Integrating chronic disease self-management education (CDSME) with health care is a key factor for scaling and sustaining evidence-based programs, such as Stanford’s Chronic Disease Self-Management Program (CDSMP) and Diabetes Self-Management Program (DSMP). We have developed a number of resources to help community-based organizations build partnerships with health care systems, form contracts, learn about the requirements for DSMT accreditation, and receive reimbursement for CDSME programs. Take a look at the listing below to find what is most helpful for you.
Community-Integrated Health Care Leadership Team
NCOA has formed a leadership team to guide community-integrated health care efforts. Learn more.
The National CDSME Resource Center is facilitating two learning collaboratives to support partners in developing sustainable CDSME delivery systems. The learning collaboratives will focus on the Medicare benefits for Diabetes Self-Management Training (DSMT) and Health Behavior and Assessment Intervention (HBAI) services.
Toolkits and Guides
- Federally Qualified Health Center (FQHC) Partnership Guide: This resource guide is designed to help community-based organizations build partnerships with FQHCs to bring CDSME to older adults and adults with disabilities in underserved communities.
- ACL DSMT Toolkit: The Administration on Aging developed this toolkit to help AAAs, community planners, and healthcare professionals operate cost-effective, accredited DSMT programs that can meet CMS requirements for Medicare reimbursement.
- Delmarva DSMT Toolkit: This toolkit for QIOs, FQHCs, healthcare professionals and other key stakeholders explains implementation and reimbursement for accredited DSMT programs that meet CMS guidelines for Medicare reimbursement. The Delmarva Foundation for Medical Care, Disparities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), prepared it.
- IHS DSMT Toolkit: This toolkit helps IHS staff get prompt Medicare reimbursement for Diabetes Self-Management Training (DSMT) services. It clearly outlines seven steps from becoming a Medicare-recognized diabetes education program to marketing DSMT services and shows how to put these steps into practice.
Frequently Asked Questions
- DSMT Frequently Asked Questions: See answers to some of the most common questions asked about using Stanford’s DSMP as the core curriculum of an expanded program to meet Diabetes Self-Management Training (DSMT) accreditation standards for Medicare reimbursement.
- Diabetes Self-Management Training: How It Benefits Seniors, and Steps to Reimbursement
- The Ins and Outs of Selling EBPs to Health Care
- Obtaining Diabetes Self-Management Accreditation and Medicare Reimbursement: What States Need to Know
- DSMT Tip Sheet: Learn to develop and operate DSMT programs that meet CMS guidelines for Medicare reimbursement.
- How to Work with a Federally Qualified Health Center (FQHC): FQHCs can provide DSMT and Medical Nutritional Therapy services if they are accredited and accepted by CMS. Learn how to partner with one.
- Health Behavior and Assessment Intervention (HBAI) Services: HBAI is a Medicare reimbursable intervention designed to enable the consumer to overcome the perceived barriers to self-management of his/her chronic disease(s). Chronic Disease Self-Management Education (CDSME), when added to the appropriate infrastructure, may be considered HBAI services.
- Medical Nutrition Therapy: The MNT benefit, used to deliver nutrition assessment and counseling to eligible Medicare beneficiaries, can be combined with CDSME programs for reimbursement. Learn about the process for offering the two Medicare benefits together.
- Handling Common Objections to Community-Based Diabetes Self-Management Training (DSMT): While there is a great need for DSME due to the high prevalence of diabetes, health care systems might object to having a community-based organization provide the DSMT benefit. Learn how to handle these objections to increase access to and use of this important benefit.
Sample Processes and Agreements
- Flowchart: Integrating DSMP and CDSMP: A sample process for integrating Disease Self- Management Programs into an existing hospital-based care management program.
- Sample Policy and Procedure Manual for Diabetes Self-Management Education Program: Use this sample to craft a policy and procedure manual for your organization.
- Sample Agreement with an Independent Contractor: Use this sample agreement between an organization and independent contractor to craft your organization’s agreement.
- Sample Memorandum of Understanding (MOU): A sample MOU between a community-based organization (CBO) and a hospital. It details the expectations, protections, and limitations of a hypothetical agreement in which the CBO provides evidence-based self-management education programs to the hospital’s patients/former patients.
Planning and Administrative Resources
- Health & Behavior Assessment & Intervention (HBAI) Readiness Review: This checklist will help you determine your degree of readiness to provide the Medicare HBAI benefit and to achieve reimbursement.
- DSMT Readiness Review: This resource will help you determine your degree of readiness for DSMT accreditation.
- DSMT and MNT Rate Changes for 2015: DSMT service rates change every year. These rates are retroactive to January 1, 2015.
- How to Get a Medicare Provider Number: Explains the required forms to obtain a Medicare provider number.
- Sample CDSMP Follow-Up Plan and Assessment Form: Use this sample as part of the Health Behavior and Assessment Intervention (HBAI). HBAI is a Medicare reimbursable intervention to enable the consumer to overcome the perceived barriers to self-management of his/her chronic disease(s).
- Sample CDSMP Participant Intake Form with Individual Education Plan: Use this sample as part of the Medicare reimbursable Health Behavior and Assessment Intervention (HBAI).