5.9 Diabetes Self-Management – Education Services

5.9.1 Job Function

DBS educates consumers about diabetes self-management.

Diabetes self-management education services are used to:

  • assess the consumer's ability to independently manage the disease at home;
  • assess the consumer's ability to independently manage the disease in the workplace;
  • assess the consumer's ability to participate in intensive rehabilitation training for persons who are blind, such as the training sessions and mini-training sessions offered by DARS CCRC;
  • prepare a consumer to make informed choices about his or her diabetes; and
  • help the consumer develop the confidence and skills to implement his or her choices.

5.9.2 Qualifications

Diabetes self-management education services are provided by a service provider who instructs and counsels the consumer and family through individual and/or group skills training.


Education and Experience Requirement

A service provider is a health professional, who:

  • is licensed or registered, as required by his or her profession;
  • has completed basic academic requirements for his or her field; and
  • has practiced for at least one year.

A service provider for consumers must be a registered nurse (RN), registered dietician (RD), or certified diabetes educator (CDE). For RNs and RDs, DARS Contract Oversight and Support (COS) unit keeps a copy of the service provider's active license on file. For a CDE, COS keeps a copy of the service provider's current certification from the National Certification Board for Diabetes Education (NCBDE) or the American Association of Diabetes Educators (AADE) on file.

Through academic preparation, continuing education, or on-the-job training, the service provider will have developed:

  • a knowledge and understanding of diabetes and its management, including the nutritional and pharmaceutical aspects of care;
  • a knowledge and understanding of basic educational and behavioral science;
  • the additional skills necessary to work in a thorough and efficient manner, such as planning, organizing, communicating, cooperating, delegating, and working without direct supervision; and
  • a knowledge of the Texas Confidence Builders philosophy.

A service provider (CDE, RN, or RD) must have at least one year of paid experience providing diabetes education. RNs and RDs must have completed 15 hours of continuing education units (CEUs) on diabetes from an accredited agency within 12 months of the application date. A CDE must have completed 10 hours of CEUs on diabetes from an accredited agency within 12 months of the application date. The CEUs must be from an agency approved by the service provider's licensing or certifying body.

The service provider must send a copy documenting the CEUs to the diabetes program specialist (DPS).

The specialist:

  • retains a copy in the specialist's file; and
  • forwards a copy to the regional program support specialist (RPSS).


Technical Skills Requirement

A service provider must:

  • be able to assess a consumer's educational needs and clinical status;
  • offer group instruction and public speaking skills;
  • offer interactive teaching techniques for individuals and groups;
  • be able to communicate technical medical information at a level appropriate for the learner;
  • be able to create a positive and accepting learning environment;
  • be able to relate positively to all consumers;
  • believe in the capabilities and independence of people with disabilities;
  • have good verbal and written communication skills;
  • have basic computer skills, including word processing; and
  • have a private email address, which will not be given to non-approved staff members.

To determine a potential service provider's knowledge about diabetes and behavioral change, a diabetes program specialist may interview the potential provider during the initial contracting process and/or ask him or her to take a skills test.


Training Requirement

Before providing services to consumers, the service provider must either:

  • attend a Texas Confidence Builders training session conducted by the diabetes program specialist; or
  • attend an approved mini-training session, followed by the next available Texas Confidence Builders training.

Veteran service providers must attend Texas Confidence Builders training at least every two years.

Texas Conference Builder training is a 14-hour training led by the diabetes program specialist. The training iincludes a two-hour blindfold experience. The service provider is expected to attend the entire training. Exceptions must be approved by the diabetes program specialist in writing before the training begins.

At the discretion of the diabetes program specialist, service providers may also be required to attend additional periodic training seminars.

If travel is necessary in order to attend the required training, the service provider is responsible for paying all travel costs including transportation, food, and lodging.

5.9.3 Service Provider Authorization and Reimbursement

Diabetes self-management education services must not begin until a service authorization (SA) has been issued by DARS. It is the service provider's responsibility to check the accuracy of the SA before scheduling a visit with the consumer.

If the service provider is unable to schedule the visit within three calendar weeks, the service provider notifies the consumer's vocational rehabilitation counselor (VRC) or independent living worker (ILW).

Service providers must have written authorization before the service provider or the provider's employees provide diabetes self-management education services to consumers. DARS does not pay for diabetes self-management education services, if the services are provided before written authorization is received.

For additional information, see Chapter 1: Basic Standards, 1.6.4 Additional Requirements/Documenting Staff Changes and Chapter 4: Service Delivery Guidelines, 4.2 Staff Information Sheets.

5.9.4 Service Delivery

Scope of Services

Up to 15 hours of individual and group diabetes self-management education services can be approved, including skills training. Additional hours must be approved by the field director and discussed with the diabetes program specialist (DPS).

Self-management of diabetes is an important component of an education plan. The education plan must be customized for each consumer

  • age;
  • schedule;
  • physical activity;
  • eating patterns;
  • cultural factors;
  • personality; and
  • diabetes-related complications or other medical conditions (ADA, 2003e).

Diabetes self-management education services include:

  • an initial assessment (up to two hours);
  • skills training on diabetes self-management (up to 12 hours); and
  • a post training assessment (up to one hour).

Individual skills training on diabetes self-management is divided into short segments (ideally two-hour blocks) to reduce travel costs and ensure that the consumer maintains the physical and intellectual stamina needed to benefit from the skills training.

Group sessions (that is, sessions for two or more consumers at a time) can be cost effective. Service providers are encouraged to coordinate group skills training sessions when they will benefit the instruction process and better meet the needs of the consumer. Approval must be obtained from the referring case manager before skills training begins.

If group skills training sessions are conducted, the initial assessment and post training assessment must be conducted individually, so that a consumer’s health information and other concerns may be addressed privately.

Providers of diabetes education are reimbursed only for the time spent teaching consumers about diabetes.

Providers are not reimbursed for:

  • travel time;
  • planning time;
  • office interaction time; or
  • time spent completing and submitting the required paperwork.

Note: If diabetes self-management education services take more or less than the recommended amount of time (for instance, if an assessment takes more than two hours), the service provider: must document the exceptions to the recommended amount of time; and include the documentation in the report before DARS will consider payment.

The required documentation must be submitted within 35 calendar days of the date that any diabetes self-management education service is provided, including initial assessment, skills training, and post training assessment.

Service providers are strongly encouraged to call or email the consumer's vocational rehabilitation counselor (VRC) or independent living worker (ILW) immediately when situations arise that affect the consumer's health or ability to participate in skills training on diabetes self-management.


Assessing Diabetes Self-Management Education Service

The service provider ensures that the individualized education plan (including the initial assessment, instructional and skills training methods, and teaching materials) is appropriate for each consumer, based on the consumer's:

  • age;
  • type of diabetes (type I or II) and duration;
  • cultural influences; and
  • learning abilities.


The Initial Assessment

The initial assessment for each consumer must include the consumer's:

  • relevant medical history;
  • cultural influences;
  • health beliefs and attitudes;
  • diabetes knowledge;
  • self-management skills and behaviors;
  • readiness to learn;
  • cognitive ability;
  • physical limitations;
  • level of family support;
  • financial status; and
  • any employment issues related to diabetes.

As part of the initial assessment, the service provider recommends the specific skills training that the consumer may need.

The training may include information on:

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


Blood Glucose Meter

For the purpose of assessing consumers and providing them with skills training, service providers may use the talking blood glucose meter recommended by DBS. If the provider recommends using another talking meter, the diabetes program specialist must approve it before skills training occurs.

If DBS changes its recommendation on a talking blood glucose meter, the service provider has 90 calendar days after being notified about the change to obtain the new talking blood glucose meter.

The consumer’s vocational rehabilitation counselor (VCR) or independent living worker (ILW) is responsible for approving the purchase of the recommended equipment or supplies.


Skills Training for Diabetes Self-Management

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

  • the initial assessment; and
  • the topics covered that are related to the consumer’s vocational and independent living goals.

Skills training on diabetes self-management must include:

  • goals for behavioral change; and
  • participation in healthy lifestyle changes.

A copy of the current DARS diabetes education materials is provided to the consumer in his or her preferred medium (for example, large print, CD, and so on).

Other education materials, resources and referrals are documented on the required forms.

Diabetes self-management education is primarily intended to:

  • provide knowledge and skills training; and
  • help the consumer identify barriers, solve problems, and develop coping skills to achieve effective self-care and behavior change.

The initial assessment and subsequent skills training on diabetes self-management is based on the seven self-care behaviors identified by the American Association of Diabetes Educators.

The AADE’s seven self-care behaviors (known as AADE7) are:

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


Group Training

Skills training for diabetes self-management can be provided:

  • in a group of two or more consumers; or
  • as a combination of one-on-one and group training sessions.

In most cases, the training should not exceed 15 hours, total.

Individual skills training for diabetes self-management may be authorized, if group training cannot be scheduled in a timely manner.

The initial assessment and subsequent skills training are usually conducted in the consumer's home. If the skills training is conducted in a group and meets outside the consumer's home, the training and payment are different. Contact the DARS regional program support specialist (RPSS) for more information.


Post-Training Assessment

Post-training (follow-up) assessments are conducted by the service provider at least one month (30 calendar days) after the skills training is completed.

As part of the post training assessment, the service provider:

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

If a post-training assessment is provided before one month (30 calendar days) after the skills training is completed, the service provider must secure approval from the referring case manager.

5.9.5 Documentation of Diabetes Self-Management Education Services

Documentation of Initial Assessments

The service provider's initial assessment and other findings for each consumer are documented using:

  • DARS2888, Diabetes Self-Management Education Assessment; and
  • DARS2901, Diabetes Pre- and Post-assessment.


Documentation of Skills Training and Equipment

Service providers must document each two-hour skills training session provided to each consumer using DARS2884, Diabetes Self-Management Educator Notes.

If the diabetes self-management education services for a consumer include providing the consumer with a talking blood glucose meter or other diabetes equipment, the service provider's responsibilities include:

  • coordinating receipt of the equipment with the local field office that purchased the service;
  • submitting DARS2889, Diabetes Self-Management Education Services - Adaptive Diabetes Equipment Receipt;
  • delivering the equipment or supplies to the consumer;
  • obtaining the consumer's signature on DARS2889 to acknowledge receipt of equipment or supplies;
  • filling out the manufacturer's warranty card by mail or online; and
  • documenting on DARS2889 that the warrantee card has been submitted.

Note: When submitting paperwork electronically, the service provider may enter the phrase "signature on file" to represent the consumer's signature. The service providers must keep the original signature on file and be able to provide it on request.


Documentation of Post Training (Follow-Up) Assessment

The one-hour post-training (follow-up) assessment must be documented using:

  • DARS2900, Diabetes Self-Management Education Posttraining Assessment; and
  • DARS2901, Diabetes Pre- and Post-Assessment.



When speaking by phone or in person to a vocational rehabilitation counselor (VRC), independent living worker (ILW), or rehabilitation assistant (RA) about differences in service delivery, including changes in a service authorization or no-show request, the provider's call or in-person discussion is documented in an email between all parties.

Exceptions, such as being unable to complete skills training or provide a blood glucose meter other than the currently approved talking glucose meter, require written approval from the diabetes program specialist (DPS).

5.9.6 Performance Measures

To adequately measure the performance of a service provider, DBS staff members ask the following questions:

  • Did the service provider meet the consumer's need for diabetes education, as requisitioned by the consumer's counselor or case manager?
  • Has the service provider met the specifications of the DARS contract?
  • Has the service provider performed all contractual services in a professional manner in accordance with the requirements detailed in this manual?
  • If a staff member of the service provider who provides contract services to consumers was hired during the contract period, did the service provider submit a staff information sheet to the regional program support specialist (RPSS) within 10 calendar days of the staff member's hire? Did the staff member meet the qualifications and was the staff member approved before his or her first visit with a consumer?
  • If a staff member of a service provider who provides contract services to consumers resigned during the contract period, did the service provider inform the RPSS about the staff member's resignation no later than the employee's last day?
  • Has the service provider adhered to DARS confidentiality standards?
  • Has the service provider submitted all required reports in accordance with DARS specifications or standards?
  • Has the service provider submitted accurate, completed invoices (including required attachments such as appropriate forms and travel logs if applicable) no later than 35 calendar days after services were completed?