VR-SFP Chapter 7: Diabetes Self-Management Education Services

Diabetes self-management education is the process of developing the customer's knowledge, skills, and abilities that are necessary to manage diabetes and improve his or her health outcomes. Vocational Rehabilitation (VR) customers might require education about diabetes to address the cause of the disease. Diabetes self-management education provides adaptive techniques and/or equipment to help the customer self-manage his or her diabetes.

Assessment and teaching of blood sugar monitoring, medication delivery, and other self-care skills related to diabetes self-management require close, hands-on evaluation and training when working with individuals who are blind or visually impaired.

Diabetes self-management education services are based on the American Association of Diabetes Educator's 7 Self-Care Behaviors™, which are:

• healthy eating;
• being active;
• self-monitoring;
• taking medications;
• healthy coping;
• problem solving; and
• reducing risk.

The diabetes self-management education services are for customers who:

• are newly diagnosed;
• need surgery or a medical procedure and are at risk of further complications because of poor diabetes management;
• are unable to maintain employment because of their diabetes;
• need additional training about diabetes management after losing their sight;
• must self-manage diabetes for admittance to training programs and for full participation in training such as that offered by the Criss Cole Rehabilitation Center; and/or
• cannot benefit from community-based educational programs; or
• have unique needs that cannot be met through medical providers paid through the Maximum Affordable Payment Schedule.

Any request to change a Service Definition, Process and Procedure, or Outcomes Required for Payment must be documented and approved by the VR director, using the VR3472, Contracted Service Modification Request for Blind and Visually Impaired Services, before the change is implemented. The approved VR3472 must be maintained in the provider’s customer case file. For more information, refer to VR-SFP 3.4.11 Contracted Services Modification Request.

7.3.1 Assessment of Diabetes Self-Management Service Description

A diabetes self-management assessment is the diabetes educator's evaluation of a customer's ability to manage the diabetes. The assessment must gather information about the customer's:

• medical history;
• age;
• cultural influences;
• beliefs and attitudes about maintaining good health; and
• knowledge about diabetes.

A diabetes self-management assessment is provided in person with the trainer and customer at the same location. The diabetes self-management assessment may be provided remotely only with a VR director approved VR3472, Contracted Service Modification Request. Remote services must follow VR-SFP 3.4.8 Remote Service Delivery.

Any request to change a Service Definition, Process and Procedure, or Outcomes Required for Payment must be documented and approved by the VR director, using the VR3472, Contracted Service Modification Request for Blind and Visually Impaired Services, before the change is implemented. The approved VR3472 must be maintained in the provider’s customer case file. For more information, refer to VR-SFP 3.4.11 Contracted Services Modification Request.

For more information refer to VR-SFP 3.4.11 Contracted Services Modification Request.

For information on acceptable signatures refer to VR-SFP sections 3.2.14 Documentation and 3.2.16 Signatures.

It is recommended that the diabetes educator use adaptive equipment and disposable supplies for demonstration during the assessment. The suggested items include:

• a talking blood-glucose meter;
• an insulin-measuring device, such as Count-A-Dose, which allows a blind or vision-impaired individual with diabetes to fill an insulin syringe without assistance;
• a syringe magnifier;
• a portion-control plate, such as Meal Measure;
• an insulin pen (or other injectable device for demonstration purposes);
• a talking blood-pressure monitor; and
• disposable supplies such as test strips, syringes, and insulin.

The customer and instructor develop an education and support plan that is created from evidence-based approaches for effective health communication and education while taking into consideration the customer's barriers to self-management, abilities, and expectations as well as information from the diabetes self-management assessment. (ADA, 2016)

The initial diabetes self-management assessment helps the diabetes educator recommend the skills training from which the customer would benefit. The training areas include information and skills relating to:

• an overview of the pathophysiology of diabetes;
• nutrition;
• exercise and activity;
• blood-glucose monitoring and how to use the monitoring results;
• diabetes-related complications;
• management of sick days;
• medical treatment;
• medication;
• foot, skin, and dental care;
• preconception care, pregnancy, and gestational diabetes, if applicable;
• insulin;
• use of the health care system;
• community resources;
• stress and psychosocial adjustment;
• goal setting;
• employment aspects and/or barriers related to diabetes; and
• adaptive diabetes self-management equipment and tools.

The initial assessment should evaluate all the above topics. The training plan should recognize the partial or complete deficits in self-management knowledge and identify the specific deficits that should be addressed. If the results of the initial diabetes self-management assessment warrant, training may begin immediately if:

• an initial diabetes self-management assessment was conducted in the previous 12 months;
• no significant change to the customer's medical status, including no new medications or new complications, has occurred;
• a service authorization has been issued; and
• the service provider has adequate information to begin skills training based on the results of the Initial Diabetes Self-Management Assessment.

Should the provider of the diabetes education training be different from the provider who conducted the initial assessment, the VR2888, Diabetes Self-Management Education Assessment, and the VR2901, Diabetes Self-Management Pre- and Post-Assessment, should be reviewed by the new provider prior to initiating diabetes education training.

If the new diabetes educator does not agree with the original assessment recommendations, a consultation between the VR counselor, new diabetes educator, and state office program specialist for diabetes education is scheduled to establish an agreement on appropriate diabetes education for the VR customer.

7.3.2 Process and Procedure

The initial diabetes self-management assessment may be conducted before or after eligibility is determined.

The diabetes self-management assessment provider begins services once a signed VR service authorization and a VR2883, Diabetes Self-Management Education Referral form, completed by the VR counselor, or the Independent Living Services for Older Individuals Who Are Blind (ILS-OIB) worker, have been received.

The VR2883, Diabetes Self-Management Education Referral Form:

• indicates why the customer is referred for diabetes education evaluation; and
• describes issues and/or questions that are addressed in the diabetes educator's report.

The initial diabetes self-management assessment must not exceed two hours and must be held for each customer individually.

The provider must discuss additional hours with the VR counselor or the ILS-OIB worker and the VR diabetes program specialist. The request must be documented and approved by the VR director using VR3472, Contracted Service Modification Request.

7.3.3 Education and Support Plan

The diabetes educator develops a written education and support plan in the Overall Recommendations section of VR2888, Diabetes Self-Management Education Assessment.

VR staff and the diabetes educator ensure that the education and support plan is appropriate, based on the customer's:

• age;
• type of diabetes (1 or 2);
• history of diabetes;
• cultural influences;
• learning abilities; and
• disability.

Diabetes educators must use the talking blood-glucose meter recommended by the VR state office diabetes program specialist to:

• assess the customer's glucose (blood sugar) level;
• assess the customer's understanding of how to check blood sugar properly; and
• provide skills training to the customer.

If the diabetes educator recommends using a different type of talking meter, the VR diabetes program specialist must authorize the purchase before the equipment is purchased and skills training occurs.

The diabetes educator completes the assessment of the customer's ability to manage the diabetes and makes recommendations for training, equipment, and services using VR2888, Diabetes Self-Management Education Assessment. The assessment report must be submitted to VR within 35 days of completion of the assessment.

Behavior change goal setting empowers the customer to fully engage in personal problem solving to change behavior and improve outcomes. Using person centered, informed decision making, the diabetes educator guides the customer in the skill of goal setting by assisting them to

• select an activity that best suits the customer’s self-management needs,
• help the customer identify strategies and resources for success as well as barriers, and
• plan a course to achieve the goal.

An initial behavior change goal must be set at the initial assessment. This is the customer’s goal and action plan. 

If the diabetes educator cannot schedule the visit with the customer to initiate the assessment within three calendar weeks, then the educator must notify the VR counselor by email, paper mail, or fax. VR may determine that it is necessary to cancel the service authorization and identify a new provider.

7.3.4 Outcomes Required for Payment

The diabetes educator documents the two-hour initial diabetes self-management assessment and other findings for each customer on the:

• VR2888, Diabetes Self-Management Education Assessment; and
• VR2901, Diabetes Pre- and Post-Assessment.

All forms must be completed in their entirety for the provider to be paid. As appropriate, the provider uses the following notations:

• N/A for "not applicable"
• N/D for "not disclosed by customer"
• N/E for "not evaluated"

The initial assessment fields are completed on the VR2901. The form is saved electronically so that the post-assessment fields can be completed later.

The VR2888, Diabetes Self-Management Education Assessment, reports the information that the diabetes educator captured during the initial assessment as well as the recommendations for equipment and training.

The VR2901, Diabetes Pre- and Post-Assessment, allows a comparison of the customer's knowledge of diabetes management before and after training.

7.3.5 Fees

For more information, refer to 7.6 Diabetes Self-Management Education Services Fee Schedule.

The post-training assessment is the final meeting provided for diabetes services. In this one-hour assessment, the customer and diabetes educator develop a follow-up plan for ongoing support. The plan includes information about goals, educational and equipment outcomes, and ongoing needs.

7.5.1 Post-Training Assessment Service Description

The diabetes educator conducts post-training assessments no sooner than 30 calendar days after the skills training is complete.

As part of the post-training assessment, the diabetes educator:

• reviews the skills training provided; and
• reinforces the behavioral changes.

The post-training assessment must be completed for all customers 30 days after the last training session. The post-training assessment may be completed in person, by phone, or by video conferencing with the customer as described in VR-SFP 3.4.8 Remote Service Delivery. The preferred method to complete the post-training assessment is in person. If a post-training assessment must be provided sooner than 30 calendar days after the skills training, the trainer must request approval from the referring VR counselor or the OIB worker before the post assessment being completed. The VR counselor or OIB worker requests approval from the VR director using VR3472, Contracted Service Modification Request for Blind and Visually Impaired Services.

Any request to change a Service Definition, Process and Procedure, or Outcomes Required for Payment must be documented and approved by the VR director, using VR3472, Contracted Service Modification Request for Blind and Visually Impaired Services before the change is implemented. The approved VR3472 must be maintained in the provider's customer case file. For more information, refer to VR-SFP 3.4.11 Contracted Services Modification Request.

For more information on acceptable signatures, refer to VR-SFP sections 3.2.14 Documentation and 3.2.16 Signatures.

7.5.2 Post-Training Assessment Process and Procedure

To document the one-hour post-training assessment, the diabetes educator completes the:

• VR2900, Diabetes Self-Management Education Post-Training Assessment; and
• VR2901, Diabetes Pre- and Post-Assessment.

To evaluate the customer's progress, the post-assessment fields are completed on the same VR2901, Diabetes Pre-and Post-Assessment that was submitted at the initial assessment.

7.5.3 Outcomes Required for Payment

The following documentation must be submitted within 35 calendar days of completion of the post-training assessment:

• Initial assessment
• Skills training
• Post-training assessment

The provider documents all conversations that he or she has had with the VR counselor, the OIB worker, and other staff about customers whom that provider is serving.

7.5.4 Fees

For more information, refer to 7.6 Diabetes Self-Management Education Services Fee Schedule.