Diabetes is a chronic disease that requires a person with diabetes to make a multitude of daily self-management decisions and to perform complex care activities. Diabetes self-management education and support (DSME/S) provides the foundation to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes (1-7). Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes self-management support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. (See further definitions in Table 1.) Although different members of the health care team and community can contribute to this process, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type 2 diabetes receive both DSME and DSMS in a consistent manner. The initial DSME is typically provided by a health professional, whereas ongoing support can be provided by personnel within a practice and a variety of community-based resources. DSME/S programs are designed to address the patient's health beliefs, cultural needs, current knowledge, physical limitations, emotional concerns, family support, financial status, medical history, health literacy, numeracy, and other factors that influence each person's ability to meet the challenges of self-management.It is the position of the American Diabetes Association (ADA) that all individuals with diabetes receive DSME/S at diagnosis and as needed thereafter (8). This position statement focuses on the particular needs of individuals with type 2 diabetes. The needs will be similar to those of people with other types of diabetes (type 1 diabetes, prediabetes, and gestational diabetes mellitus); however, the research and examples referred to in this article focus on type 2 diabetes. The goals of the position statement are ultimately to improve the patient experience of care and education, to improve the health of individuals and populations, and to reduce diabetes-associated per capita health care costs (9). The use of the diabetes education algorithm presented in this position statement defines when, what, and how DSME/S should be provided for adults with type 2 diabetes.

Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and is necessary in order to improve patient outcomes. The National Standards for DSME are designed to define quality diabetes self-management education and to assist diabetes educators in a variety of settings to provide evidence-based education. Because of the dynamic nature of health care and diabetes-related research, these Standards are reviewed and revised approximately every 5 years by key organizations and federal agencies within the diabetes education community.A Task Force was jointly convened by the American Association of Diabetes Educators and the American Diabetes Association in the summer of 2006. Additional organizations that were represented included the American Dietetic Association, the Veteran's Health Administration, the Centers for Disease Control and Prevention, the Indian Health Service, and the American Pharmaceutical Association. Members of the Task Force included a person with diabetes; several health services researchers/ behaviorists, registered nurses, and registered dietitians; and a pharmacist.The Task Force was charged with reviewing the current DSME standards for their appropriateness, relevance, and scientific basis. The Standards were then reviewed and revised based on the available evidence and expert consensus. DEFINITION ANDOBJECTIVES -Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.GUIDING PRINCIPLES -Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would be used to guide the review and revision of the DSME Standards. These are:1. Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term (1-7). 2. DSME has evolved from primarily didactic presentations to more theoretically based empowerment models (3,8). 3. There is no one "best" education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes (9 -11). Additional studies show that culturally and ageappropriate programs improve outcomes (12-16) and that group education is effective (4,6,7,17,18). 4. Ongoing support is critical to sustain progress made by participants during the DSME program (3,13,19,20). 5. Behavioral goal-setting is an effective strategy to support self-management behaviors (21). STANDARDSStructure Standard 1. The DSME entity will have documentation of its organizational structure, mission statement, and goals and will recognize and support quality DSME ...

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The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. Methods The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Results Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Conclusion Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

These findings highlight the importance of shared responsibility for diabetes self-care through early to middle adolescence.

Independent risk factors for poor metabolic control included poor self-care, disturbed eating behavior, depression, and peer relations; parental support was an independent resistance factor for girls. Future research should examine mechanisms by which these relations emerge.

OBJECTIVE -To determine whether using the chronic care model (CCM) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes. RESEARCH DESIGN AND METHODS-This multilevel, cluster-design, randomized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community. Eleven primary care practices, along with their patients, were randomized to three groups: CCM intervention (n ϭ 30 patients), provider education only (PROV group) (n ϭ 38), and usual care (UC group) (n ϭ 51).RESULTS -A marked decline in HbA 1c was observed in the CCM group (Ϫ0.6%, P ϭ 0.008) but not in the other groups. The magnitude of the association remained strong after adjustment for clustering (P ϭ 0.01). The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group (non-HDL cholesterol: Ϫ10.4 mg/dl, P ϭ 0.24; self-monitor blood glucose: ϩ22.2%, P Ͻ 0.0001), with statistically significant between-group differences in improvement (non-HDL cholesterol: P ϭ 0.05; self-monitor blood glucose: P ϭ 0.03) after adjustment. The CCM group also showed improvement in HDL cholesterol (ϩ5.5 mg/dl, P ϭ 0.0004), diabetes knowledge test scores (ϩ6.7%, P ϭ 0.07), and empowerment scores (ϩ2, P ϭ 0.02).CONCLUSIONS -These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes. Diabetes Care 29:811-817, 2006D iabetes affects ϳ7% of the U.S. population and has reached epidemic proportions (1). Diabetes represents a significant public health burden worldwide by decreasing quality of life and causing death and disability at great economic cost (2). Though quality diabetes care is essential to prevent long-term complications, care often falls below recommended standards regardless of health care setting or patient population, emphasizing the necessity for system change (3-6).The chronic care model (CCM) (3,4,7,8) is a multifaceted framework for enhancing health care delivery. The model is based on a paradigm shift from the current model of dealing with acute care issues to a system that is prevention based (3,5,(7)(8)(9). The premise of the model is that quality diabetes care is not delivered in isolation and can be enhanced by community resources, selfmanagement support, delivery system redesign, decision support, clinical information systems, and organizational support working in tandem to enhance patient-provider interactions (3,4,7-13). Currently, few efforts exist to implement multifaceted approaches to improve quality of care in diabetes despite studies that demonstrate their proven effectiveness (3,4,11,14,15).The objective of the current study was to determine the effectiveness of an intervention based on the CCM in primary care settings. We hypothesized that patient clinical (glycemic, blood pressure, and lipid control), behavioral (selfmonitoring of blood glucose), psychological/psychosocial (qualit...