Provider Resources

Find resources and other information for:

  • Prediabetes and the National Diabetes Prevention Program (National DPP) 
  • Diabetes management and Diabetes Self-Management Education and Support Service (DSMES) Programs 
  • Cholesterol management and guidelines 
  • Hypertension management and guidelines 
  • Healthy lifestyle promotion 


Idaho resources
  • Stay up to date with the rapid delivery of time-critical, health-related information with the Idaho Health Alert Network.
  • Stroke and heart attack are time-sensitive emergencies. The Idaho Time Sensitive Emergency System creates a seamless transition between each level of care and integrates existing community resources to improve patient outcomes and reduce costs.
  • Tobacco cessation is important to reduce the risk of cardiovascular disease and diabetes. Assess and counsel patients on tobacco cessation and refer patients to Idaho’s Project Filter. 
Medical professionals in a hospital hallway

The U.S. Preventive Services Task Force (USPSTF) recommends screening for prediabetes in adults aged 35 to 70 years who have a diagnosis of overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions.

CDC’s National Diabetes Prevention Program (National DPP) is an evidence-based lifestyle change program for preventing type 2 diabetes. The National DPP research study showed that lifestyle changes reduced the risk of developing type 2 diabetes by 58% in people with prediabetes. The National DPP is offered throughout the state. National DPP participants participate in the program over the course of one year with the support of trained lifestyle coaches who empower participants to take charge of their health. 

Coeur d Alene Lake and North Idaho Mountains with blue sky partly cloud
National Diabetes Prevention Program (National DPP)

Prediabetes resources

Which patients are eligible for a referral to a National DPP?

To participate, patients must: 

  • Be at least 18 years old.
  • Be overweight with a BMI of 24 or greater; 23 or greater if Asian.
  • Not diagnosed with type 1 or type 2 diabetes.
  • Not currently pregnant.

And meet one of the following criteria:

  • Have established risk factors for developing type 2 diabetes based on risk test.
  • Have been diagnosed with prediabetes within the past year.
  • Have been previously diagnosed with gestational diabetes.
Why should I refer a patient to a National DPP?

The National DPP can improve patients’ overall health by helping them lose weight, eat healthier, and be more active. The National DPP is based on the Diabetes Prevention Program research study (2002), led by the National Institutes of Health (NIH) and supported by the Centers for Disease Control and Prevention (CDC), which showed that lifestyle change was nearly twice as effective (58% vs 31%) as taking prescription medicines in reducing the risk of type 2 diabetes among people with prediabetes.

This research has shown that weight loss of 5-7% achieved by making healthier food choices and achieving 150 minutes of physical activity each week reduced the risk of type 2 diabetes by 58% in people at high risk for disease, and up to 71% among people aged 60 and older.

How do I refer a patient to a National DPP?

Find a National DPP in your area, contact the program, and build a referral relationship to refer your patients who are at risk for type 2 diabetes.

Prevent type 2 diabetes in your patient population

The American Medical Association (AMA) provides tools for physicians to prevent type 2 diabetes in their patient population. The M.A.P. framework was developed by the AMA and focuses on three approaches to addressing challenges in diagnosing and treating chronic disease. These approaches are:

  1. Measure accurately
  2. Act rapidly
  3. Partner with patients
Order free prediabetes materials for your clinic

Visit the Health Tools website to order free prediabetes materials for your clinic. Relevant prediabetes materials include: 


If an individual has been diagnosed with type 1 or type 2 diabetes, they can receive a referral from a healthcare provider for Diabetes Self-Management Education and Support (DSMES) services. DSMES is a patient-centered, evidence-based service that provides support, knowledge, and skills necessary to manage diabetes. With a healthcare provider referral, diabetes education may be covered by Medicare, Medicaid, and most insurance plans. 

Idaho skyline
Diabetes Self-Management Education and Support (DSMES)

Diabetes resources

Screen for prediabetes and type 2 diabetes in adults aged 35 to 70 years

The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have a diagnosis of overweight or obesity.

Visit the USPSTF website for additional information on screening for prediabetes and type 2 diabetes.

Screen for gestational diabetes at 24 weeks of gestation or after

The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.

Visit the USPSTF website for additional information on gestational diabetes screening.

When should a patient be referred for DSMES services?

The Association of Diabetes Care & Education Specialists (ADCES), formally known as the American Association of Diabetes Educators, American Diabetes Association (ADA), and Academy of Nutrition and Dietetics issued an algorithm and guidance to healthcare practitioners on when to refer patients to diabetes educators and others. 

Referrals should be considered at initial diagnosis.

Providers should consider referring patients under the following circumstances:

  1. Poorly controlled diabetes.
  2. Have questions about healthy lifestyle behaviors as it relates to their diabetes.
  3. If there have been significant changes to treatment or a new condition that affects their diabetes (i.e., diagnosis of a new health condition, changes to medication, or stressful life events).
DSME/T and MNT fact sheet

ADCES and ADA also developed a backgrounder and education fact sheet that includes a summary of Medicare MNT benefit requirements and DSME/T requirements, as well as examples of how MNT and the DSME/T services can be coordinated for qualifying Medicare beneficiaries.

DSMES and Medical Nutrition Therapy (MNT) order form

The Centers for Medicare & Medicaid Services (CMS) uses the term training instead of education. DSMES is also known as Diabetes Self-Management Education/Training Services (DSME/T) when defining the reimbursable benefit. DSME/T and MNT benefits are significantly underutilized by Medicare beneficiaries. Data from Medicare Quality Improvement Organizations reveals the root causes of this underutilization are clinicians' limited awareness/confusion of the benefits and how to order the benefits for a patient.

In response, the ADCES and ADA joined forces to develop the Diabetes Services Order Form, which is designed to be an easy and convenient way for a physician or a qualified non-physician practitioner to refer their Medicare patients with diabetes to a diabetes educator for DSME/T and a registered dietitian for MNT.

The standardized referral form can be used by any facility or healthcare professional and includes the key referral information required to meet Medicare regulatory requirements for MNT and/or DSME/T referrals, but the form itself is not required by Medicare.

ICD-10 codes for DSME/T

October 1, 2015, marked the switch from ICD-9 codes to ICD-10 codes. The new set of codes is greatly expanded from the previous version, allowing for more specificity in diagnoses. For additional information about the codes, CMS provides detailed information.

Standards of medical care in diabetes

Annually, the ADA updates the standards of medical care in diabetes. The standards of care is available in an app format, intended to help clinicians, patients, researchers, policymakers, and other healthcare professionals navigate the different aspects of diabetes care, general treatment goals, and tools to assess the quality of care. The topics covered include:

  1. Improving care and promoting health in populations
  2. Classification and diagnosis of diabetes
  3. Prevention or delay of type 2 diabetes and associated comorbidities
  4. Comprehensive medical evaluation and assessment of comorbidities
  5. Facilitating positive health behaviors and well-being to improve health outcomes
  6. Glycemic targets
  7. Diabetes technology
  8. Obesity and weight management for the prevention and treatment of type 2 diabetes
  9. Pharmacologic approaches to glycemic treatment
  10. Cardiovascular disease and risk management
  11. Chronic kidney disease and risk management
  12. Retinopathy, neuropathy, and foot care
  13. Older adults
  14. Children and adolescents
  15. Management of diabetes in pregnancy
  16. Diabetes care in the hospital
  17. Diabetes advocacy

The goals of treatment for diabetes are to prevent or delay complications and optimize quality of life. View the decision cycle for patient-centered glycemic management in type 2 diabetes.

Guiding principles

In 2018, the National Institute of Diabetes and Digestive and Kidney Disease updated its guiding principles for the care of people with or at risk for diabetes. These principles are areas of general agreement among existing guidelines to help guide healthcare providers and teams to deliver quality care. The principles include:

  1. Identify people with undiagnosed diabetes and prediabetes
  2. Manage prediabetes to prevent or delay the onset of type 2 diabetes
  3. Provide comprehensive, patient-centered diabetes care
  4. Provide ongoing self-management education and support for people with diabetes
  5. Encourage lifestyle modification for people with diabetes
  6. Address overweight and obesity in the management of diabetes
  7. Individualize blood glucose management for people with diabetes
  8. Provide multifactorial cardiovascular disease risk reduction
  9. Detect and monitor diabetes microvascular complications and provide treatment to slow their progression
  10. Consider the needs of special populations with diabetes
Order free diabetes materials for your clinic

In 2021, an estimated 360,827 Idaho adults reported they had high cholesterol (among those screened). In 2018, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines provided a guideline on the management of cholesterol. The guideline includes 10 take-home messages to reduce the risk of cardiovascular disease through cholesterol management.

Million Hearts has also provided a “create your own protocol” utilizing flow diagrams from the 2018 guidelines and/or adapting them from other evidence-based protocols.


The second edition of the Hypertension Control Change Package outlines a listing of process improvements that outpatient clinical settings can implement as they seek to control hypertension. The change package includes change concepts, change ideas, and evidence-or practice based-tools and resources.

Hypertension resources

Screen all adults 18 years or older for hypertension

In 2021, the USPSTF updated its Hypertension in Adults: Screening recommendation to screen all adults 18 years or older for hypertension with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Screen asymptomatic pregnant persons

In 2023, the USPSTF released a Hypertensive Disorders of Pregnancy: Screening recommendation. The USPSTF recommends screening for hypertensive disorders in individuals who are pregnant with blood pressure measurements throughout pregnancy. 

Blood pressure guidelines

Preference for blood pressure guideline recommendations differs between healthcare providers. Blood pressure guidelines are recommendations and are not a substitution for clinical judgment. The Joint National Committee’s eighth report in 2014 (JNC8) and the ACC/AHA 2017 guidelines are linked for reference.

Idaho Blood Pressure (BP) Toolkit

Accurate BP measurement is essential for the diagnosis and management of hypertension. The BP Toolkit provides evidence-based instructions and valuable education on blood pressure measurement for clinical providers at all levels. The BP Toolkit is designed for any healthcare professional who measures blood pressure. The BP Toolkit is divided into four sequential steps:  

  1. Accurate Blood Pressure Measurement for Health Professionals Video  

  2. Blood Pressure Sights and Sounds Module 

  3. Supplemental Provider Materials Resource 

  4. Online Post-Test and a Certificate of Completion 

Self-Measured Blood Pressure Monitoring (SMBP)

Strong scientific evidence supports SMBP in addition to clinical support to lower blood pressure in people with hypertension. Many goals can be achieved utilizing SMBP. For patients newly diagnosed with hypertension or patients who have difficulty adhering to medication, SMBP engages the patient to help determine medication dosage. For patients with undiagnosed hypertension, SMBP eliminates white coat syndrome to accurately diagnose hypertension. For patients who are unable to visit the office frequently, SMBP keeps patients engaged in BP management. Self-measured refers to any monitoring done outside of the clinical setting. Clinical support includes routine individual counseling, telehealth support, and educational classes. 

An Implementation Toolkit developed by the National Association of Community Health Centers provides guidance for organizations to implement SMBP.

Validated Device Listing (VDL)

Accurate blood pressure measurements ensure that patients are properly diagnosed and treated. U.S. Blood pressure VDL are devices that fulfill the criteria to independently validate the clinical accuracy of blood pressure measurement. Ensure your office, kiosk, and your patient's blood pressure measurement device meet the VDL criteria.

In 2020, AHA and AMA released a joint statement supporting SMBP using a VDL.

Order free heart disease materials for your clinic

Visit the Health Tools website to order free heart disease materials for your clinic. Relevant heart disease materials include: 

Discuss healthy lifestyles with your patients

Weight is a sensitive topic. Patients may often have feelings of judgment and failure when a healthcare provider discusses weight. Created by the Strategies to Overcome and Prevent (STOP) Obesity Alliance, the "Why Weight?" tool is a guide for healthcare providers to begin having constructive conversations about weight and health with their patients.

The USPSTF recommends counseling for a healthy diet and physical activity to help people at risk for cardiovascular disease. Offer or refer adults at risk for interventions that promote a healthy diet and physical activity to help people stay healthy. 


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Idaho Diabetes, Heart Disease, and Stroke Prevention (DHDSP) Program