Practice Resources

Make a Referral

Studies show diabetes self-management education and support (DSMES) reduces diabetes-related complications and encourages better management of the disease. Diabetes educators work with their clients to create individualized care plans that focus on the whole health of an individual, considering factors like culture, language, lifestyle and socio-economic status. But that can only happen if the primary care provider takes the initial step to refer the individual to an accredited DSMES program. For additional information visit the CDC’s DSMES Toolkit.

Who to Refer

To qualify for DSMES services, an individual must have the following:

  • Documentation of diagnosis of type 1, type 2 or gestational diabetes
  • Under Medicare and many commercial payers diagnosis must be made using the following criteria:
    • Fasting Blood glucose of 126 mg/dL on two separate occasions
    • 2-Hour Post-Glucose Challenge of ≥200 mg/dL on two separate occasions
    • Random Glucose Test of >200 mg/dL with symptoms of unmanaged diabetes
  • A written referral (see sample forms below) from the treating physician or qualified non-physician practitioner (including nurse practitioner, physician assistant, clinical nurse specialist or advanced nurse practitioner)
    • A new referral is required for follow up visits after one year

When to Refer

AADE, the American Diabetes Association and the Academy of Nutrition and Dietetics issued joint guidance on when DSMES is most critical and a referral is needed for optimal outcomes. These include:

  1. At Diagnosis
  2. During an annual assessment
  3. When a person with diabetes faces new complicating factors
  4. When there is a transition in care

Coverage

Medicare covers up to 10 hours of DSMES (referred to as diabetes self-management training - DSMT - within Medicare) as a once-in-a-lifetime benefit that must be used within 12 consecutive months once started. Each subsequent calendar year, Medicare covers up to 2 hours of DSMT with a new referral.  Most commercial insurers follow Medicare, but its best to have each person check with their insurer to verify coverage. DSMT programs may be able to assist participants with this.

How to Refer

AADE has created sample referral forms that can be downloaded.  If using an EMR, it is particularly helpful to have the referral order built in and easily accessible.  

Referrals should be made to programs that are accredited by one of the two National Accrediting Organizations for the Centers for Medicare and Medicaid Services (CMS), the American Diabetes Association and AADE. These programs meet national standards for quality DSMES. To find an accredited program near you, visit DiabetesEducator.org/Find.​​

Follow Up

Knowing the progress of a patient is key to their continued care. The National Standards for Diabetes Self-Management Education and Support require DSMES programs to communicate the education provided and participant outcomes to the referring provider, so they will have an idea of progress after the referral. Contact the DSMES program for reporting procedures.

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