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Slide 1 12 Keys to
Financially
Sustaining
DSME and Other
Patient Education
Programs:
5 F’s and 7 P’s
Mary Ann Hodorowicz, RD, LDN, MBA, CDE
Certified Endocrinology Coder
Mary Ann Hodorowicz Consulting, LLC
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Slide 2 This information is intended for educational and reference purposes only. It does not
constitute legal, financial, medical or other professional advice.
The information does not necessarily reflect opinions, policies and/or official positions
of the Center for Medicare and Medicaid Services, private healthcare insurance
companies, or other professional associations. Information contained herein is subject
to change by these and other organizations at any moment, and is subject to
interpretation by its legal representatives, end users and recipients. Readers should
seek professional counsel for legal, ethical and business concerns. The information is
not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice
Guidelines or American Diabetes Association’s Standards of Medical Care in Diabetes.
As always, the reader’s clinical judgment and expertise must be applied to any and all
information in this document.
Mary Ann Hodorowicz Consulting, LLC [email protected]
708-359-3864
Information on products below at: www.maryannhodorowicz.com
“Money Matters in MNT and DSMT: Increasing Reimbursement Success in All
Practice Settings, The Complete Guide ©”, 5th. Edition, 2012
“Establishing a Successful MNT Clinic in Any Practice Setting ©”
“EZ Forms for the Busy RD” ©: 107 total, on CD-r; Modifiable; MS Word
Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, Plus 3
Free DSMT Assessment Form and MNT Superbills: 18 Forms
Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms
Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and
Other Business/Office and Record Keeping Forms: 84 Forms
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Slide 3 Learning Objectives
• Name the 5 F’s for sustaining DSME programs and
other outpatient education programs in various
outpatient practice settings.
• Name the 7 P’s for sustaining DSME programs and
other outpatient education programs in various
outpatient practice settings.
• Name 4 of the many types of off-site locations where
out patient programs can be delivered.
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Slide 4 5 F’s
1. Financial bottom-line
2. Focus on billing basics
3. Format
4. Full Diabetes Services
5. First Rate Quality
Standards
7 P’s
1. Provider Status
2. Programs
3. Place
4. Promotion
5. Patient Centeredness
6. Practice Management
Essentials
7. Perfect Teamwork
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Slide 5 1. Financial Bottom-Line
Ask your team:
1. WHO is regularly identifying our program’s and
practice’s bottom-line? Is it someone from:
− Our own department?
− Accounting?
− Finance?
− Operations?
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Slide 6 1. Financial Bottom-Line, Cont.
Ask this person:
2. What exactly IS our program’s or practice’s
bottom line? Are we:
− Making money?
− Losing money?
− Breaking-even?
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Slide 7 1. Financial Bottom-Line, Cont.
If losing money, ask:
3. HOW can we fix it?
− Key word is “WE” !
− Your willingness to roll up your sleeves can
help:
− Save your program AND
− Save your job!
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Slide 8 1. Financial Bottom-Line, Cont.
4. Ask: “What expenses are charged to our program?”
− Request hard-copy of financial reports on regular
basis….example:
• Revenue and Expense Reports
• Income Statements
– Examine reports carefully and ask:
• Do these expenses really belong to our
program?
• Are they accurate and reasonable?
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Slide 9 2. Focus on Billing Basics
5. Ask billers and coders:
– Are ALL of our DSME/MNT visits being billed?
– Are ALL other services we furnish being billed?
− CGM?
− Insulin pump starts?
− Are services billed in
timely manner?
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Slide 10 2. Focus on Billing Basics, Cont.
6. On claims, is ALL coding correct?
− CPT procedure codes? Examples:
• MNT codes 97802, 97803, 97804,
− HCPCS procedure codes? Examples:
• MNT codes G0270, G0271
• DSME codes G0108, G0108
– Number of “units” of above codes entered?
• MNT 97802, 97803, G0270: 1 unit = 15 min.
• MNT 97804, G0271: 1 unit = 30 min.
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Slide 11 2. Focus on Billing Basics, Cont.
• DSME G0108, G0109: 1 unit = 30 min.
− Revenue codes (OP hospital only)
• 942 for Medicare DSME and MNT claims from
OP hospital setting
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Slide 12 2. Focus on Billing Basics, Cont.
− ICD-9 diagnosis codes?
• Is 5-digit diabetes dx code used on ALL
diabetes-related services to Medicare?
− Place of service codes? Examples:
• 11 = Office
• 12 = Home
• 13 = Assisted Living Facility
• 22 = Outpatient Hospital
• 31 = Skilled nursing facility
• 32 = Nursing facility
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Slide 13 2. Focus on Billing Basics, Cont.
On your claims:
7. Is primary ICD-9 diagnosis code (reason for
today’s visit) entered as the #1 dx code in
diagnosis field?
− Example: If pt’s visit for DSME, is 5-digit dx
code for diabetes entered as the #1 dx code?
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Slide 14 2. Focus on Billing Basics, Cont.
On your claims:
8. Does procedure code entered on claim “point to”
the matching/corresponding diagnosis code?
− Example: Procedure code G0109 (group DSME)
must “point to” the diabetes diagnosis code.
− If code “points to” hyperlipidemia diagnosis on
claim, claim will be rejected, as G0109 is for
DSME….this does not “match”.
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Slide 15 2. Focus on Billing Basics, Cont.
On your claims:
9. Are ALL the diagnoses documented on physician’s
referral actually entered in diagnosis field?
− They should be!
− Can affect payer’s decisions on:
− Medical necessity of service
− Approval of claim as payable, AND
− Amount of reimbursement
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Slide 16 2. Focus on Billing Basics, Cont
Ask your team:
10. Are we tracking our claims ourselves, via regular
“Reimbursement Tracking Reports” from IT to:
− Identify each claim’s payment status:
• Paid? Rejected? Denied?
– Determine if ALL services billed?
– Determine if ALL pt co-payments, deductibles
and OOP payments collected in timely manner?
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Slide 17 2. Focus on Billing Basics, Cont.
11. Re: claims that have been denied and rejected:
− Is your team AND your billers investigating these
claims to identify root problem(s)?
− Are root problems then fixed?
− Are these claims then:
• Re-billed in timely manner, OR
• Appealed?
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Slide 18 2. Focus on Billing Basics, Cont.
For more complete information on how to complete
CMS 1500 claim form, can access online:
Medicare Claims Processing Manual
Chapter 26 - Completing and Processing
Form CMS-1500 Data Set
Just copy and paste this URL into your browser:
www.cms.gov/manuals/downloads/clm104c26.pdf
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Slide 19 3. Format
Ask your team:
1. Is our time being used efficiently to pt volume and
payer reimbursement by:
– Doing more group DSME and MNT?
– Holding group programs in staggered starts in
several different locations?
– Doing shared medical appointments (SMAs)?
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Slide 20 4. Full Diabetes Services
Ask your team: Do we offer all needed services to pts?
− Medical nutrition therapy
− Weight loss program
− Exercise program
− BG pattern management
− Shared medical appointments
− Continuous glucose monitoring
− Insulin pump starts (CSII)
− Diabetes shoes
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Slide 21 4. Full Diabetes Services, Cont.
− Specialist consultants and/or their services:
• Endocrinologist
• Diabetologist
• Pedorthist
• Podiatrist
• Psychologist
• Ophthalmologist
• Nephrologist
• Gynecologist specializing in diabetes
− Point of care testing (instant A1c, lipids, etc.)
− Insulin and injectable medication initiation
− Pregnancy and GDM diabetes services
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Slide 22 5. First Rate Evidence-Based Quality
Standards
Sackett et al defined evidence-based medicine as:
“The conscientious, explicit, and judicious use of
clinically relevant research in making decisions
about the care of individual patients.” 1
1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS:
Evidence-based medicine: what it is and what it isn’t. BMJ 312:71–72,
1996
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Slide 23 5. First Rate Evidence-Based Quality
Standards, Cont.
• Strengths of evidence-based medicine:
– Moves clinical practice:
FROM
– Anecdotal experience and expert opinion
TO
– Strong scientific foundation
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Slide 24 5. First Rate Evidence-Based Quality
Standards, Cont.
– Integrates clinical medicine with basic and clinical
research
– Enhances effectiveness and safety of diagnostic,
preventive and therapeutic measures. 2
2. Evidence-Based Diabetes Care, Herman, William H. MD, MPH, Clinical
Diabetes, January 2002 vol. 20 no. 1 22-23 doi: 10.2337/diaclin.20.1.22
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Slide 25
1. National Standards for DSME as guiding principles
– 10 evidence-based standards used to:
• Provide blue print to manage DSME program
• Optimize pt outcomes
• Ensure quality of entire DSME program from
both clinical and operational perspective
– Adherence to is required for accreditation of
DSME program by AADE and Amer Diab Assoc
5. First Rate Evidence-Based Quality
Standards, Cont.
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Slide 26
2. Evidence-based standards of diabetes medical care:
− American Diabetes Association
− American College of Obstetricians and
Gynecologists
− American Association of Clinical Endocrinologists
− American College of Endocrinology
− World Health Organization
− National Institute of Diabetes and Digestive and
Kidney Diseases
5. First Rate Evidence-Based Quality
Standards, Cont.
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Slide 27
• BUT, evidence-based standards (EBS) MUST be
incorporated with:
– HCP’s JET
• Judgment….Experience…..Training
– Pt’s
• IV’s
– Issues….Values….Variables
• NEWS
– Needs….Expectations….Willingness….
Stage of readiness
5. First Rate Evidence-Based Quality
Standards, Cont.
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Slide 28
EBS
HCP’s
J.E.T.
Pt’s
I.V.s and
N.E.W.S.
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Slide 29 1. Provider Status
1. IF they CAN be, are members of your DSME team
in-network providers for:
• Medicare?
• Medicaid?
• Larger private payers in area?
2. IF in-network private payer status NOT allowed,
have they asked private payers if they can bill as
out-of-network providers?
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Slide 30 1. Provider Status, Cont.
3. Or, do you practice M.B.A.?
− Management By Assumptions?
• Assume that private payers do NOT credential
RDs as in-network providers for MNT or
nutrition counseling, so don’t make call?
• Assume you cannot bill as out-of-network
provider, so don’t make the call?
M.B.A. can leave LOTS of YOUR earned money in
the pockets of the payers! Not good!
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Slide 31 1. Provider Status, Cont.
Remember:
• MOST large private payers pay for MNT or nutrition
counseling in diseases for which evidence exists
that diet in integral part of treatment plan
• 46 states have state insurance laws mandating
payment for DSME
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Slide 32 2. Programs
Think out of the box……ask your team:
1. Do we TYPES of programs to patient volume?
When insurance rates
Then patient volume must
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Slide 33 2. Programs, Cont.
2. Do we do other programs 100% compatible
with our core program (DSME)?
– MNT program?
– Weight loss program?
– Behavior change program?
– Exercise program?
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Slide 34 2. Programs, Cont.
– Monthly 1 hour “hot topic” community programs
for a small OOP fee? Examples:
− Nov: How to Avoid Holiday Weight Gain
− Dec: Healthy Baking Tips for the Holidays
− Jan: Lose Pounds the Healthy Weigh
− Feb: Heart Healthy Chocolate Desserts
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Slide 35 2. Programs, Cont.
3. Do we charge OPP fees or bill insurers for these
other patient programs?
– Many private payers now reimburse for these
– Many patients will pay out of pocket
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Slide 36 3. Place
Ask your team:
1. Do we bring our education programs TO our pts in:
– Malls (open “Health Stores”)?
– Employers’ place of business?
– Physician offices?
– Clinics (free-standing + inside big-box stores)?
– Libraries?
– Senior centers?
– Recreation departments?
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Slide 37 4. Promotion
Ask your team:
1. Do we do any marketing to physicians, mid-levels
and community to let them know we exist?
2. Do we maintain on-going communication with
referring physician/mid-level after each pt visit?
3. Do we promote completion of/encourage pts to
complete ALL billable hours of DSME program
and hours of other covered benefits, such as MNT?
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Slide 38 4. Promotion, Cont.
4. Do we focus our marketing efforts on our 4 main
target markets?
Existing patients
Physicians
Mid-levels: NP’s, PA’s, CNS’s
Community people
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Slide 39 4. Promotion, Cont.
5. What TYPES of marketing are used, do we
TRACK effectiveness? Do we VARY types?
− Pads of customize referral forms?
− Deliver pads to physicians’ offices in person?
− Tri-fold marketing brochures or slim jims for
placement on office reception desks, local
health fairs, employer groups, etc.?
− Create our website?
6. How OFTEN to we implement each type?
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Slide 40 5. Patient Centeredness
Ask your team:
1. Do we ensure medical care, DSME, and all education
programs based on patients’ needs, not office
schedule or curriculum?
– This pt outcomes and patient volume as it:
• Leads to revenue, via in “R and R”:
– Referrals to DSME and other programs
– Retention of patients in education programs
Patient
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Slide 41 5. Patient-Centeredness, Cont.
Primary
Care
Physician
Diabetes
Educators
Physician
Specialists
Support
Networks
Insurance
Company
2 Way Communication: Up and Down
Patient
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Slide 42 5. Patient Centeredness, Cont.
2. Do we use the more pt-centered counseling styles?
– Motivational Interviewing (MI)?
– Patient Empowerment (PE)?
3. Do we incorporate Adult Learning and Retention
(ALR) principles when counseling in group and 1:1?
Patient
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Slide 43 5. Patient Centeredness, Cont.
Example of teaching aid that embraces ALL 3
key counseling styles & principles: MI, PE, ALR:
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Slide 44 6. Practice Management Essentials
(PMEs)
PMEs maximize these
key areas in your practice:
A - E - I - O - U
Essentials
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Slide 45
A = Adherence to quality standards:
– Standards of practice
– Standards of professional performance
– Diabetes standards of care
– National standards of DSME
– Evidence-based nutrition practice
guidelines
6. Practice Management Essentials
(PMEs), Cont.
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Slide 46
E = Expense control
E = Ethics in management
– Operations
– Clinical
– Financial
E = Efficiency
6. Practice Management Essentials
(PMEs), Cont.
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Slide 47
I = Income
– Insurance reimbursement
– Patient OOP payments
– Patient deductibles and co-payments
6. Practice Management Essentials
(PMEs), Cont.
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Slide 48
O = Outcomes of patients
– Knowledge
– Behavior
– Clinical
– Cost-Savings (Financial)
– Satisfaction
• Patient
• Physician
• Payer
6. Practice Management Essentials
(PMEs), Cont.
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Slide 49
U = Utilization of all resources to the maximum:
– CGM equipment
– Insulin pump initiations
– POC testing…example:
• Instant A1c, BG, u.microalbumin, lipids, BP
– EMR and other software
– Shared medical appointments
– All pt education programs, in addition to DSME
– Services of consultant specialists
6. Practice Management Essentials
(PMEs), Cont.
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Slide 50
Just what are
Practice
Management
Essentials?
6. Practice Management Essentials
(PMEs), Cont.
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Slide 51
1. Initiate and maintain on-going communication with
patients, physicians and payers
2. Ensure ALL requirements of provider-insurer
contracts and coverage provisions are met
3. Develop policies & procedures (P&Ps)
that ensure consistency with:
– Standards of professional practice/performance
– Licensure/certification requirements
– Insurers’ coverage guidelines
– Patients’ rights, responsibilities, expectations
6. Practice Management Essentials
(PMEs), Cont.
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Slide 52
4. Attempt to become in-network credentialed provider
with private insurers
− Compile database of insurer-specific coverage
conditions for each service to be delivered
5. Implement HIPPA compliant systems that meet all
CMS’, government, state and federal statutes
6. Develop records storage and retrieval systems that
assure clear, accurate and timely documentation of
all services delivered
6. Practice Management Essentials
(PMEs), Cont.
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Slide 53
7. Implement financial systems that ensure complete,
accurate & timely billing and collections procedures
8. Implement CQI/quality management system at all
levels of and types of service delivery
9. Implement regular in-house training of clinical and
administrative staff on all elements of ethical billing
10. Review/renegotiate provider-insurer contracts with
insurers at least annually
6. Practice Management Essentials
(PMEs), Cont.
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Slide 54
11. Implement clinical systems that are 100%
compliant with:
− Standards of professional practice/performance
− Current evidence-based standards of:
• Medical care for diseases/conditions treated
• Medical nutrition therapy
• Diabetes self-management training
• CGM
• Insulin pump training
6. Practice Management Essentials
(PMEs), Cont.
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Slide 55 7. Perfect Team Communication
and Collaboration
• Perfecting your team communication and
collaboration allows your DSME program and
other education programs to thrive….not just
survive!
• T. E. A. M. S.U.C.C.E.S.S. T.O. L.A.S.T.
spells out exactly what your team needs to do…
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Slide 56 T Take the ‘Golden Rule’ to heart.
E Ensure all business information is shared with ALL
team members in timely manner.
A Avoid team member ‘turf wars’ at all costs!
There’s a place for everyone,
and everyone has their place!
M Make decisions based on fact, not assumptions.
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Slide 57 S Show respect always, even when disagreeing.
U Understand that the ‘blame game’ is destructive to
team communication and collaboration.
C Compliment one another often, and say ‘thank you’.
C Consider both sides of patient-educator conflict…
disgruntled pt doesn’t necessarily mean educator is
at fault.
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Slide 58 E Ensure team members make collaborative decisions
based on democracy…
NOT autocratic rule.
S Share ALL patient information is shared with ALL
team members on a timely basis.
S Separate your personal issues and business and
patient issues when at work.
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Slide 59 T Tackle team problems team (whether personal,
business or patient-related) to reduce/resolve ASAP
‘Stewing and brewing’ only intensifies the issue.
O Opt for a policy of never criticizing team members
to patients, staff, administration …and especially to
each of the other members.
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Slide 60 L Listen to each other (much different from ‘hearing’).
We’ll read poem about listening skills later.
A Arrange team meetings at least once per month.
S Stick to the rules…and that means everyone!
What’s good for the goose is good for the gander!”
T Tame down gossip (trim back the grape vine!)
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Slide 61 Don’t Be ‘Deaf’ To Good Listening Skills!
Listen well, a key for team success!
Quite different from what you ‘hear’!
First, do admit your biases,
And second, from judgment stay clear.
Third, dry subjects don’t tune out,
And fourth, ask questions when in doubt!
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Slide 62 Fifth, while others speak, do not multi-task,
A sign that listening skills you surely lack!
And refrain from planning what to say next,
It will put your comprehension to the test!
To ensure the message you do hear,
Keep a pad of paper very near!
Take good notes, as it’s a good bet,
That team communication will be met!
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Slide 63 Embracing these 5 F’s and 7 P’s
will help insure your goal of
making your DSME Program and
other patient education programs
financially sustainable!
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