Title: Putting Empowerment into Diabetes Self-Management Education
1Putting Empowerment into Diabetes Self-Management
Education (DSME)
- Naval Hospital Bremerton
- Edward L. Lee RN CDE
- Head, Medical Management Div.
- edward.lee_at_med.navy.mil
2Learning Goals
- Discuss relationship between DSME and
- Chronic Care Model
- Review Evidence of DSME Benefits
- Review ADA standard on DSME
- Discuss various Theories and Concepts that help
assure successful DSME outcomes.
3Challenges for aging Patient with Chronic Illness
such as Diabetes
- Increased health
- vulnerability.
- Simple problem can rapidly exacerbate condition.
- Self-care becomes more disproportionately complex
with age. - Difficulty navigating through a complex MHS.
4Chronic Disease Management, CPG and Health Care
Delivery System.
- PROBLEM Chronic Illness CPGs require more time
than PCMs have available for patient care
overall. - 2. SOLUTION Streamline local CPG version and
incorporate alternative delivery of care system
to meet standards of care. - Annals of Family Medicine Is There Time for
Management of Patients With Chronic Diseases in
Primary Care? Truls, et al, 2005.
5Patient Expert Program A Long Term Solution
- people who have trained in self-management tend
to be more confident and less anxious - make fewer visits to the doctor
- can communicate better with health professionals
- take less time off work
- less likely to suffer acute episodes requiring
admission - More empowered to boldly navigate the system
6Patient Expert Program Training includes
- Setting goals
- Writing an action plan
- Problem solving skills
- Fitness and exercise
- Better breathing (participants are taught
diaphragmatic breathing) - Fatigue management
- Healthy eating
- Relaxation skills
- Communication with family
- Working better with health care professionals,
including communicating better with them - Making better use of medications.
7The Chronic Care Model (CCM)
Community Resources Policies
Health System Organization
Organization of Care
Decision Support
Clinical Information Systems
Self-Management Support
8Diabetes Self-Management Involves
- care of the body
- management of the condition
- adapting to everyday activities/demands
- roles to the condition
- dealing with the emotions arising from having the
conditionÂ
9Diabetes Self-Management Education or Training (
DSME or DSMT)
- fundamental component of diabetes care.
- needs to be theory-based to increase patient
involvement in their care. - measurable behavior change is the desired
outcome.
10Diabetes Management Support
- is the care and encouragement provided to people
with chronic conditions to help them understand
their central role in managing their illness,
make informed decisions about care, and engage in
healthy behaviors.
11Diabetes Self-Care Behaviors aka AADE 7
- Healthy Eating
- Being Active
- Monitoring
- Taking Medication
- Problem Solving
- Healthy Coping
- Reducing Risks
12Although there is no known prototype for the
optimal DSME program, the recommended processes
are
- Assess specific education needs
- Identify 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 individuals attainment of
self-management goals
13ADA DSME Curriculum
- Diabetes disease process and treatment options
- Incorporate appropriate nutritional management
- Incorporate physical activity into lifestyle
- Use medications for therapeutic effectiveness
- Monitor blood glucose and urine ketones (when
appropriate), and using results to improve
control - Prevent, detect, and treat acute and 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)
14Standards of Medical Care in Diabetes2007 (DSME)
- People with diabetes should receive DSME
- DSME should be provided by health care providers
who are qualified to provide DSME based on their
professional training and continuing education. - DSME should address psychosocial issues,
- since emotional well-being is strongly
associated with positive diabetes outcomes
15Benefits of DSME and their Level of Evidence
- Education helps people with diabetes initiate
effective self-care when they are first diagnosed
(B). - Ongoing DSME also helps people with diabetes
maintain effective self-management as their
diabetes presents new challenges and treatment - advances become available (E).
- DSME helps patients optimize metabolic control,
prevent and manage complications, and maximize
quality of life, in a cost-effective manner (C).
16The Diabetes Educator
- present the information using principles of
teaching/learning theory and lifestyle
counseling. - presentation is individualized for persons of all
ages, incorporating their cultural preferences,
health beliefs, health literacy and preferred
learning styles.
17Adult Learning Theories Principles in DSME
- Autonomous and Self-Directed
- New knowledge is related to life experience is
relevant and practical - Goal-oriented
- Respect and dont judge
18Health Beliefs Model
- Based on the understanding that a person will
take - a health-related action if patient feels
- Perceived Susceptibility
- Perceived Severity
- Perceived Benefits
- Perceived Barriers can be overcome
- Perceived Self-Efficacy
- Cues for Action
19Motivational Interviewing Techniques for
Behavioral Change
- is a patient-centered counseling style for
eliciting behavior change by helping clients to
explore and resolve ambivalence and help improve
self-efficacy.
20Basic Approach to Motivational Interviewing
Techniques (OARS)
- Open ended questions
- Affirmation
- Reflective Listening
- Summaries
F\MI interaction techniques.htm
21Sample Motivational Interviewing Techniques for
Behavioral Change
- Understand the patients perspective of diabetes
via reflective listening. - Express acceptance and affirmation rather than
judgment. - Reinforce patient's self motivational statements.
- Do not jump ahead of patients readiness for
change. -
22A four-step patient empowerment model
- Explore the problem or issue
- Clarify feeling and meaning
- Develop a goal and start a plan
- Commit to action
231. Explore Problem or Issue
- Sample Questions
- What is hardest for you? What concerns you about
diabetes? - Encourage them to tell their story, if you sense
ambivalence, have them tell you about both sides.
As you listen, try to form statements out of what
they say. - Emphasize important points when you summarize.
- Motivational statements you want elicited
includeRecognition of the problem "Gee, I guess
my work schedule is the problem."Expressing
concern "I'm really worried about my
feet.."Stating intention to change "I think it's
time I changed..."Optimism to change "I think I
can do it..."
24Clarify Feeling and Meaning
- Are you feeling (angry, sad, frustrated)
because...? - Summarize building motivation "I heard you say
that you recognize that not testing your blood
sugar regularly is a problem, and that you've
noticed you don't feel as well when your blood
sugar is high. I also heard you say that you
would like to take steps to change this
situation."
253. Develop a Goal and Start a Plan.
- "Where would you like to be regarding____ (3
months, 1 year) from now? What are options? What
are barriers? Who could help?" - Offer advice only when requested, and offer it as
things you have seen other similar people do.
Offer as a cluster of ideas with a preface..."I
don't know if any of these ideas would work for
you, but I work with some other people with
diabetes and they have...
264. Commit to Action
- "What are you going to do? When? How will you
know you've succeeded? How confident are you? - Use action plan-specific goal and plan for the
next week or two at most. Explore confidence and
readiness. If not ready, "This is a big decision.
If you're not ready yet, I don't think you should
make a commitment. You think about it and we'll
talk again next planned visit."
27(No Transcript)
28Patients are empowered when they have
- Enough Knowledge to make rational decisions
- Enough control
- Enough resources to implement their decisions
(Personal Diabetes Medical Home) - Enough experience to evaluate their effectiveness
of their action
29Expert Patients
- Feel confident and in control of their lives
- Aim to manage their condition and its treatment
in partnership with PCM. - Communicate effectively with PCM and be willing
to share responsibility on treatment - Realistic about the impact of their disease on
themselves and their family - Use their skills and knowledge to lead full
lives.
30Stages of Change
31Match Intervention to the Stage of Change
Pre-contemplation
- INTERVENTIONS
- Raise awareness
- Provide personalized information
- Indicate readiness to help
- Be aware of emotional issues
- TIPS
- Use environmental events (celebrity, news
breakthroughs), developmental events (mid-life
crises) - Link current problems to behavior
- Education may move peopleprovide booklets,
pamphlets, brochures
32Match Intervention to the Stage of Change
Contemplation
- INTERVENTIONS
- Increase confidence in patients ability to
change - Identify benefits of change
- Encourage support networks
- TIPS
- Suggest considering change in next 6 months
- Inform patients that it takes time, dont expect
quick change. - Tip the balance in favor of change, work to
decrease ambivalence
33Match Intervention to the Stage of Change
Preparation
- INTERVENTIONS
- Resolve ambivalence
- Develop action plan
- Identify small steps taken
- Reward small changes made
- TIPS
- Suggest taking action in next month
- Support the balance of pros outweighing cons
- Provide choices
- Reinforce positive changes.
34Match Intervention to the Stage of Change
Action
- INTERVENTIONS
- Set short-term goal
- Identify support needed
- Problem-solve barriers
- Identify follow-up
- TIPS
- Set a date to start the new behavior
- Prepare the patient for the effort needed to
change, liken it to having surgeryallow for
recovery, allow for other aspects of life to be
put on hold. - Lots of reinforcement needed in this stage
- Keep relapse in perspective (a slip and not a
fall) - Early relapse is linked to poor preparation
- Late relapse is linked to emotional problems
35Match Intervention to the Stage of Change
Maintenance
- INTERVENTIONS
- Problem-solve difficulties
- Identify local resources and support
- Identify relapse strategy
- TIPS
- Maintenance can be very difficult.
- Remember the example from another behavior
change smoking usually takes 7-10 yrs to quit
and 4-5 attempts.
36NH Bremerton Personal diabetic Self-Management
Medical Home
- A place for diabetics glucose testing supplies,
accessories and assistance such as for
trouble-shooting. - A place for downloading their glucose readings
into a computer for data-based review by PCMs. - AHLTA as EMR of choice.
- A standard Personal Diabetes Profile.
- Primary care clinic access to the diabetes action
list from the NHB Population Health Database. - Patient and staff diabetes education resource
room. - A voice-tree telephone system in Primary Care
Clinics.
37NH Bremerton DSME
- Offered Monthly on Thursdays.
- Four weekly series of 3-hour workshops
- Core Curriculum based on ADA
- Facilitators are RN, RD and Health Educator
- Uses Adult Learning principles, Health Beliefs
Model, Stages of Change, Motivational
Interviewing techniques and Empowerment approach - Returning patient can register at any week they
want
38RN Staff Education on Diabetes / Management
- Pre-diabetes and Diabetes
- Natural History of Diabetes
- Diabetes Action Plan for Hypo/Hyperglycemia and
Sick Day. - Stage Diabetes Management
- a. Oral Monotherapy stage
- b. Combined oral meds therapy
stage - c. Combined oral meds
Long-acting insulin/ Exenatide stage - d. Long-acting Rapid-acting
insulin Amylin stage - Naval Hospital Bremerton Titrate to Target
protocols - Use of different glucose monitors and
trouble-shooting - Basic Diabetes Education for Newly Diagnosed
Diabetics - Seven Diabetics Self-Care behavioral goals by
AADE -
39Initial DSME
- Follow on Self-Management Support via
- Planned visit
- Lifelong management program such as
- Support Group
40Efficacy of DSME
- Improved self-care behaviors resulting in
improved glycemic control, psychosocial
adjustment, and other health-related outcomes. - Empowerment approach meet individual patient
needs while taking advantage of the experiences
of a group of patients to provide support and
assistance to each other.
41Future of DSME
- to establish an evidence base indicating which
theoretical approaches and strategies used in
group education are most effective in the short
and long terms. - raising awareness among stakeholders who are not
educators about the increasing number of dynamic,
progressive, and conceptually sophisticated
patient education programs being developed and
evaluated.