and health Evidence-based diabetes prevention programs are available 3

4 STEP 4. REFER PATIENTS TO EVIDENCE-BASED DIABETES PREVENTION PROGRAM DIABETES PREVENTION PROGRAMS, VIRGINIA 2017 DiabetesLocal Use CDC s registry for programs in Virginia: spx Check local YMCA programs Have patient check with their employers Virtual programs: Omada Health, Solera Health, Canary Health, Retrofit Diabetes Prevention Programs GROWTH OF CDC RECOGNIZED PROGRAMS IN VA STEP 5. FOLLOW UP ON PROGRESS Increase from 8 sites in January 2016 to 44 sites in March Free Clinics 1 Rural Health Center 9 Health Systems 4 YMCA s overseeing 64 sites 1 FQHC s 1 Employer-based 4 Physician, NP or Pharmacist-based Practices 1 Area Agency of Aging 1 Virginia Cooperative Extension 1 Air Force Health Promotion 1 Church 1 Fitness Center 1 healthcare business Plan a 3-6 month follow up with patients to assess: Whether or not they joined a program Their progress Barriers to weight loss and lifestyle changes What changes they have made-reinforce the positive 1 site in Virginia is now fully-recognized COMMON QUESTIONS WHAT ARE THE KEY COMPONENTS OF A DIABETES PREVENTION/LIFESTYLE CHANGE PROGRAM? CDC-approved curriculum 12-month program First six months: at least 16 sessions Month 7-12: Monthly (6 sessions) Group format Focus on making lifestyle changes A lifestyle coach, specially trained to lead the program Data collection on weight loss, physical activity and attendance to assure program effectiveness 4

5 DIABETES PREVENTION PROGRAM AT PEOPLE S PHARMACY WHO IS ELIGIBLE FOR REFERRAL? Be at least 18 years old Be overweight (body mass index 25; 23 if Asian) Have no previous diagnosis of type 1 or type 2 diabetes Have a blood test result in the prediabetes range within the past year: Hemoglobin A1C: 5.7% 6.4% or Fasting plasma glucose: mg/dl or Two-hour plasma glucose (after a 75 gm glucose load): mg/dl or Be previously diagnosed with gestational diabetes, or Score 9 or higher on CDC Prediabetes Risk Test Score 5 or higher on ADA Type 2 Diabetes Risk Test HOW MUCH DOES A PROGRAM COST? It varies Average cost is $400-$500 for yearlong program Medicare will begin reimbursing in April 2018 Other insurers are likely to follow Many employers are now providing program for diabetes prevention WHERE ARE WE WITH REIMBURSEMENT? Medicare will begin to pay for in-person group programs April 2018 Nationally, some private insurers offer diabetes prevention programs. Expect more to follow Virginia Most major health systems: employee benefit UVA, INOVA, Sentara, Bon Secours Cosco and Lowe s: Omada Health Virtual DPP MEDICARE DIABETES PREVENTION REIMBURSEMENT Performance Goal Performance Payment per person with required minimum wt loss Performance Payment per person without required minimum wt loss 1 st Core Session Attended $25 $25 4 total Core Sessions Attended $50 $50 9 total Core Sessions Attended $90 $90 2 Sessions attended in first maintenance (mos 7-9) 2 Sessions attended in first maintenance (mos 10-12) $60 $15 $60 $15 5% Wt loss Achieved $160 $0 9% Wt loss Achieved $25 $0 2 Sessions attended in maintenance (mos 13-24) $50 $0 Total Performance Payment $670 $195 WHAT IS NEEDED IN ORDER TO BE RECOGNIZED AS A CDC-LIFESTYLE CHANGE PROGRAM? Submit an application for recognition Use of a CDC-approved curriculum Ability to begin offering the lifestyle program Capacity and commitment to deliver the program 22 sessions over one year period Ability to submit data on participants progress including attendance, weight loss, and physical activity Every 6 months Trained lifestyle coach & DPP coordinator Meet health and attendance benchmarks 5

6 WHAT IS INVOLVED IN STARTING UP MY OWN PROGRAM? Complete a capacity assessment Designate staff who need to complete a lifestyle coach training Apply for pending recognition with CDC Develop & implement HIPPA compliant policy Implement program within 6 mos Provide data every six months WHO CAN BE A LIFESTYLE COACH? Eligibility People trained to deliver required curriculum content Can have credentials (RDN, CDE) but not required Knowledge and Skills Knowledge of basic health, nutrition, and fitness principles Knowledge of principles and ability to guide behavior change Strong interpersonal and communications skills Organization skills, specifically re: data collection WHERE DO LIFESTYLE COACHES GET TRAINED? PREVENTING DIABETES IN VIRGINIA STRATEGIC PLAN Organizations who have signed an MOU with CDC to provide Lifestyle Coach Training include: University of Virginia Virginia Center for Diabetes Prevention and Education American Association of Diabetes Educators Black Women s Health Imperative Quality and Technical Assistance Center (QTAC) Diabetes Training and Technical Assistance Center (Emory University) Magnolia Medical Foundation Solera Health Inc. State of Wellness University of Pittsburgh Diabetes Prevention Support Center The Preventing Diabetes in Virginia Strategic Plan is available on the following websites: ORGANIZATIONS INVOLVED IN VDC VISION: To improve the lives of Virginians affected by diabetes MISSION: To bring partners together to identify and promote best practices for diabetes prevention, control, and treatment in Virginia Medical/Hospital Systems UVA Sentara INOVA Children s Hospital of Richmond, VCU Bon Secours August Health Carilion Health Reston Hospital Diabetes Center Medstar Washington Hospital Center Valley Health Diabetes Management Program Angels of Mercy Pediatric Specialist of VA Chidlren ss National Medical Cntr Southside Regional Medical Center Faces of Hope, VA Riverside Diabetes Services Mary Washington HC Centra Health Reston Hospital Novant Health Corporate Diabetes Services Medical Associates of Central VA Central VA Health Svces Children s Hospital Kings Daughter Universities University of Virginia VCU Appalachian College of Pharmacy George Mason University Eastern VA Med School Virginia State Univ Businesses Boehringer Ingelheim Pharmaceuticals Novo Nordisk Sanofi Remington Drug Food City Tandem Diabetes Aviant Health Walgreens Type Zero Technologies Insulet People s Diabetic Pharmacy Medtronic Giant Food B2L Consulting Associations American Diabetes Association Community Care Network of VA National Association of Chronic Disease Directors Juvenile Diabetes Research Foundation of VA Health Quality Innovators T1DE Non-profits, Government and Community Organizations YMCAs across VA Virginia Dept Health Health Districts across VA Baptist General Convention of VA Portsmouth Naval Virginia Center for Diabetes Prevention & Education Virginia Department of Education Optima Health Virginia Oral Health Coalition Read Mountain Middle School Lavender Om Wellness Virginia Department of Aging and Rehab Services (DARS) Public School Nurses across VA Virginia Cooperative Extension 6

7 THANK YOU ANNE WOLF, MS,RD 7

8 Incorporating Diabetes Self- Management Education and Support (DSMES) into your Pharmacy Practice Disclosure Dr. Anna Peoples, PharmD, declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holding, and honoraria. Dr. Anna Peoples, PharmD 2018 VPhA Midyear Conference Roanoke, Virginia March 24, 2018 Presentation Objectives Describe Diabetes Self-Management Education and Support (DSMES) Gain Knowledge on the National Standards of DSMES Understand the Importance of Providing DSMES to the Community for Reducing the Burden of Chronic Disease in Virginia Pre-Knowledge Check 1. One out of every people living in Virginia have diabetes. a) 9 b) 15 c) 10 d) 3 e) Which of the following is NOT a DSMES self-care behavior? a) Healthy Eating b) Community Support c) Healthy Coping d) Being Active Pre-Knowledge Check 3. For every $1 spent on out patient DSMES, there is a net savings of up to in averted diabetes related hospital expenses. a) $5.92 b) $11.13 c) $2.04 d) $ A pharmacist must have additional credentials such as CDE or BC-ADM in order to provide and bill for DSMES. a) True b) False 5. A pharmacist must have a collaborative practice agreement (CPA) and physician referral in order to provide and bill for DSMES. a) True b) False Prevalence of Diabetes in Virginia Virginia Department of Health, 2015 One out of every 11 people living in Virginia have diabetes 1 1. Virginia Department of Health. Diabetes in Virginia Infographic. 1

9 Diabetes Burden in Virginia Diabetes Self-Management Education and Support (DSMES) The ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care, as well as the activities that assist the person with diabetes in implementing and sustaining the behaviors needed to manage his or her conditions on an ongoing basis, beyond or outside of formal self-management training. Why DSMES In Your Pharmacy? Reduce the Burden of Diabetes in Virginia Innovative Patient Education Model Expansion of Patient Care Efforts Increased Reimbursement Opportunities Accreditation American Diabetes Association Education Recognition Program (ERP) American Association of Diabetes Educators Diabetes Education Accreditation Program (DEAP) AADE Accreditation/ ADA Recognition Comparison AADE Accreditation/ ADA Recognition Comparison 2

10 Why Get Accredited? Pharmacy accreditation through AADE or ADA allows for alternative reimbursement models and expansion of clinical services in community care. Accredited DSMES Services are eligible for Medicare reimbursement and the pharmacy may bill CMS for DSMES, if the pharmacy is a Part B provider (pharmacists may not bill as an individual provider). Pharmacies are uniquely positioned in that commercial payers seeking quality care may refer patients to your accredited pharmacy and will reimburse for services. Accreditation allows pharmacists the opportunity to improve diabetes care by impacting patient health outcomes. Applying for Accreditation 1. Find and negotiate with a Medicare provider or apply and receive approval to be your own Medicare provider. 2. Identify who the Quality Coordinator, team members and external stakeholders will be and ensure they have current credentials and licenses. 3. Review the National Standards for DSMES to ensure that you can provide the proper infrastructure and documentation. 4. Enroll patients in program and track outcomes. One patient must complete the program through follow up to apply for accreditation. 5. Two documents you need to submit for your application are time-sensitive: Continuing education must be obtained within the 12 months prior to the application date Your de-identified chart must be for a participant that went through your services within 6 months prior to the application date Applying for Accreditation 6. Submit application to AADE/ADA. Application must be started and completed within 90 days and documents uploaded as individual pdfs. 7. AADE/ADA will contact you to clarify that you have completed all the steps and are ready to start your program. 8. Within 2-6 weeks AADE will contact you to set up a phone interview or site audit; No interview for ADA. 9. Upon receipt of the accreditation certificate, the Medicare provider must submit a copy of accreditation certificate to their Medicare Administrative Contractor (MAC) as proof of completion of the accreditation standards. 10. The provider will then be formally recognized by Medicare as an approved provider of DSMES. National Standards for DSMES ADA Recognition and AADE Accreditation requires DSMES Programs to adhere to the National Standards for Diabetes Self Management Education and Support (DSMES) Accredited DSMES programs follow 10 National Standards Standards 1-4: Structure outline needed to provide DSMES Standards 5-8: Process Standard 9-10: Outcomes Ten National Standards Accredited DSMES Programs Follow 10 National Standards Standard 1 Internal Structure Standard 2 Stakeholder Input Standard 3 Evaluation of Population Served Standard 4 Quality Coordinator Overseeing DSMES Services Standard 5 DSMES Team Standard 6 Curriculum Standard 7 Individualization Standard 8 Ongoing Support Standard 9 Participant Progress Standard 10 Quality Improvement Standard 1 Internal Structure Organizational support Defined leadership and lines of communication Mission statement Goals 3

11 Standard 2 Stakeholder Input Identify people and organizations partnering with your services for optimal outcomes Provide ongoing input, information, and ideas Improve DSMES service utilization, quality, measurable outcomes and sustainability Standard 3 Evaluation of Population Served Understand community served to ensure necessary educational alternatives available to meet community preferences Identify barriers that prevent access to DSMES Can increase DSMES access via technology One Quality Coordinator Standard 4 Quality Coordinator Overseeing DSMES Services Designated to ensure implementation of the Standards and oversees DSMES services Responsible for all components of DSMES including: Evidence-based practice Service Design Evaluation Continuous Quality Improvement May be in solo practice or part of DSMES team Standard 5 DSMES Team At least one of the facilitators is a RN, RD, or Pharmacist with DSMES training/experience Facilitator may also be another Health care professional with CDE or BC-ADM Health care workers and diabetes paraprofessionals may contribute to DSMES Must have DSMES training Must be supervised and supported by RN, RD, or RPh with training or Health care professional with CDE or BC-ADM Team members must maintain current credentials and document diabetes-related CE Standard 6 Curriculum Flexible and includes practical problem-solving, psychosocial issues, behavior change, and strategies to sustain self-management efforts Adopts AADE7 Self-Care Behaviors Individualized education plan according to participant need(s) Adapted for age, developmental stage, type of diabetes, cultural factors, health literacy/numeracy and comorbidities Participant education on navigating health care system, self-advocacy, and e-health Standard 7 Individualization Person-centered care practice focused on participant priorities and values Collaborative assessment Evidence based communication strategies non static lectures Participant empowerment for personal problem solving behavior 4

12 Standard 7 Individualization Documentation of assessment, education plan, intervention and outcomes in participant health record Participant determines when DSMES intervention is complete based on goal attainment DSMES is ongoing and lifelong process Digital technology use to empower participants and improve outcomes (Caution: Not currently reimbursable by Medicare) Standard 8 Ongoing Support Defined as resources that help participant implement and sustain ongoing skills, knowledge, and behavior changes needed to manage their diabetes Ongoing support beneficial post DSMES intervention Strategies identified within and outside of DSMES services for ongoing support Opportunities available via clinicians, paraprofessionals, community programs, peer support groups, technology/social networking Standard 9 Participant Progress Behavior change goal setting strategies to meet personal targets Measure achievement of SMART goals (Specific, Measurable, Achievable, Realistic, and Time-bound) Track relevant evidence-based outcomes (knowledge, behavior, clinical, quality of life, cost-savings, satisfaction) at appropriate intervals AADE7 Self-Care Behavior outcomes as framework for assessment, documentation and evaluation Behavior change is key outcome Standard 10 Quality Improvement Conduct a systematic evaluation of outcome and process data/measures Outcome measure - indicates results of a process Process measure - information about what caused results DSMES Measures Behavioral, Clinical, Operational, Process Measure the impact and effectiveness of DSMES utilizing CQI plan Continuous Quality Improvement (CQI) Methods Plan Do Study Act Six Sigma Lean Re-AIM Workflow mapping DSMES Services Follow 7 Self-Care Behaviors DSMES Services Follow and Teach 7 Self-Care Behaviors Healthy eating Making healthy food choices and portion sizes. Being active Having daily physical activity is important for overall fitness, weight management, and blood glucose control. Monitoring blood glucose levels Daily monitoring can assist the individual on adjustments they may need to make to have better control over their diabetes and lower their risk of complications. Problem Solving Problem solving is crucial to the management of blood glucose levels by being able to make changes to daily activities regulate blood glucose levels Taking medications as prescribed Effective drug therapy and taking medications correctly can reduce the risk of developing complications as well as elevated blood glucose levels Coping in a healthy way Coping with diabetes is sometimes difficult and can make selfmanagement harder for the individual. Reducing risks of developing complications Risk reduction behavior such regular eye, foot, and dental examinations and regular blood glucose monitoring as well as smoking cessation can reduce the risk of complication development. 5

13 Medicare Enrollment Applications Medicare Reimbursement for DSMES DSMES 101 Pharmacy must first enroll in the Medicare program as a supplier using the Medicare enrollment application (Form CMS-855S) To provide DSMES to Medicare beneficiaries, pharmacy suppliers need only to enroll to provide Part B drugs (Form CMS- 855B) Process for Obtaining Medicare Approval-CMS 855S Process for Obtaining Medicare Approval-CMS 855S 1. Pharmacy obtains required NPI, surety bond and/or accreditation PRIOR to completing and submitting CMS 855S 2. Pharmacy pays required application fee (via PRIOR to completing and submitting CMS 855S to NSC 3. Pharmacy supplier completes and submits the enrollment application (CMS-855S) and all supporting documentation to the NSC 4. Pharmacy supplier submits fingerprint background check At NSC request Returned to CMS 5. NSC reviews the application and conducts a site visit Verifies compliance with supplier standards (42 C.F.R. sections , , and et seq.) 6. NSC notifies the pharmacy supplier in writing about its enrollment decision Note: The NSC may request additional documentation to support or validate information reported on the submitted CMS-855S application Process for Obtaining Medicare Approval-CMS 855B Provider Transaction Access Number (PTAN) DSMES is a Medicare Part B Benefit Covers Diabetes Self-Management Education and Support (DSMES) Covers 80% of DSMES charges once deductible is met Approximately 95% of Medicare beneficiaries elect to participate in Part B & pay the monthly premium CMS-855B is processed by local State Medicare Administrative Contractor (MAC) A PTAN is a Medicare-only number issued to providers by MAC upon approval by Medicare Medicare uses the NPI and PTAN together to identify the provider in their programs and maintains a record of both numbers in their Provider Enrollment Chain & Ownership System (PECOS) 6

14 Medicare Part D Covers outpatient prescription medications Patient Eligibility Requirements Eligible if within the last 12 months, a patient has one of the following: Diagnosed with diabetes Started taking a diabetes medication or went from PO to insulin Have diabetes and became eligible for Medicare At risk for complications of diabetes Must receive education through ADA recognized or AADE accredited program Medicare DSMES Eligibility Referral from physician managing their diabetes Initial year Up to 10 hours of education (lifetime Medicare benefit) Subsequent years Up to 2 hours of education (annually) Education provided in group setting unless barriers indicate patient needs (1 on 1) individual instruction Insulin teaching Language limitations Vision, Cognitive, or Hearing Impairment Coding and Billing Requirements for DSMES Requires use of G codes G0108: Individual Session G0109: Group Session Must be billed in 30 minute increments May be billed on either UB92 (Hospitals & Facilities) HCFA1500 forms (Physicians & Allied Health Professionals) May bill paper claims or process online using an EHR/EMR Medicare Reimbursement Medicare beneficiary pays co-pay Medicare covers 80% of the allowed adjusted rate, beneficiary pays 20% G0108 DSMES individual session face-to-face with patient, each 30 min. of training 2018 Medicare Fee Schedule reimbursement: $ $79.25 (varies by geographic region & carrier) Commercial Reimbursement for DSMES G0109 DSMES group session (2 or more patients) Each 30 min. of training 2018 Fee Schedule $13.48-$21.62 (varies by geographic region & carrier) 7

15 Virginia State Requirements for Commercial Insurers Current Virginia State Insurance Coverage for DSMES Setting your Fees In order to develop a proforma, you need to estimate income Commercial Reimbursement for DSMES Commercial payer rates often higher than CMS reimbursement Reimbursement for DSMES depends on the policies of the commercial payer as well as the location where the services are provided Commercial health plans may cover all diabetes education to patients with type 1, type 2, gestational diabetes, nondialysis kidney disease, and post kidney transplants Exclusions existstate/federal employer health plans often exempt from state mandates In order to estimate income, you need to set your fees for each service you provide Many commercial payers reimburse higher than Medicare Reimbursement is based on the amount your normal or their allowable fee, whichever is lowest Consider setting your fee as a percentage of Medicare ( %) Audits Post-Knowledge Check Medicare or AADE can audit your program even if you are not billing for your services Set a goal to see at least 10 patients per year, whether you are billing or not in order to have data to maintain accreditation Know what codes to use to bill for DSMES (G0108 and G0109) and that you understand CMS s rules for coverage of DSMES services Auditor checklists available online 10,11 1. One out of every people living in Virginia have diabetes. a) 9 b)15 c) 10 d) 3 e) Which of the following is NOT a DSMES self-care behavior? a) Healthy Eating b) Community Support c) Healthy Coping d) Being Active 10. AADE ADA. 8

16 Post-Knowledge Check 3. For every $1 spent on out patient DSMES, there is a net savings of up to in averted diabetes related hospital expenses. a) $5.92 b) $11.13 c) $2.04 d) $ A pharmacist must have additional credentials such as CDE or BC-ADM in order to provide and bill for DSMES. a) True b) False 5. A pharmacist must have a collaborative practice agreement (CPA) and physician referral in order to provide and bill for DSMES. a) True b) False Contact Information Dr. Anna Peoples, PharmD Peoples Diabetic Clinic & Pharmacy Office: Fax: peoplespharmacy@hrcoxmail.com Website: References 1. Virginia Department of Health. Diabetes in Virginia Infographic ChangeLab Solutions Virginia: Background, Benefits, and Insurance Coverage of DSME/T. Retrieved from 3. Beck J, Greenwood DA, Blanton L, et al National Standards for Diabetes Self-Management Education and Support. The Diabetes Educator Jul;45(5): ( 4. Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care Mar;23(3): ( 5. American Association of Diabetes Educators (2018). AADE Diabetes Education Accreditation Program. Retrieved from 6. American Diabetes Association. (2018). Education Recognition Program. Retrieved from 7. American Association of Diabetes Educators. Comparing the Processes. Accreditation and Recognition, Diabetes Educator 2010 March/April; 36 (2); Centers for Medicare & Medicaid Services. (2018). Physician Fee Schedule Look-Up Tool. Retrieved from Payment/PFSLookup/index.html?redirect=/pfslookup/02_PFSsearch.asp 9. National Conference of State Legislatures. (2016). Diabetes Health Coverage: State Laws and Programs. Retrieved from American Association of Diabetes Educators. (2016). Competencies for Diabetes Educators and Diabetes Paraprofessionals. Retrieved from American Diabetes Association Audit Toolkit. Retrieved from final.pdf 12. Centers for Disease Control and Prevention. (2011). National Diabetes Fact Sheet, Retrieved from Beck J, Greenwood DA. (2017) Revision of the National Standards for Diabetes Self-Management Education and Support. Retrieved from 9