7.1 Overview of 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.

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7.2 Staff Qualifications and Training

Before any services are provided, the service provider director must approve the VR3455, Provider Staff Information form, completed by staff such as a trainer and aides, and submit the approved form to the provider's assigned contract manager and assigned regional program specialist. The VR3455 documents the provider's qualifications and provides evidence of meeting those qualifications by providing the:

  • provider’s staff résumé demonstrating diabetes education experience as an essential function of the job; and
  • documentation of required continuing education hours on diabetes education topics.

7.2.1 Diabetes Educators

A diabetes educator must have at least one year of paid experience providing diabetes education as an essential function of the job while currently licensed as a:

  • registered nurse;
  • registered dietician; or
  • diabetes educator certified by the National Certification Board for Diabetes Education.

7.2.2 Annual Training

The diabetes educator must have continuing education units (CEUs) in diabetes self-management education topics from an agency approved by the diabetes educator's licensing or certifying body. The CEUs may not include the Texas Confidence Builder training.

Diabetes Educator

CEUs Required

Frequency

Registered Nurses

15

Within the 12 months immediately preceding the contract date and an additional 15 hours within the term of the contract

Registered Dieticians

15

Within the 12 months immediately preceding the contract date and an additional 15 hours within the term of the contract

Certified Diabetes Educator

10

Within the 12 months immediately preceding the contract date and an additional 10 hours within the term of the contract

7.2.3 Texas Confidence Builder Training

All diabetes educators must attend and participate in the VR Texas Confidence Builder Training. This 14-hour training is completed before a contract is awarded or before services are provided by the diabetes educator, and the training must be retaken every two years.

If the Texas Confidence Builder training is not available at the two-year renewal date, the VR diabetes program specialist and the contract manager must request that the requirement be waived or postponed. The request must be documented and approved by the VR director using VR3472, Contracted Service Modification Request.

VR does not pay the provider's travel costs for transportation, food, and lodging to attend Texas Confidence Builder Training or other trainings.

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7.3 Assessment of Diabetes Self-Management

7.3.1 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.

When the Center for Disease Control and Prevention (CDC) or federal, state, and/or local governments issue health and safety protocols such as social distancing, diabetes self-management assessment may be provided only with a VR director approved VR3472, Contracted Service Modification Request.

The VR3472 must include:

  • how the service will be delivered:
    • in person, remotely, or a combination thereof;
    • following health and safety protocols; and
    • meeting the customers individual training needs,
  • justification for need of the service; and
  • verification the customer has agreed to participate in the services as described above.

For more information refer to VR-SFP 3.6.4.2 Evaluation of Service Delivery.

For information on acceptable signatures refer to VR-SFP 3.11.1 Documentation and 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:

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.

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7.4 Diabetes Skills Training

7.4.1 Service Description

Diabetes skills training is provided by a diabetes educator who instructs and counsels the customer and family by means of individual and/or group skills training sessions that have been authorized by means of a service authorization.

Diabetes skills training is provided in person with the trainer and customer at the same location.

When the Centers for Disease Control and Prevention (CDC) or federal, state, and/or local governments issue health and safety protocols, such as social distancing, diabetes skills training may be provided only with a VR director approved VR3472, Contracted Service Modification Request.

The VR3472 must include:

  • how the service will be delivered:
    • in person, remotely, or a combination thereof;
    • following health and safety protocols; and
    • meeting the customer's individual training needs,
  • the number of hours for each training service;
  • justification for the need of the service; and
  • verification the customer has agreed to participate in the services as described above.

For more information refer to VR-SFP 3.6.4.2 Evaluation of Service Delivery.

For information on acceptable signatures refer to VR-SFP 3.11.1 Documentation and Signatures.

Diabetes skills training is intended to:

  • provide self-management education;
  • identify best methods for managing diabetes medication(s); and
  • help the customer identify barriers, solve problems, and develop coping skills to achieve effective self-care and behavior changes.

Diabetes skills training helps customers set goals and make effective health and care decisions that fit their values and lifestyles. Diabetes educators help customers:

  • develop a plan to improve their health;
  • develop goals through individualized problem solving;
  • provide motivation; and
  • incorporate health recommendations into daily life.

The number of training hours recommended for individual diabetes self-management is based on:

  • the initial assessment; and
  • the topics covered that are related to the customer's vocational goals.

Up to 12 hours of skills training for diabetes self-management can be provided:

  • individually;
  • in a group of two to eight customers; or
  • as a combination of one-on-one and group training sessions

Diabetes educators are reimbursed only for the time spent teaching customers. Trainers are not reimbursed for:

  • planning time, such as in meetings or talking with VR staff; or
  • time spent completing and submitting the required paperwork,

7.4.2 Process and Procedure

The VR counselor or the ILS-OIB worker submits a referral and issues service authorizations for diabetes skills training.

The diabetes educator must divide all diabetes skills training into two-hour segments to ensure that the segments do not fatigue the customer and consequently reduce the benefit of the skills training.

The diabetes educator helps the customer develop specific, measurable, achievable, realistic, and timely (SMART) goals.

A new behavior-change goal should be set at each visit between the educator and the customer and achievements evaluated at the next visit. The diabetes educator helps the customer overcome barriers to success and employ problem-solving strategies.

It is recommended that the diabetes educator use adaptive equipment and disposable supplies for demonstration during training such as:

  • a talking blood-glucose meter;
  • an insulin measuring device, such as Count-A-Dose, that 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 diabetes educator documents the provision of education materials, resources, and referrals on VR2884, Diabetes Self-Management Educator Notes.

The VR counselor or the ILS-OIB worker is responsible for approving the purchase of the recommended equipment or supplies. Documentation should identify:

  • what was taught;
  • what the customer gained from the instruction; and
  • any barriers or gaps in knowledge.

If the customer is unable to participate in skills training on diabetes self-management because of his or her health, the diabetes educator must inform the VR counselor by email, paper mail, or fax within three business days. The diabetes educator must document such notification in the customer's file.

7.4.3 Outcomes Required for Payment

Service providers must document each two-hour skills training session provided to each customer using VR2884, Diabetes Self-Management Educator Notes.

A complete and accurate invoice may be submitted after completion of the services. All required documentation must be submitted within 35 calendar days of the date that the service is provided, including initial assessment, skills training, and post-training assessment.

If the diabetes self-management education services include providing the customer with a talking blood-glucose meter or other diabetes equipment, the diabetes educator must:

  • coordinate receipt of the equipment with the local field office that purchased the service;
  • submit a VR2889, Diabetes Self-Management Education Services Adaptive Diabetes Equipment Receipt;
  • deliver the equipment or supplies to the customer;
  • have the customer sign the VR2889 to acknowledge receipt of equipment or supplies;
  • fill out the manufacturer's warranty card by mail or online; and
  • document on VR2889 that the warranty card has been submitted.

7.4.4 Fees

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

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7.5 Post-Training Assessment

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 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.

7.5.2 Process and Procedure

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

The post-training assessment must be completed for all customers 30 days after the last training session. Only the post-training assessment may be completed in person, by phone, or by video conferencing with the customer. 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 prior to the post assessment being completed. The VR counselor or OIB worker requests approval from the VR director using VR3472, Contracted Service Modification Request.

For more information, refer to VR-SFP 3.6.4.2 Evaluation of Service Delivery.

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.

For more information on acceptable signatures, refer to VR-SFP 3.11.1 Documentation and Signatures.

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.

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7.6 Diabetes Self-Management Education Services Fee Schedule

Diabetes Self-Management Education Services

Unit Rate

Comment

Diabetes Self-Management Assessment

$117.00 per hour

  • Two-hour initial assessment
  • Includes only the time spent assessing the customer

Diabetes Skills Training (Individualized Services Only)

$117.00 per hour

  • Includes only the time spent teaching skills to the customer
  • Each session should be two hours

Diabetes Skills Training (Group Services Only)

$60.00 per hour

  • Includes only the time spent teaching skills to the customer
  • Group services require a minimum of two customers and no more than eight customers per group

Post-training Assessment

$117.00 per hour

  • One-hour post-assessment session 30 days after completion of training
  • Includes only the time spent assessing the customer

 

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