Improving Referrals to Diabetes Self-Management Education and Support Programs

Background: In Utah, 8.6% of adults have diabetes, the state's leading cause of renal failure, blindness in adults <75 years old, and non-traumatic lower-extremity amputation. Diabetes self-management education and support programs improve glucose levels and prevent complications. The American Diabetes Association recommends that everyone with diabetes attends diabetes self-management education at diagnosis, annually, when diabetes complications arise, and at life or care transitions. Up to 50% of eligible patients are referred to diabetes education by their primary care providers, yet only 5- 6.8% of people with newly diagnosed diabetes attend. The purpose of this project was to improve referrals (rate and quality) to diabetes self-management education and support for people with type 1 or type 2 diabetes at a small, urban clinic. Methods: The Social Cognitive Theory was used to develop interventions to improve diabetes education referrals by addressing personal, environmental, and behavioral factors. In phase one of the project, the principal investigator conducted a retrospective chart review to determine clinic referral rates to diabetes self-management education over the previous year. Providers and staff completed a survey to assess knowledge and perceived barriers and facilitators to making referrals. Phase two involved developing a tailored diabetes education referral program based on survey feedback. This program included a staff presentation and referral toolkit, which contained a workflow algorithm, electronic health record referral templates, chart tags, patient education handouts, and other documents to assist providers in patient education and the referral process. Phase three involved providing education and training to healthcare team and disseminating the toolkit. In phase four, referrals to diabetes self-management education and survey data were analyzed to determine changes in referral rates and knowledge scores. Referred patients' attendance status was evaluated through follow-up phone calls. Demographic and language preference data of eligible and referred people with diabetes was collected to examine referral inequities. Staff completed a post-intervention survey to measure the feasibility, usability, and satisfaction of the diabetes education referral program. Results: Diabetes self-management education and support (DSMES) referral rates increased significantly from 5% (n=4) in 52 weeks pre-intervention to 44% (n=22) in 13 weeks post-intervention (p< .01). Mean referral criteria knowledge scores for providers and staff increased from 3.7 (SD=0.95) pre-intervention to 4.3 (SD=1.11) post-intervention. All (n=8, 100%) providers and staff reported that the toolkit addressed barriers to making DSMES referrals and intend to continue using the toolkit in the future. There was overall high satisfaction with the toolkit components. Providers and staff reported 100% (n=8) satisfaction for six of seven toolkit components and 75% (n=6) satisfaction for the other toolkit component. Conclusions: The DSMES referral toolkit with staff education resulted in a significant increase in DSMES referral rates. Clinic staff feedback indicated that this QI project was feasible, usable, and they were satisfied overall with the toolkit components. Six weeks post project completion, clinic providers and staff continued to use the referral toolkit. Next steps include comparing patients' intention to attend diabetes education to their successful program attendance. An intervention to increase diabetes attendance may be indicated if actual attendance remains low.