Bright Spot: Diabetes Smart: Diabetes Education Recognition Program (DERP)

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This bright spot was originally published in the 100 Million Healthier Lives Change Library and is brought to you through partnership with 100 Million Healthier Lives and the Institute for Healthcare Improvement.


Detailed Description

In order to address diabetes, the North Carolina Division of Public Health Diabetes Prevention and Control Program established the Diabetes Education Recognition Program (DERP) in 2006. Through the Diabetes Education Recognition Program, the NC Division of Public Health serves as the sponsoring agency recognized by the American Diabetes Association (ADA). It is under this umbrella program that local health departments provide and are reimbursed for Diabetes Self-Management Education (DSME). To receive third party reimbursement for DSME, a site must obtain recognition by ADA, the American Association of Diabetes Educators (AADE) or Indian Health Service. ADA-recognized programs may bill Medicaid, Medicare and private insurers for diabetes self-management training.The reimbursement offered under the Diabetes Education Recognition umbrella program builds capacity at the local level to provide self-management education for the uninsured and underinsured. As a result of Diabetes Education Recognition Program, people with diabetes, in all areas of the state, have increased access to self-management training.

Expected Outcomes

The expected outcomes are:

  • An increase in the percentage of patients performing daily foot self-exams (behavioral goal).
  • An increase in the percentage of patients having an A1C of 7% (outcomes goal).
  • An increase in the percentage of patients having a BP of 130/80 or less.

Cost Details

As of June 2014, the cost of this intervention is as follows:

  • The costs are mostly associated staff training (CEU credits, Chronicle training, attending meetings with DERP staff).
  • ADA-recognized programs may bill Medicaid, Medicare and private insurers for the diabetes self-management training.
  • Reimbursement for services to people initially diagnosed with diabetes is based on ten hours of education. Reimbursement for education following initial diagnosis is based on two hours per year. Each participating health department will contribute 10% of the income earned from the Diabetes Self-Management Program or $1,000 (whichever is greater) to the NC Public Health Foundation to sustain the program. Health departments will be invoiced twice yearly in April and October. Health departments with 80% or greater uninsured are exempt from these contributions. In addition to this Local health departments who wish to add expansion sites are responsible for the $100 fee for each expansion site.

For the latest cost details, please contact the Diabetes Education Recognition Program directly.

Key Steps for Implementation

The Health Department is required to implement the following components of the NC Diabetes Education Recognition Program (DERP):

  • Designate qualified staff to serve as "Instructional Staff" for the ADA Education Recognition Program, specifically RN, RD or pharmacist
  • Ensure that Instructional Staff will obtain 20 continuing education units (CEUs) per year related to diabetes and provide evidence of CEU to state ADA Education Recognition Instructional Team
  • Ensure that Instructional Staff are supported (time and travel) in attending ADA Education Recognition Program Staff meetings
  • Ensure adequate and appropriate teaching and educational materials are available for Instructional Staff use Install, train and support the use of Chronicle Software, specifically designed for data collection for ADA Education Recognition sites
  • Ensure availability of computer (laptop or desktop) and internet access for Instructional Staff to perform data entry in Chronicle software
  • Agree to use NC Diabetes Education Recognition Program's forms, manuals, etc. without exception Provide the required monthly reports to NC DPH by the 5th of each month
  • Participate in quality improvement activities as requested Commit to perform/obtain HbgA1C (regardless of patient ability to pay) from all patients seen through the program
  • Commitment to participate in monthly conference calls/webinars with NC DPH Commitment to attend meetings, trainings and educational sessions as needed
  • Ensure availability of classroom space and office/space for one on one visits with patients
  • Copy/reproduce patient education manuals if needed

Purchase patient education materials as needed

Required Staffing (FTEs)

Two educators/instructional staff. One program coordinator for planning|implementing and evaluating the DSME.

Special Infrastructure

Classroom space and office/space for one on one interaction between the educator and patient is required.


  1. Each new participating local health department will be requested to attend an initial Program Staff/Curriculum training.
  2. The two day long training will include: Review and discussion of required forms/documentation processes, referral processes, marketing patient education manuals, educator manuals, diabetes education, and review of AADE Diabetes Self-Management Curriculum (provided for each site).
  3. Continuing education hours will be offered if possible. All site educators must maintain current professional licensure and have 20 diabetes-related continuing education unit (CEU) hours each year.

Types of Staff

The primary educator must be an RN, RD or pharmacist. (A site is single-discipline if there is only one instructor or there are 2 or more instructors, but the professional instructors are all of the same discipline, i.e. all RN's or all RD's, etc. A multi-discipline site must have at least 2 different disciplines) The Program Coordinator does not need to be a clinical person. They do need to have the following qualifications:

  • The Program Coordinator must be able to oversee the planning, implementation, and evaluation of the DSME program at all sites.
  • She/he must have academic or experiential preparation in areas of chronic disease care, patient education and/or program management.
  • The coordinator does not have to be a CDE (or BC-ADM) but must have 15 hours of CEUs

Return on Investment Details

In March 2012, an analysis was performed to determine the effectiveness of NC DERP. The target population for this analysis included adult patients who were enrolled in NCDERP between 2007 and 2010, have type 2 diabetes, and have both baseline and post-program A1C measurements. Based on a review of various participant data sheets, 310 participants met all of these criteria. Analysis of their records indicated that NCDERP generates $1.21 in medical care cost-avoidance benefits for every $1 spent on this intervention, representing a 21% return on investment. Source: Joanne Rinker & Marti Wolf, N.C. Diabetes Education Recognition Program: ADA Recognition for a Combined Program at Local Health Departments and community Health Centers in North Carolina, 30 Clinical Diabetes 110 (2012).

Outcome Measures

Participant Behavioral Outcomes:

  • Self Foot Exams:
    • Increase in the percentage of patients performing daily foot self-exams (Goal: 75% of patients report they are checking their feet daily).
  • Outcome Measure:
    • Hemoglobin A1c: Increase in the percentage of patients having an A1C of ? 7% (Goal: 75% of patients with a pre- and post-test will have a Hgb A1c of 7% or less).
    • Blood Pressure: Increase in the percentage of patients having a BP of 130/80 or less (Goal: 75% of patients who complete the DSME program will have a post-program BP of 130/80 or less).
    • Gestational Diabetes: For those health departments participating in the NC Diabetes Education Recognition Program that provide diabetes self-management education to women with gestational diabetes, the health department will measure A1c, BP and checking blood glucose four times a day (not self foot exams).
    • Participant Behavioral Outcomes: Increase in the percentage of patients with gestational diabetes checking their blood glucose four times a day (Goal: 75% of women with gestational diabetes will report checking) their blood glucose four times a day.

Process Measures

The NC Diabetes Education Recognition Program will meet all of the standards established by the American Diabetes Association in the current National Standards for Diabetes Self-Management Education. One component of these standards is establishing a method to measure the effectiveness of the education processes and determine opportunities for improvement using a written continuous quality improvement plan that describes and documents a systematic review of the process and outcome data. Continuous Quality Improvement (CQI) is a formal process/plan that is a cyclic series of steps designed to enhance DSME processes leading to improved participant and DSME outcomes. The N.C. Division of Public Health has adopted the PDSA (Plan, Do, Study, Act) methodology for quality improvement.

PDSA steps include:

  1. Select the problem/process that will be addressed first and describe the improvement opportunity.
  2. Describe the current process surrounding the improvement opportunity.
  3. Describe all of the possible causes of the problem and agree on the root cause.
  4. Develop an effective and workable solution and action plan including targets for improvement.
  5. Implement the solution or process change.
  6. Review and evaluate the result of the change.
  7. Reflect and act on learnings.

All sites may be asked to complete a documentation chart audit to assure that ADA standards are being met. Audit sheets will be sent to the sites, and the sites will be asked to audit 10 charts, or 10%, whichever is greater. Sites will be given 30 days to complete the audit forms and return components, and will follow up with theindividual/family with each site to discuss any necessary action. In addition, during each site visit, the Instructional Team will conduct a random chart audit of 10% of charts (maximum of 10) to confirm that standards are being met. While chart audits are not a quality improvement method alone, the purpose of the audits is to identify and address any issues of documentation. Information gleaned from the audits may be incorporated into a quality improvement opportunity. Results of all performance improvement activities will be reported during the annual meeting of the Advisory Committee, and recommendations for action will be made. The results obtained will be used as part of the PDSA process to improve the diabetes self-management education program offered at the sites to ensure that all ADA Standards are met.

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