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Diabetes White Paper: Defining the Delivery of Nutrition Services in Medicare Medical Nutrition Therapy vs Medicare Diabetes Self-Management Training Programs

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Abstract

Registered dietitians (RDs) have a defined and unique role in care for patients with diabetes that differs depending on whether the service is for medical nutrition therapy (MNT) or part of a diabetes self-management training (DSMT) program (DSMT and diabetes self-management education [DSME] are used interchangeably in this article). The purpose of this article is to describe the current regulatory and practice framework that supports nutrition care under Medicare Part B for people with diabetes. A description of MNT and DSMT provided under Medicare Part B is included. The role of RDs and other health care professionals involved as program instructors in DSMT programs is also addressed. Revisions to the National Standards for Diabetes Self-Management Education are discussed to clarify RDs' involvement in DSME programs.

Section snippets

Diabetes as an Epidemic

Diabetes affects nearly 24 million people in the United States, an increase of more than 3 million in approximately 2 years, according to new 2007 prevalence data estimates released in 2008 by the Centers for Disease Control and Prevention. This means that nearly 8% of the US population has diabetes. In addition to the 24 million with diabetes, another 57 million people are estimated to have prediabetes, a condition that puts people at increased risk for diabetes. The 2007 total estimated cost

The Standards of Practice and Standards of Professional Performance for RDs in Diabetes Care

To reflect the current practice of dietetics as it relates to diabetes care for Medicare and other payers, ADA's Diabetes Care and Education practice group has published its Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care (2, 9). Standards of practice (SOP) are authoritative statements that describe a competent level of practice related to direct client care demonstrated through nutrition

National Standards for DSME

Similar to the evidence-based nutrition practice guidelines that RDs apply for MNT, national standards for diabetes education are also in place for services provided by recognized DSMT programs. The DSME Standards are a blueprint that defines quality DSME, allowing diabetes educators to provide evidence-based education. These Standards are reviewed approximately every 5 years by key organizations and federal agencies within the diabetes education community (14). Health care payers, such as

Nutrition Education Activities Provided by Program Instructors of Nationally Recognized DSMT Programs

There may be instances in which several of the key members of a multidisciplinary diabetes team (ie, a registered nurse, RD, and pharmacist) are not available to provide DSMT education, so one qualified program instructor administers all content for the program. CMS DSMT regulations indicate that, “In a rural area, an individual who is qualified as a registered dietitian and as a CDE [certified diabetes educator] that is currently certified by an organization approved by CMS … may furnish

Conclusions

RDs have a defined and unique role in diabetes care that differs depending on whether the service is for MNT or part of a DSMT program. RDs may participate in recognized DSMT programs as a sole program instructor or as part of a multidisciplinary team. RDs or other qualified health care professionals who operate as solo instructors in DMST programs must practice only at the level at which they are competent, which will vary depending on an individual's education, training, and experience.

A. Daly is cofounder and director of nutrition and diabetes education, Springfield Diabetes & Endocrine Center, Springfield, IL

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  • Cited by (16)

    • The diabetes nutrition education study randomized controlled trial: A comparative effectiveness study of approaches to nutrition in diabetes self-management education

      2016, Patient Education and Counseling
      Citation Excerpt :

      Although DSME/S improves diabetes knowledge, self-care behaviors, quality of life, and glycemic control [7–11], approaches to DSME/S vary widely. Nutrition counseling is a critical component of DSME/S [12] and improves glycemic control similar to many glucose-lowering medications [13]. DSME/S allows for multiple approaches to carbohydrate monitoring, including gram counting, exchanges, and experience-based estimation [14].

    • Design of the Lifestyle Improvement through Food and Exercise (LIFE) study: A randomized controlled trial of self-management of type 2 diabetes among African American patients from safety net health centers

      2014, Contemporary Clinical Trials
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      The control group received two group classes covering diabetes self-management training and diabetes nutrition education, taught in the clinics by a registered dietitian. This amount of diabetes education corresponds to the type and amount of diabetes education covered by the Centers for Medicare and Medicaid Services after the first year of diagnosis [34]. Like the intervention group classes, the content of the control group classes covered topics recommended in the National Standards for Diabetes Self-Management Education [41].

    • Clinical practice guidelines for healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults: Cosponsored by the American association of clinical endocrinologists/the American college of endocrinology and the obesity society

      2013, Endocrine Practice
      Citation Excerpt :

      MNT is more sophisticated than healthy eating, is typically provided by a health care professional experienced with DM management, and is directly coordinated with physician-directed medical therapy (342 [EL4, NE]; 343 [EL4, NE]). Evidence-based recommendations for MNT have been previously published and serve as the basis for many of the recommendations offered in the Executive Summary of this CPG (9 [EL4, NE]; 342 [EL4, NE]; 344 [EL4, NE]; 345 [EL4, NE]; 346 [EL4, NE]). This section complements these previous reports on MNT by providing basic recommendations about healthy eating that physicians can provide to their patients with DM.

    • Community Participation and Diabetes Control

      2013, Bioactive Food as Dietary Interventions for Diabetes
    • American Dietetic Association Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care

      2011, Journal of the American Dietetic Association
      Citation Excerpt :

      The differences between the provision of nutrition education and counseling in diabetes care were defined and described in a Diabetes White Paper (28). Diabetes self-management training and community programs include nutrition education (ie, instructional methods) that promote healthful behaviors by imparting information that individuals and groups can use to make informed decisions about food, eating habits, and health (28). MNT “is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention.” (7)

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    A. Daly is cofounder and director of nutrition and diabetes education, Springfield Diabetes & Endocrine Center, Springfield, IL

    P. Michael is director, ADA Nutrition Services Coverage, Chicago, IL

    E. Q. Johnson is principal consultant, EQJ Associates, North Reading, MA

    C. C. Harrington is program coordinator, Aspirus Diabetes Education Center/Aspirus Nutrition Counseling, Wausau, WI

    S. Patrick is vice president of Policy Initiatives and Advocacy in ADA's Washington, DC, office

    T. Bender is communications manager, ADA Nutrition Services Coverage, Chicago, IL

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