A Process of Teaching Diabetes Self-Management

Introduction

You’ve been diagnosed with Type 2 Diabetes, now what?  The idea and topic of diabetes can be overwhelming for anyone, from patient to provider.  The content outlined in this paper reflects the need for a plan to implement and educate patients newly diagnosed with Type 2 Diabetes to help them be successful in managing their diabetes and not letting diabetes take control of their lives.  If you think about the idea of diabetes singularly as a diagnosis you have now just given someone a life sentence in a sense.

  That person will now have to think before every action for the rest of their life in terms of a diagnosis.  Now, think of being that patient that is told that you now have this complex life changing disease.  How do they go about learning all the things that have to be altered, adjusted, added or completely removed from their life up to that point?  The medical provider bears a great deal of responsibility in managing this task and will hopefully explain to the newly diagnosed patient now living with diabetes, the multifaceted approach that will be taken in assisting this person with their new diagnosis.  A key component to their success is a Diabetes Self-Management Education (“DSME”) plan that is thorough and individualized to that patient’s lifestyle and personality type.

Problem Statement

Diabetes is a complex chronic disease process.  “Diabetes mellitus is one of the most common non-communicable diseases affecting people around the world.” (Portnip, et al 2019).  What a person knows before diagnosis and at the time of diagnosis can be shown to be hindering or helpful to their treatments and outcomes. The DSME for newly diagnosed patients living with diabetes is needed to help guide them through their life changing diagnosis.   Funnel, et al (2010) defines a DSME as:

“…the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self care.  This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.  The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.” (p S89).

A provider is thereby tasked with making sure that the patient is informed and supported through the course of their care beginning with critical assessments and education from diagnosis. If not, the provider is setting the patient up to fail.  Their new diagnosis needs to be presented not as what cannot be done but what can be done to help them succeed and stay in control and healthy.  Topics that the DSME should focus in on are the patient’s diet, activity, weight, medicines, monitoring blood glucose, sickness/illnesses, support and confidence.  Helping guide the patient with these topics will surely help establish a course that will allow the patient to be successful and have some autonomy when approaching and managing their new diagnosis instead of feeling like they have no control.  In the end, the patient will have better outcomes, healthier regulated lab results and lower their medication and health expenses.

Assessment of patient’s knowledge of health literacy

Prior to implementing a DSME, the provider should assess the patients understanding of the disease, their skills, confidence level and health literacy.  “Health literacy refers to individuals’ knowledge, motivation and skills to obtain, understand, appraise and apply health information in order to take health-related decisions in everyday life.” (Vandenbosch, et al 2018)  In 2010, Vandenbosch, et al distinguished 3 types of health literacy (“HL”):

“(1) Functional HL, which refers to basic skills in writing and reading that are required to effectively function in everyday situations; (2) communicative/interactive HL, which refers to more advanced skills that are needed to extract and understand information from various sources; and (3) critical HL, which refers to advanced cognitive skills that allow the individual to critically assess information and apply it make health-related decisions.” (p. 351)

In addition to health literacy, the health care provider should assess the patients general understanding of the disease as well as their abilities.  Some of the assessments that could be facilitated to gauge this information would be the Michigan Diabetes Knowledge Test (“MDKT”), Patient Activation Measure (“PAM”), and General Self-Efficacy Scale (“GES”) (Flode, et al, 2017).  Having a general understanding of the receptiveness of the information from the audience you are teaching, and their health literacy allows the provider to customize the DSME so that the patient can receive the most benefits.  However, Vandenbosch, et al found that although HL influenced the outcome, a DSME benefits all participants and patients that received this education.

Cultural Considerations

Diabetes continues to rise in numbers across all populations and cultures with lower economic and third world countries leading the trend.  Reducing health disparities and reaching out across all cultures will allow for a greater impact and success in managing the disease. Thinking outside of the box and using means other than the normal traditional health care team will allow for more individuals living with diabetes to receive education and support. (Seligman, et al 2018).  The educator and health care provider must learn how to facilitate the education and support for those multi-cultural groups effected.  Most cultures use food as a staple for many of their life events.  So, in example, trying to explain to a Hispanic patient that the corn staple that the rely so heavily on is now something that is causing the spike in their glucose readings and detrimental to their health must be approached with options and alternatives readily available. Many newly diagnosed patients that are now living with Type 2 diabetes feel like withdrawing from their social lives due to the numerous changes that must be made. (Patient and Provider, 2018). Trying to incorporate DSME meal planning and teaching into the daily routine is key for success.  Being a support mechanism and resource that can prove healthier substitutes will make these cultural barriers less of a negative aspect for the patient to overcome.

DSME Plan

Following the diabetes algorithm is critical in establishing an education plan that is founding on a successful model.  The algorithm directs the provider on how to identify the four times that an individual living with diabetes should be referred for education.  Those are: at diagnosis, annually, when there are new or complicating factors, and when there is a transition in care. (Powers, et al 2015).  A DSME should be explained to the patient in a sense that this is not something that will automatically succeed or fail but rather this will be a work in progress. Understand that a lot of information will need to be covered during that initial diagnosis meeting and subsequent DSME visits.  Group and individual meetings and plans are normally offered.  However, individual planning at the initial diagnosis is key.   The healthcare provider making the diagnosis needs to be aware of their competency or limitations and provide their patient with the best and most qualified service available.  This sometimes means referring a patient out to a specialized educator, dietician or provider. The plan will focus on the diagnosis and pathophysiology, treatment goals, concerns of the patient (social, socioeconomic, psychosocial, psychological, behavioral), diet (meal planning, portion control, meal timing), exercise/activity, blood glucose management (taking readings and applying those to lifestyle, diet and medications), and finally medications if there are any needed at this time.  It is important to get the patient to understand that the DSME will be implemented over more than one visit.  An example of a DSME program by Portnip, et al, (2019), includes a 2-visit structure with the first visit including several sessions that focus in on one session that covers diabetes and risks.  Then additional sessions which cover foot care, being active, healthy eating, taking medications, SMBG/hypoglycemia, foot screening, problem solving, healthy coping and reducing risks. The second visit reviews the patient’s abilities and skill evaluations. (p. 79)  The American Diabetes Association has a user-friendly website that offers the newly diagnosed patient on choosing what to eat and when to eat it, on being active and how it effects diabetes, medicines used in diabetes care, how and when to check blood glucose, evaluating feelings and how to go about getting support.  There are many links to digital programs, educational materials and printed journals/periodicals offered by ADA that are available to the patient and not only the professional health care provider or educator which empowers the patient with valuable and credible information at any given time of day.  (Recently diagnosed, 2019)  Whatever plan, model or algorithm followed it is important to keep the patient involved, keep lines of communication open, have information readily available to share and be knowledgeable of that information, be supportive and coordinate care throughout the daily lives of the patients.

Evaluation of Plan

The most common way to evaluate the effectiveness of the plan is by looking at the numbers.  Looking at the A1C, fasting, and non-fasting blood glucose are obvious markers of success or failure.  However, taking a holistic approach toward the patient and looking at their behavior,  BMI, blood pressure, and lipid levels will give you an indication of whether the patient’s overall health is stable and balanced.  Another way to monitor success is through the patient’s reported self-efficacy.  (Carpenter, et al 2018).  “Self-efficacy is considered an important factor in behavior change with attainment of goals leading to increased self-efficacy which can lead to the setting of further goals.” (O’Donnell, et al, 2018).  Getting the patient to evaluate their goals and buying into the treatment plan and DSME gives them the power to make positive changes and encourages them to make the changes to their lifestyles that they will be able to see and motivate them to continue to follow the treatment plans.

Conclusion

In conclusion, diabetes is a chronic health care diagnosis that effects a large population of people that varies from every socioeconomic class and from the young to old.  The complexity of diabetes makes the management of this disease process difficult for the seasoned patient but can be overwhelming, to say the least, to the newest diagnosed patient.  Having great support groups of an interdisciplinary team of providers along with support from family, friends, co-workers and community is a critical component of successful management for the newly diagnosed patient.  One thing that has been proven to reflect better outcomes is the buy in mentality of the patient in to their diabetes management.  A well thought and individualized DSME plan can be crucial to that success.  Making sure that the patient knows that the DSME will be ever evolving and changing to fit their needs helps to reassure their self-efficacy when goals are not met.  Giving the newly diagnosed patient living with diabetes resources to succeed most often makes this huge transition much easier.

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