Putting Empowerment into Diabetes Self-Management Education

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Putting 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

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Learning 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.

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Challenges 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.

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Chronic 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.

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Patient 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

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Patient 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.

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The Chronic Care Model (CCM)
Community Resources Policies
Health System Organization
Organization of Care
Decision Support
Clinical Information Systems
Self-Management Support
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Diabetes 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
  condition 

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Diabetes 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.

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Diabetes 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.

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Diabetes Self-Care Behaviors aka AADE 7

• Healthy Eating
• Being Active
• Monitoring
• Taking Medication
• Problem Solving
• Healthy Coping
• Reducing Risks

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Although 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

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ADA 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)
  

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Standards 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

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Benefits 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).

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The 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.

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Adult 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

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Health 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

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Motivational 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.

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Basic Approach to Motivational Interviewing
Techniques (OARS)

• Open ended questions
• Affirmation
• Reflective Listening
• Summaries

F\MI interaction techniques.htm
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Sample 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.

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A four-step patient empowerment model

• Explore the problem or issue
• Clarify feeling and meaning
• Develop a goal and start a plan
• Commit to action

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1. 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..."

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Clarify 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."

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3. 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...

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4. 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."

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Patients 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

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Expert 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.

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Stages of Change
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Match 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

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Match 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

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Match 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.

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Match 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

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Match 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.

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NH 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.

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NH 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

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RN 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

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Initial DSME

• Follow on Self-Management Support via
• Planned visit
• Lifelong management program such as
• Support Group

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Efficacy 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.

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Future 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.