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CDCES Study Guide
DSMES definition ✔ Ans - ongoing process of facilitating knowledge, skills, and ability necessary for prediabetes and diabetes self-care. Incorporates the needs, goals, and life experiences of PWD and is guided by evidence based standards. support informed decision-making, self-care behaviors, and problem solving 7 ADCES self-care behaviors ✔ Ans - -healthy coping -taking medications -healthy eating -being active -monitoring -problem solving -reducing risks DSMES services ✔ Ans - -develop 10 standards in order to apply for accreditation and recognition -needs to be accredited and recognized in order to receive reimbursement -need to have another Part B billing service with Medicare as part of requirements DSMES objectives ✔ Ans - -Informed decision making -Self-care behaviors -Problem solving -Active collaboration with the healthcare team to improve clinical outcomes, health status, and quality of life 10 standards of DSMES ✔ Ans - 1. Internal structure
- Stakeholder Input
- Evaluation of Population Served
- Quality Coordinator Overseeing DSMES services
- DSMES Team
- Curriculum
- Individualization
- On-going support
- Patient Progress
- Quality Improvement topics in curriculum ✔ Ans - -disease process -treatment options -physical activity -medications -monitoring -preventing, detecting, and treating acute complications -preventing, detecting, and treating chronic complications -strategies for psychosocial issues and concerns -navigating healthcare system, learning self-advocacy, and e- health education patient generated health data standards of practice for diabetic educators ✔ Ans - - Provide assessable, safe environment -Use pt specific, appropriate teaching materials -Structure DSME program from survival to advanced self- management -Address self-monitoring skills -Adjust to stress, age, psychological, etc changes with pt -Provide peer support opportunities -Integrates DMSE plan into overall plan of care -Establish follow-up and appropriate referrals teaching methods ✔ Ans - -adult learning techniques -participatory, NOT didactic -storytelling and shared experiences -problem solving -role playing Medicare benefits ✔ Ans - -10 hours of DSMES during initial year, 1 hour as 1-on-1 and the other 9 in group settings -3 hours of MNT during initial year with an RD -2 hours yearly after first year to follow up on goals and needs -2 hours of MNT with RD after first year
-annual assessment of education, nutrition, and emotional needs -when new complicating factors influence self-management -when transitions in care occur Empowerment Approach ✔ Ans - promotes active participation in one's care, provided they have the information to make informed decisions instructional team for certified diabetes center ✔ Ans - primary educator must be an RD, RN, pharmacist, and/or a CDE diabetes diagnostic criteria ✔ Ans - -fasting plasma glucose >= 126 mg/dL on 2 separate occasions OR -symptoms of hyperglycemia and casual plasma glucose of >= 200 mg/dL -2 hour plasma glucose >= 200 mg/dL when not to look at A1c ✔ Ans - sickle cell disease, pregnancy (second and third trimesters and the postpartum period), glucose-6-phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, or erythropoietin therapy normal triglyceride range ✔ Ans - below 150 mg/dL LDL range ✔ Ans - 100 mg/dL or under HDL range ✔ Ans - above 40 mg/dL total cholesterol range ✔ Ans - under 200 mg/dL assessment for DSMES ✔ Ans - -lifestyle issues and factors -promote self-disclosure of concerns -identify special needs or barriers of ADLs -respect cultural differences -health disparity barriers
-uncover priorities of medical need medical history ✔ Ans - -personal and family health history -nutrition habits and practices -physical therapy -meds - OTC, herbal, and Rx -history of substance abuse -mobility and dexterity issues -food insecurity and basic needs psychosocial history ✔ Ans - -previous education and knowledge of self-behavior skills -barriers to learning - vision, literacy, hearing, cognitive -behavioral health -family support -financial and occupational concerns components of education plan ✔ Ans - -learning objective: what should be achieved by end of session -content: info to help make positive behavior change -teaching strategies: how to demonstrate the info -evaluation of education plan lifespan and behavior changes ✔ Ans - -readiness to learn and make changes depend on person's age and maturity -make sure goals are age specific -involve support system learning objectives ✔ Ans - what the participant will achieve at the end of a specific educational session. point in time. knowledge measurement behavioral objectives ✔ Ans - -measurable change in specific behavior that is achieved during a specific period in time -takes time
- provide group format when possible formative evaluation ✔ Ans - -make adjustments to program as needed -ongoing component of assessment, planning, implementation summative evaluation ✔ Ans - -determines effects of teaching -what happened health belief model ✔ Ans - -importance of individual's perception of risk factors, likelihood of making behavior changes -more serious or higher the risk, more likely person will make preventative behavior change -perceived susceptibility, severity, benefits, barriers -self efficacy -cues to action social cognitive theory ✔ Ans - -people learn not only from their personal experience but also from observation of other's behaviors/consequences -uses psychosocial elements and behavioral change methods -help identify how they can make positive changes theory of reasoned action/planned behavior ✔ Ans - - individual behavior is based on attitudes and beliefs of targeted behavior -affected by how others in their community think about the targeted behavior -dependent on skills and knowledge person has to perform the targeted behavior change transtheoretical model ✔ Ans - -6 stages of readiness to make behavioral change
- pre-contemplation (not aware of problem and no intent to change)
- contemplation (aware of problem, thinking about a change)
- preparation (making plans)
- action (engages in behavioral change)
- maintenance (positive, long term change)
- relapse (need to focus on previous success) empowerment model ✔ Ans - -identify problem -identify concerns/feelings -identify long term goals -identify short term goals -implement and evaluate plan family concerns ✔ Ans - -stress and coping -guilt -problem solving -medication issues -financial issues -nutrition (food deserts, shopping) -QOL -social interactoins -trust with caregivers and providers concerns with kids ✔ Ans - -coping with stress and burden of care -establishing schedules and limits -depression, eating disorders, risky behaviors -family conflicts -growth and development concerns -emotional disturbances -needle anxiety -chaotic family environment parents and teens ✔ Ans - need to have good role models and get encouragement/praise. parent needs to help with transportation to events, promoting healthy lifestyles, advocating for proper health care adult support system concerns ✔ Ans - -weaker system or no support -less motivated to make self-care changes
fee for service ✔ Ans - -provider bills insurance after services have been provided -insured person pays monthly premium and deductible medical necessity ✔ Ans - if person needs coverage, supplies, meds and they aren't covered under current policy criteria, provider can fill out documentation to justify the additional coverage is needed type 1 diabetes ✔ Ans - -autoimmune destruction of beta cells in pancreas -absolute deficiency of endogenous insulin -lower in adults, rapid in children -low C peptide levels -prone to other autoimmune issues -GAD antibody is best immunologic predictor of this honeymoon period ✔ Ans - glucose control appears normal but beta cell destruction continues type 2 diabetes ✔ Ans - -insulin resistance and relative insulin deficiency -exogenous insulin not needed for immediate survival -abdominal body fat increases risk -develops gradually, often asymptomatic -significant genetic predisposition testing for GDM ✔ Ans - screen for this between 24- weeks gestation pre diabetes ✔ Ans - -glucose levels are above normal but not yet in range to be classified as full diabetes -risk factors: increased abdominal fat, dyslipidemia, HTN -make lifestyle changes to delay onset fuel metabolism ✔ Ans - -insulin and amylin help regulate glucose levels -insulin transports insulin in the blood, inhibits production of glucose from liver, inhibits glucagon release from alpha cells
-amylin inhibits glucose secretion, inhibits glucose in blood by slowing gastric emptying fasting state ✔ Ans - -blood sugars maintained by liver -body not provided energy = liver releases glucgon fed state ✔ Ans - -carbs are eaten -fuel metabolism is started -insulin takes action, glucagon is low post-absorptive state ✔ Ans - -4-16 hours after carbs eaten -insulin levels decrease -glucagon increases -blood sugar maintained by hepatic resources pre diabetes diagnosis criteria ✔ Ans - -fasting blood sugar between 100- -blood glucose between 140-199 2 hours OGTT -A1c 5.7-6.4% weight loss goals ✔ Ans - -5-7% decrease in weight can positively affect BP, glucose control, A1c, lipids, energy, improve attitude -approach goals in achievable baby steps and then focus on maintenance -small and stable is better than large and fast -consistent CHO intake and increase activity -bariatric surgery if BMI >= 35 CGM time in range goals ✔ Ans - -in range >= 70% in 14 days -below range <4% and severe low <1% in 14 days -above range <25% for 181-250 and <5% for over 250 in 14 days diet issues to address ✔ Ans - -portion control -food labels -meal planning -shopping
-150 minutes of moderate activity each week -reduce fat and calories in diet -14gm/1000 calories of dietary fiber daily, half from whole grains kids/teens nutrition needs ✔ Ans - -involve them with food planning and shopping -involve with food prep -need to involve entire family -adjust to meet nutritional needs for growth and activity -focus on nutrient dense foods type 2 in kids and teens goals/interventions ✔ Ans - - promote 60 minutes per day of physical activity -limit non-academic screen time to less than 2 hours daily -cessation of excessive weight gain -get to near normal fasting glucose levels and A1c macronutrients ✔ Ans - -carbohydrates, proteins, and fats -carbs affect blood glucose levels -protein and fat support body but do not raise glucose -no specific percentages to aim for -individualize needs micronutrients ✔ Ans - -vitamins, minerals, water -no research for specific supplements identified -multi vitamin and healthy diet usually meets nutritional needs -elderly, strict vegetarians, calorie restricted diets, post bariatric surgery, pregnant women may need supplementation glycemic index ✔ Ans - -estimates the post meal impact for cabs -ranks foods on scale of 1-100 over a 2 hour period -high GI = more rapidly digest and absorb into blood stream -low GI = slower to digest and gradually absorb into blood stream -balance high and low index
glycemic load ✔ Ans - -looks at quantity of food and GI value of food GL = GI x grams CHO where are carbs found? ✔ Ans - fruit, veggies, grains, starches, milk, milk substitutes dietary fats ✔ Ans - -<7% should come from saturated fats (animal fats, coconut, palm oil, vegetable oils) -<10% polyunsaturated fats (corn oil, sunflower oils, walnuts) -monounsaturated fats are most beneficial (nuts, canola, olive, peanut oils) -daily cholesterol <300 mg/day (egg yolks, organs, dairy fat) look AHEAD study ✔ Ans - -looked at effectiveness of intentional weight loss interventions in reducing rates of heart disease, stroke, CVD in overweight and obese T2D -stopped early due to significant improvements with intensive intervention meds that cause weight gain ✔ Ans - -sulfonylureas -TZDs -meglitinides -insulin meds that are weight neutral ✔ Ans - -metformin -DPP- -alpha glucosidase -canagliflozin meds that cause weight loss ✔ Ans - -GLP- -pramlintide diabetes & pregnancy goals ✔ Ans - -achieve normal glycemic levels -prevent ketosis -tight glycemic control reduces risk for complications -weight loss not recommended -find good ratio of food intake to glycemic control
-healthy food choices, increase physical activity, moderate and maintained weight loss -achieve and maintain ideal body weight -emphasize variety of nutrient dense foods and appropriate portions nutrition in T1D ✔ Ans - -primary goal is to integrate insulin therapy into eating routines and physical activity pattern -if on fixed regimen: consistency in timing and amount of carbs -if on MDI or pump: focus on carb counting and meal planning -avoid excessive hypoglycemia nutrition in T2D ✔ Ans - -emphasize healthy eating behaviors that result in reduction of energy, saturated and trans fats, cholesterol and sodium -increase physical activity -weight loss through focusing on behaviors that can be changed nutrition in pregnancy and lactation ✔ Ans - -minimize blood sugar excursions -provide calorie intake that isn't excessive but will achieve appropriate weight gain without ketosis -safe nutrients for fetal health -focus on stability before conception -hypoglycemia common in first trimester -insulin needs increase in 2nd and 3rd trimester nutrition in kids/teens ✔ Ans - -involve whole family and meet developmental needs of child -need enough caloric intake for normal growth and development -focus on intake of nutrient dense food -avoid the word diet, stick to meal plan -encourage kid to help with grocery shopping and meal prep nutrition in older adults ✔ Ans - -incorporate cultural foods
-meet calorie and nutrient needs -emphasis on protein -take into account taste preferences, lifelong eating habits, financial constraints, food prep abilities problem solving ✔ Ans - -learned behavior that includes generating a set of potential strategies for problem resolution, selecting the most appropriate strategy and evaluating the effectiveness of the strategy -most difficult to teach; they're also the most difficult to learn -One of the AADE 7, but can be applied to all of the other 6 behaviors -3 Components: pt is goal directed., reaching a solution or goal requires a sequence of mental processes, mental processes involved are cognitive rather than automatic -complex mental process evolve through education, training and/or experiential learning rather than occurring spontaneously theoretical model of problem solving ✔ Ans - -identifying the problem -generating alternative solutions -selecting, implementing, and evaluating a solution problem solving skills ✔ Ans - -approach to dealing with problems and includes effective and ineffective approaches -effective: rational, logic -ineffective: impulsive, careless, avoidant problem solving orientation ✔ Ans - -reflects emotional and attitudinal cognitive sets towards dealing with DM related problems or barriers -positive: effective for self management -negative: ineffective for self management transfer of past learning experiences (problem solving) ✔ Ans - -problem solving leads to new learning because working through a problem creates potential for acquiring new knowledge or experience
-Environment- includes financial constraints, job- related issues and other competing priorities measurement tools for identifying problems ✔ Ans - -some require a fee and may not be available to all educators -PAID questionnaire -used to facilitate discussion -can be limiting clinical problem solving by educator ✔ Ans - problem solving used as a clinical skill to assist in identifying/ diagnosing a problem, planning a course of action or treatment for the individual, and evaluating effectiveness (ie medications adjustments, managing pt during illness) patient as observer or partial contributor to problem solving by educator ✔ Ans - -pt may provide input but educator carries the active role of the main problem solver Steps:
- Identify problem 2.educator generates solutions which pt is encouraged to try -Used when pt is not able/does not assume autonomous role in decision making. patient and professional as collaborative team (problem solving) ✔ Ans - preferred approach after initial education preferred in helping pts to feel engaged in their treatment; equalizing power and joining in a common direction patient as problem solver facilitated by diabetes educator ✔ Ans - pt is the problem solver. Educator guides pt through pt centered questions and responses using a problem solving process to allow pt to come up with their own solution planning for problem solving training/intervention ✔ Ans - -assess pt's needs and assets (knowledge, skills, beliefs)
-understand pt's problem solving skills to design problem solving training and to select intervention techniques problem solving assessment strategies/measures ✔ Ans - - interviewing assesses pt's intervention needs as well as formal measures, which have the advantage of standardizing the problem solving assessment and quantifying pt's problem solving ability 2 measures can be used in evaluating educator's program: -Diabetes Specific Measures- can be administered in interviews, questionnaires, multiple choice or open ended questions, and address different diabetes specific knowledge based problem solving, specific problem solving style or ability -Broader Measures: generic measures have been used in diabetes research and show that generic problem solving measures may be somewhat less sensitive to diabetes outcomes than diabetes specific measures diabetes specific problem solving training ✔ Ans - visual media, computer based education, discussion groups, DSME classes, diabetes summer camps, PCP offices; some focus on problem solving intervention approach, others focus on problem solving skills training or problem resolution as the core intervention problem solving in group setting ✔ Ans - -conduct basic needs assessment of all participants (assessment tool, etc.) -educator may have opportunity to model the problem solving approach and teach the group in the process -establish rapport with group to assist w/ effectively facilitating discussion -can help with empowerment factors influencing problem solving ✔ Ans - -cognitive impairment - dementia, psych disorders, autism, etc. -age: childhood, older adults -education level
