Self Management and Beyond in Diabetes Care

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Self Management and Beyond in Diabetes Care

• Dr Chris Gillespie
• Consultant Psychologist
• Derby Hospitals Foundation NHS Trust.
• LNR Diabetes Network Meeting
• Leicester 6th October 2005

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Variation
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The significant problems we face cannot be
solved by
the same level of thinking
that created them.
A. Einstein
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Patient's journey
new complications
Non diabetes admissions
heart disease

• Ongoing
  Care

life events
stroke
PREVENTION
85 of care
treatment change eg insulin
ED
EVENTS
Diagnosis
Initial Management
Continuing Care
Pregnancy
Severe hypos
Institutional care
ketoacidosis
Foot issues
protenuria
Eye problems
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System Reform
Personalised care/choice
Diabetes
Public Health
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Policy and Social Environment
Health System
Community
Organization of
Clinical
Self-
Health Care
Information
Management
Resources
Systems
Support
and
Policies
Delivery
Decision
System
Support
Design
Informed,
Prepared,
Productive
Proactive
Activated
Interaction
Practice Team
Patient
Functional and Clinical Outcomes
www.improvingchroniccare.org
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System Reform
Personalised care/choice
Diabetes
Public Health
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To every complex question, there is a simple
answer.......
and it is wrong
H. L. Mencken
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WHAT HAS WORKED WELL?
1. Patient-centered, empowerment
approaches
Conceptual and philosophical
shift
Incorporated into most diabetes
self-management programs
Anderson RM, Funnell M. (2000) The art of
empowerment, ADA.
Anderson RM, et al. (1995) Diabetes Care,
18943-949.
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2. Guidelines and systems change
interventions
Nurse care management
Proactive, planned population-
based care
It is not the patients fault not
the providers fault but the system
Aubert RE, et al. (1998) Ann Int Med
129605-612.
Sadur CN. (1999) Diabetes Care 222011-2017.
Glasgow RE, Hiss R, et al. (2001) Diabetes Care
24124-130
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The Real Answer has a History

• Difficulties encountered in Diabetes
• Centres throughout Europe for over
• 20 years
• 1. Poor patient motivation
  78
• 2. Lack of training in patient education 54
• 3. Organisation of centre for
• integrating education and treatment
  53
• (Assal and Lion 1983)

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Motivation Compliance

• Patient not meeting diabetes targets
• Elevated A1c
• Limited or no BGM
• Not following meal plan/weight loss
  recommendations
• Not taking medicines according to plan
• Canceling or not coming to appts.
• Patient is in denial
• Patient does not accept his/her diabetes
• TRANSLATION Patient is BAD or DIFFICULT
• or Non-
  compliant

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Defining non-compliance in real terms

• Insulin adherence estimates 20-80
• Meal plan adherence 65
• Blood glucose monitoring 57-70
• Exercise adherence 19-30
• Global adherence in diabetes 7

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Compliance vs. Adherence the Semantics
Debate(Lutfey and Wishner, Diabetes Care, 1999)

• Compliance conformity to medically defined goals
  only.
• Adherence patient is more active, autonomous
  partner in pursing medical goals.
• self-care
• self-management
• patient empowerment
• autonomy motivation
• collaborative management

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What gets in the way of adherence?

• Adjusting to diagnosis and to new lifestyle
  demands.
• Patient and provider communication
• Motivation, perfectionism, goal-setting
• Diabetes burnout
• Depression and diabetes

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Adjusting to Diagnosis and New Life-style Demands

• In the post-DCCT/UKPDS age, the aim of treatment
  is at near normal blood glucose (A1c lt 7).
• This Goal Requires
• Multiple shots/meds daily
• Frequent blood glucose checks
• Weight management and carbohydrate/fat counting
• Exercise regimen
• Treatment/prevention of hypo- and hyperglycemia

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More on Diabetes Lifestyle Demands

• Diabetes management is a 24 hour a day, 7 day a
  week job.
• Complex decisions/behaviors.
• Up-to-date knowledge.
• The burden of care lies with the patient and
  his/her support network.

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Patient Provider Communication

• Speaking 2 different languages
• Patients focus personal experience
• Providers focus scientific or medical facts
• Patient Empowerment and Motivational Interviewing
• Changes providers role from advisor to
  consultant
• Emphasizes collaborative approach
• Patient sets priorities for what, when, and how
  to change

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Approaches that work

• Use open-ended style questions
• What are the hardest parts of your diabetes?
• What are the easiest parts?
• What would you like to change?
• Where does your motivation come from?
• What is the cost to you of not changing?
• Define behavioral plans clearly
• What are you ready to do to change first?
• How will you go about doing it?

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More approaches that work

• Track behavior change closely
• How will we know if it is going according to
  plan?
• Use self-monitoring tools like food, blood
  glucose logs
• Link self-care behaviors to easily remembered
  routines
• Use pre-emptive problem-solving
• What has gotten in the way in the past?
• What can you do differently this time?
• Anticipate slips as NORMAL
• Diminish guilt and re-establish problem-solving

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More approaches that work

• Evaluate and re-evaluate progress
• Do you need more time to have this solidify?
• Re-establish motivation for change
• What are you ready to try next?
• CELEBRATE successes
• Help patients recognize success
• Help patients determine rewards

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Approaches to avoid

• Fear tactics and guilt dont work
• Patients know the risks
• They already feel self-critical, ashamed, and
  afraid of diabetes complications
• Fear/guilt lead to paralysis and avoidance
• Vague advice
• You really need to lose weight.
• You need to eat less fat.
• You should exercise more.

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Diabetes Burnout

• Burnout is what happens when you feel
  overwhelmed by diabetes and by the frustrating
  burden of diabetes self-care. People who have
  burned out realize that good diabetes care is
  important for their health, but they just dont
  have the motivation to do it. At a fundamental
  level, they are at war with their diabetes - and
  they are losing.
• (Polonsky, 1999)

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Helping patients overcome burnout

• Diabetes is not a do it yourself disease. (Joan
  Hoover, a diabetes-advocate, 1st Congressional
  Advisory Committee on Diabetes, l970's)
• Remind patients to reach out to others
• Support system might include family, friends,
  co-workers, or diabetes treatment team.
• Be on the lookout for diabetes police or
  misguided helpers. (Polonsky and Anderson).

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Helping patients overcome burnout

• 2) Help patients set realistic goals.
• Gradual changes and improvements
• Attainable and sustainable, not perfection.
• Where does the patient want to start?
• Follow their lead.
• Help patients to break tasks down into smaller
  steps, making them less overwhelming.

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Helping patients overcome burnout

• 4) Change expectations on blood sugar monitoring
• A1c represents an average
• BY DEFINITION blood sugars fluctuate
• Anticipate seeing numbers that they like and
  numbers that they dont like
• The important part is how they respond to the
  numbers.
• Blood sugars dont play by the rule book
• There is not a 11 correspondence between blood
  sugar results and behavior.

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Helping patients overcome burnout

• 5) Recognize/reward success and learn from it.
• What has worked and what hasnt?
• What still needs to be improved?
• Involve patients in problem-solving.
• 6) Language can shape expectations/feelings.
• Good/Bad blood sugars vs. High/Low
• Blood Tests vs. Blood Checks
• Cheating vs. Eating

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Helping patients overcome burnout

• 7) Balance the focus on quality of health and on
  quality of life.
• Be alert to diabetes overshadowing other aspects
  of life.
• Be willing to step back and re-evaluate things in
  collaboration.
• Adjust diabetes self-management to match
  lifestyle, rather than vice versa.

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Helping patients overcome burnout

• 8) Keep a long-term view
• Intensive management goals are NOT goals for all
  patients in the beginning
• Find something (anything!) that the treatment
  team and the patient agree on as step one
• REALISTIC goals are key
• Be willing to compromise
• Focus on relationship-building

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TOOLS OF THE TRADE

• Three basic tools in health care
• The Herb
• The Knife
• The Word
• (Grant 1995)

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Psychological Model of Motivation

• The ingredients of motivation
• IMPORTANCE(Why)
• 
  READINESS
• CONFIDENCE (How) (TO CHANGE)

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Practical Strategies
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Enhancing Motivation in Diabetes Care

• VALUES autonomy of the patient
• SKILLS non confrontational interview style
• information exchange
  skills
• assessment of
  importance confidence
• continual monitoring of
  readiness to change
• ROLES Practitioner structure, direction,
  support
• 
  information requested
• 
  elicit patients views and aspirations
• Patient IS AN
  ACTIVE DECISION MAKER

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The best way to
predict the future
is to create it