Putting Empowerment into Diabetes Self-Management Education DSME

1. Putting Empowerment into Diabetes Self-Management Education (DSME) Naval Hospital Bremerton Edward L. Lee RN CDE Head, Medical Management Div. edward.lee@med.navy.mil

4. Template Management is based on Acute Care System.Template Management is based on Acute Care System.

5. 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

6. 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.

7. Patients with�chronic illness�need support, as well as information, to become effective managers of their own health.� In order to meet these needs, it is essential for them to have the following: Basic information about their disease Understanding of an assistance with self-management skill building Ongoing support from members of the practice team, family, friends, and community Patients with�chronic illness�need support, as well as information, to become effective managers of their own health.� In order to meet these needs, it is essential for them to have the following: Basic information about their disease Understanding of an assistance with self-management skill building Ongoing support from members of the practice team, family, friends, and community

8. 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�

10. 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.

11. Diabetes Self-Care Behaviors aka AADE 7 Healthy Eating Being Active Monitoring Taking Medication Problem Solving Healthy Coping Reducing Risks The AADE7 Self Care Behaviors� framework reflects the best practice of Diabetes Self-Management Training (DSMT) by measuring, monitoring, and managing behavioral outcomes as specified by the National Standards for DSMT. Educators should measure both individual and aggregate AADE7 Self-Care Behaviors� at a minimum of pre- and post- intervention. Additional follow-up measurements are ideal, and should be applied as appropriate to the practice setting. �The AADE7 Self Care Behaviors� framework reflects the best practice of Diabetes Self-Management Training (DSMT) by measuring, monitoring, and managing behavioral outcomes as specified by the National Standards for DSMT. Educators should measure both individual and aggregate AADE7 Self-Care Behaviors� at a minimum of pre- and post- intervention. Additional follow-up measurements are ideal, and should be applied as appropriate to the practice setting. �

12. 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 individual�s attainment of self-management goals

13. 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)

16. 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. Create a shame-free learning environment.Create a shame-free learning environment.

20. Open �ended questions Affirmation Reflective Listening Summaries

22. 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

23. 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 include:Recognition 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..."

24. 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."

25. 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...

26. 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."

28. 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

29. 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.

30. Stages of Change 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.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.

31. Match Intervention to the Stage of Change 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 people�provide booklets, pamphlets, brochures

32. Match Intervention to the Stage of Change INTERVENTIONS: Increase confidence in patient�s ability to change Identify benefits of change Encourage support networks TIPS: Suggest considering change in next 6 months Inform patients that it takes time, don�t expect quick change. Tip the balance in favor of change, work to decrease ambivalence

33. Match Intervention to the Stage of Change 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.

34. Match Intervention to the Stage of Change 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 surgery�allow 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

35. Match Intervention to the Stage of Change 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.

40. 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.

41. 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.