What We Want to Achieve Through Systems Changes

Patient-Centered Care: Patient Education

Diabetes Self-Management Education

The diabetes management plan should be formulated as an individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team. Any plan should recognize diabetes self-management education as an integral component of care. A variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management.16

Process

(Based on the American Association of Diabetes Educators Scope of Practice www.aadenet.org/AboutUs/99ScopeStandards.shtml)

Diabetes education is considered a therapeutic modality and is integral to the care of people with diabetes and their families, support systems, and caregivers. Diabetes self-management education is an interactive, collaborative, ongoing process involving the person with diabetes and the educator. The educator will:

• Assess the individual’s specific education needs
• Identify the individual’s specific diabetes self-management goals
• Plan the teaching-learning and behavioral change process
• Implement the education and behavioral intervention to help the individual achieve self-management goals
• Evaluate the individual’s attainment of self-management goals.

Diabetes Educator Skills and Role

(Based on the American Association of Diabetes Educators Scope of Practice www.aadenet.org/AboutUs/99ScopeStandards.shtml)

The primary area of responsibility for diabetes educators is the education of people with diabetes, their families, and appropriate support persons about diabetes self-care management and related issues. A diabetes educator is a healthcare professional who has mastered the core of knowledge and skills in the biological and social sciences, communication, counseling, and education, and who has experience in the care of people with diabetes.

The role of the diabetes educator can be assumed by various healthcare professionals, including, but not limited to, registered nurses, registered dietitians, pharmacists, physicians, mental health professionals, podiatrists, and exercise physiologists.

A goal for all diabetes educators should be to meet the academic, professional, and experiential requirements to become a Certified Diabetes Educator (CDE).

Curriculum 17

The content of a self-management program should at a minimum describe ways to:

• Explain the diabetes disease process and treatment options
• Incorporate appropriate nutritional management
• Incorporate physical activity into lifestyle
• Use medications (if applicable) for therapeutic effectiveness
• Monitor blood glucose and urine ketones (when appropriate), and using results to improve control
• Prevent, detect, and treat acute complications
• Prevent (through risk reduction behavior), detect, and treat chronic complications
• Set goals to promote health and solve problems related to daily living
• Integrate psychosocial adjustment into daily life
• Promote preconception care and management during pregnancy or gestational diabetes (if applicable)

The diabetes educator should present the necessary information using established principles of teaching/learning theory and lifestyle counseling. The instruction is individualized for persons of all ages, incorporating their cultural preferences, health beliefs, and preferred learning styles. The goal is to assist the person with diabetes discover how to manage their diabetes.

Strategies for helping patients effectively self-manage diabetes
Rather than formal, didactic teaching focused on the transfer of information, patient education should identify the patient's readiness to make changes and help the patient assume responsibility for his or her disease management. Problem solving discussions can help prepare the patient to deal effectively with self-management issues. Several studies have shown that patients with diabetes who participated in a brief self-management program improved their health or had less deterioration and used fewer health care services over time, compared with their status when they began the program.6, 18-20 People with diabetes may be in different stages of change for different behaviors. Re-assessment of progress is important at every interaction and self-management support tailored accordingly.

Health care providers and educators may select from the following three different strategies according to comfort level, experience, and feasibility for use of the strategy in their practice setting.

1. A four-step patient empowerment model helps the provider effectively counsel patients about diabetes self-management:

• Explore the problem or issue
• Clarify feeling and meaning
• Develop a goal and start a plan
• Commit to action.4
• For more information on the four-step patient empowerment model to provide patient self-management support, click here.

2. Motivational interviewing, initially developed for addiction counseling, has increasingly been applied in public health, medical, and health promotion settings.21 22 It can promote self-efficacy, which is a person's belief that he/she can accomplish a specific behavior and is a key factor in behavior change. Public health nurses have effectively used interviewing techniques to motivate patient’s to identify and adopt behaviors that enhance their health.23 In a randomized controlled trial, investigators were able to help patients with diabetes make lifestyle changes using an individualized approach in which realistic manageable goals for lifestyle change and ways to overcome barriers were negotiated using brief motivational interviewing.24 Click here for more information on motivational interviewing.

3. Stages-of-change assessment focuses on an individual's readiness to change and is based on Prochaska's model, which postulates that change is a gradual process proceeding through specific stages, each of which has key characteristics.25 Stages range from precontemplation and contemplation to preparation, action and maintenance stages. It has been used effectively to help determine which patients are likely to succeed with smoking cessation, alcohol abstinence and other behavior change efforts.26

A small pilot study suggests that a patient's readiness to change diabetes self-management as measured by four simple questions was significantly associated with the likelihood of a successful clinical outcome.27 Patients were asked which of four willingness to change statements they agreed with most. Patients in the action or preparation stages were able to reduce A1C levels significantly more quickly and to a greater degree that those patients in the contemplation or precontemplation stages. The reductions in A1C in the action and preparation groups persisted for at least 12 months. Use of this simple tool may help providers and educators design interventions that are more effective and acceptable to patients.

Click here for a table with the statements aligned with the stage of readiness to change.

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