1. DEBORAH F. CHRISTIAN, PA-C
Diabetes Self-Management Education Program Manager
Health Services Advisory Group (HSAG)
Everyone with Diabetes Counts:
Diabetes Self-Management Education

2. HSAG: Your Partner in Healthcare Quality
• HSAG is the Medicare Quality Innovation
Network-Quality Improvement Organization
(QIN-QIO) for California, Arizona, Florida, Ohio,
and the U.S. Virgin Islands.
• QIN-QIOs in every state and territory are united in
a network administered by the Centers for
Medicare & Medicaid Services (CMS).
• The QIN-QIO program is the largest federal
program dedicated to improving health quality at
the community level.
2

3. HSAG’s QIN-QIO Responsibility
3
HSAG is the Medicare QIN-QIO for Arizona, California,
Florida, Ohio, and the U.S. Virgin Islands.
Nearly 25 percent of the
nation’s Medicare beneficiaries

4. QIO Task Areas
4
Improve
Coordination
of Care
Improve
Medication
Safety
Improve
Nursing Home
Quality
Reduce
Hospital
Infections
Improve Health
Through Health
Information
Technology
Improve
Cardiac
Health
Prevent and
Manage
Diabetes
Patient is at the
center of care.

5. Everyone with Diabetes Counts (EDC)
• Diabetes was the seventh leading cause of death in the US
• Nearly 30 million Americans have diabetes.
• 8.1 million Americans are undiagnosed
• Upwards of 86 million Americans prediabetes
• Among the Older Adults
– More than 25 percent of Americans age 65 and older have diabetes.
– 51 percent are estimated to have pre-diabetes.
• 11th Scope of Work
– Reduce health disparities
– Initiative: Everyone with Diabetes Counts or EDC
– Economic burden $245 billion annually (2012)
Data Source: CDC National Diabetes Statistics Report, 2014, available at:
http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-united-
states.pdf
5

6. The Burden of Diabetes in California
• Over 4 million Californians have diabetes (13.4% of adult
population)
• Over 11 million Californians have pre-diabetes (38% of
adult population)
• Diabetes costs an estimated $37.1 billion / year
– Direct medical expenses $27.6 billion in 2012
– Indirect cost $9.5 billion in 2012
6
Data Source: Centers for Disease Control & Prevention (CDC)

7. • African Americans
• Hispanics/Latinos
• American Indians/Native
Americans/Alaska Natives
• Asians/Pacific Islanders
• People living in rural
areas
• California Incidence
– AA & Hispanics: 14%
– Asian population
• Filipino: 15%
• South Asian: 16%
• Pacific Islanders: 18%
Disparities Exist in Diabetes Care
7

8. HSAG’s Role in EDC
• Increase adoption and implementation of diabetes
self-management education (DSME)
– Diabetes Self-Management Program, Stanford University
– Project Dulce, Scripps Health Whittier Diabetes Institute
– Diabetes Empowerment Education Program™ (DEEP),
University of Illinois at Chicago (UIC)
• Train organizations & individuals statewide to offer
DSME
• Provide assistance to organizations offering DSME
• Impact more than 7,000 Medicare beneficiaries with
diabetes or pre-diabetes
8

9. Goals and Target Population
Goals:
– Reduce diabetes care disparities
– Prevent and/or reduce adverse health outcomes
related to diabetes
– Reduce risk factors associated with diabetes
– Increase self-management skills
– Facilitate short- and long-term behavioral change
Special consideration for:
– Includes low-health literacy and low-literacy individuals
9

10. DEEP
Program Description
– Evidence-based program
– Six weekly workshops
– Each class is two hours long
– Taught by one certified DEEP Peer Educator
– Can be delivered in any language
– FUN
• Interactive, hands-on, group learning activities, and games,
including visual aids and demonstrations
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11. DEEP Modules
• Diabetes risk factors and complications
• Nutrition
• Physical activity
• Use of the glucose meter
• Medications
• Building partnerships with diabetes healthcare team
• Psychosocial effects of illness
• Problem-solving strategies
• How to access community diabetes resources
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12. “Tell me and I forget,
teach me and I may remember,
involve me and I learn.”
-Benjamin Franklin
12

13. Why DEEP Works
• Incorporates adult education,
empowerment principles, and
participatory techniques
• Speeds changes in knowledge and
behavioral and clinical indicators
• Meets the needs of
participants in real time
• Connects the dots in easy-to-
understand language
13

14. Interactive Demonstrations
14

15. Understanding a Food Label
15

16. Visualizing Fats and Carbohydrates
16
Cheeseburger Cola Soda Fries
Total Fat 24 g = 6 teaspoons 0 g 29 g = 7 teaspoons
Total Sodium 897 mg = .16 teaspoons 15 mg = negligible 328 mg = .06 teaspoons
Total Carbs 39 g = 8 teaspoons 35 g = 7 teaspoons 63 g = 13 teaspoons
Total Fat, Salt, and Carbs
13 teaspoons of lard
½ teaspoon of sodium
28 teaspoons of sugar

17. • Certified peer educator/ workshop leader
• Only one leader required to lead workshop
• Allows for make-up sessions
Program Delivery Method
17

18. Training Requirements
• Attend a three-day, train-the-
trainer workshop, and receive
certification to facilitate DEEP
workshops as a peer educator.
• Peer educator training is taught
by lead trainers.
• Lead trainer training is taught by
senior trainers.
• No-cost training offered.
18

19. Goals are Outcomes-Based and Data-Driven
• HSAG will help track and analyze data.
• HSAG tracks pre- and post-activation measures.
• HSAG tracks clinical outcomes for 10 percent of
participants:
– HbA1c
– Lipids
– Blood pressure
– Weight
– Foot exams
– Eye exams
19

20. • 1,124 Medicare beneficiaries with diabetes or pre-diabetes
graduated from a DSME workshop.
• 470 Medicare beneficiaries completed both the Pre- and
Post-Patient Activation Surveys.
• Gender
– Male: 27 percent
– Female: 73 percent
• Average age: 72
• Reported Health Conditions
– High Blood Pressure: 61 percent
– High Cholesterol: 52 percent
– Arthritis: 35 percent
– Eye Disease: 18 percent
– Heart Disease: 14 percent
– Lung Disease: 5 percent
20
California Demographics
(January 2015 to April 2016)

21. California Demographics (cont’d)
Ethnicity
21
52%
Not
Hispanic
or Latino
48%
Hispanic or
Latino
Race
• White: 29 percent
• African American: 15 percent
• Asian: 13 percent
• American Indian: 6 percent
• Native Hawaiian: 2 percent
• Other: 35 percent

22. Pre- and Post-Patient Activation Survey
• 14 total questions
– 4 questions: Diabetes knowledge
– 5 questions: Coping with diabetes
– 5 questions: Self-care methods
• Administered during first week and then again at
sixth week
22

23. Diabetes Knowledge
78%
64%
80%
71%
97% 94% 92% 90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
How exercise
affects blood sugar
How to take care of
feet
What is a retinal
exam?
How carbohydrates
break down in body
Pre-PAS Post-PAS23

24. Coping with Diabetes
40%
43%
70%
81%
68%
40%
84%
92%
95%
90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Feeling
overwhelmed
Handling stress Asking for
support
Asking doctor
questions about
treatment plan
Ability to make a
plan to control
diabetes
Pre-PAS Post-PAS
24

25. Self-Care Measures
5
4.1
5
6.7
5.65.7
4.8
5.9
6.7
6.4
0
1
2
3
4
5
6
7
Eating Fruits
and Vegetables
Exercising 30
Minutes
Testing Blood
Sugar
Taking
Medications
Checking Feet
Pre-PAS Post-PAS25
In the last week, average number of days doing self-care
NumberofDays

26. DEEP Retention Rate in California: 79 Percent
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27. Program Costs
• Organizational License: $600/five-year license
• Peer Educator Certification: $100/three-year certification
• Training Cost (for UIC):
– Peer educator training fee: $800 per person
– Off-site training fee: $10,500, plus travel expenses
• Training Cost (for HSAG): None
• Participant Cost: None
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28. Program Costs (cont.)
For a limited time, HSAG will provide:
• Leader training at no charge to organizations committed
to offering this program in their community.
• Materials for conducting workshops.
• Licensing and certification fees may also be provided.
• $40 per DSME completer who meets
contract requirements:
– Medicare beneficiary (65+) and
– Has diabetes or pre-diabetes and
– Completes five of six classes
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29. Will You Join Us?
• Offer DEEP internally
• Outsource DEEP to partnering organizations
• HSAG will provide training
and assistance to your
organization and your
community partners.
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30. Thank you!
818.395.3988 - cell
dchristian@hsag.com

31. This material was prepared by Health Services Advisory Group, the Medicare Quality
Improvement Organization for California, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and
Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No. CA-11SOW-B.2-08162016-01
CMS Disclaimer