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Putting Empowerment into Diabetes SelfManagement Education DSME


Discuss relationship between DSME and. Chronic Care Model. Review Evidence of DSME ... Promote preconception care and management during pregnancy or gestational ... – PowerPoint PPT presentation

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Title: Putting Empowerment into Diabetes SelfManagement Education DSME

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

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.

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.

Chronic Disease Management, CPG and Health Care
Delivery System.
  • PROBLEM Chronic Illness CPGs require more time
    than PCMs have available for patient care
  • 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.

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
  • More empowered to boldly navigate the system

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.

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

Diabetes Self-Management Education or Training (
  • fundamental component of diabetes care.
  • needs to be theory-based to increase patient
    involvement in their care.
  • measurable behavior change is the desired

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.

Diabetes Self-Care Behaviors aka AADE 7
  • Healthy Eating
  • Being Active
  • Monitoring
  • Taking Medication
  • Problem Solving
  • Healthy Coping
  • Reducing Risks

Although there is no known prototype for the
optimal DSME program, the recommended processes
  • Assess specific education needs
  • Identify specific diabetes self-management goals
  • Plan the teaching-learning and behavioral change
  • Implement the education and behavioral
    intervention to help the individual achieve
    self-management goals
  • Evaluate the individuals attainment of
    self-management goals

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
  • Prevent, detect, and treat acute and chronic
  • 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)

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

Benefits of DSME and their Level of Evidence
  • Education helps people with diabetes initiate
    effective self-care when they are first diagnosed
  • 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).

The Diabetes Educator
  • present the information using principles of
    teaching/learning theory and lifestyle
  • presentation is individualized for persons of all
    ages, incorporating their cultural preferences,
    health beliefs, health literacy and preferred
    learning styles.

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

Health Beliefs Model
  • Based on the understanding that a person will
  • a health-related action if patient feels
  • Perceived Susceptibility
  • Perceived Severity
  • Perceived Benefits
  • Perceived Barriers can be overcome
  • Perceived Self-Efficacy
  • Cues for Action

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

Basic Approach to Motivational Interviewing
Techniques (OARS)
  • Open ended questions
  • Affirmation
  • Reflective Listening
  • Summaries

F\MI interaction techniques.htm
Sample Motivational Interviewing Techniques for
Behavioral Change
  • Understand the patients perspective of diabetes
    via reflective listening.
  • Express acceptance and affirmation rather than
  • Reinforce patient's self motivational statements.
  • Do not jump ahead of patients readiness for

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

1. Explore Problem or Issue
  • Sample Questions
  • What is hardest for you? What concerns you about
  • 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..."

Clarify Feeling and Meaning
  • Are you feeling (angry, sad, frustrated)
  • 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

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...

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."

(No Transcript)
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

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

Stages of Change
Match Intervention to the Stage of Change
  • 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
  • Link current problems to behavior
  • Education may move peopleprovide booklets,
    pamphlets, brochures

Match Intervention to the Stage of Change
  • Increase confidence in patients ability to
  • 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

Match Intervention to the Stage of Change
  • 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.

Match Intervention to the Stage of Change
  • 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
  • Early relapse is linked to poor preparation
  • Late relapse is linked to emotional problems

Match Intervention to the Stage of Change
  • 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.

NH Bremerton Personal diabetic Self-Management
Medical Home
  • A place for diabetics glucose testing supplies,
    accessories and assistance such as for
  • 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
  • A voice-tree telephone system in Primary Care

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

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
  • c. Combined oral meds
    Long-acting insulin/ Exenatide stage
  • d. Long-acting Rapid-acting
    insulin Amylin stage
  • Naval Hospital Bremerton Titrate to Target
  • Use of different glucose monitors and
  • Basic Diabetes Education for Newly Diagnosed
  • Seven Diabetics Self-Care behavioral goals by

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

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.

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
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