Diabetes Education in your Practice: Keeping patients engaged in their self care

Kristy Merritt RN BSN CDE

Education Coordinator for Diabetes Services

Methodist Lebonheur HealthCare

Diabetes Education in your Practice

Educational Objectives

The Learner will be able to :

Discuss prevalence and impact of non-adherence

in diabetes

Discuss appropriate self-management goals for

patients with diabetes

Discuss how improving adherence in practice and

incorporation of patient centered care through use

of motivational interviewing helps patients set

achievable self-management goals

Diabetes Education in your Practice

Fact A total of 125 million individuals are coping

with chronic medical conditions, affecting almost 50 percent of the U.S. population and

touching every sector of society 1

Nearly 80 percent of Medicare recipients have at least one chronic condition and 50

percent have more than one 2

Diabetes Education in yourPractice

Fact There are about 26 million U.S Adults age 20

years and older with a known diagnosis of Diabetes 3

The number of annual cases of diabetes diagnosis has progressively increased over

the past 30 years 4

Diabetes Education in your Practice

Fact The estimated National Cost of Diabetes

in 2012 was $245 billion, of which $176 billion (72%) represented direct health care cost attributed to diabetes and $69 billion (28%) represented lost productivity from work-related absenteeism, reduced productivity at work and at home, unemployment from chronic disability, and premature mortality5

Diabetes Education in your Practice

Fact Diabetes HealthCare Utilization

includes hospital inpatient days, nursing/residential facility days, physician office visits, emergency room visits, hospital outpatient visits and pharmacy prescriptions

About ½ of all physician office visits are incurred by people with diabetes6

Diabetes Education in your Practice

Fact Total utilization of prescription medications

attributed to diabetes has more than doubled since 2007, reflecting a dramatic increase in the use of medications treating general conditions and diabetes comorbidities among people with diabetes7

Diabetes Education in your Practice

Fact The annual attributed health care cost per

person with diabetes increases with age, primarily as a result of increased use of hospital inpatient and nursing facility resources, physician office visits, and prescription medications8

Diabetes Education in your Practice

Fact ~25 percent of patients do not adhere to

their physicians recommendations 9

A study of diabetes patients revealed that only 60 % adhered to a diabetes meal plan

and only 19 % followed regular exercise recommendations 10

Diabetes Education in your Practice

Fact Medication therapy adherence rates among

patients with chronic conditions, such as diabetes, are low, dropping most

dramatically after the first six months of therapy 11

Diabetes Education in your Practice

The Bottom Line…The ProblemMore cases of diabetes=More healthcare

utilization=More cost

SolutionTo decrease diabetes prevalence and/or to

more effectively deliver evidenced based care in efforts to decrease health care cost

Diabetes Education in your Practice

Decrease Diabetes Prevalence:

Raise awareness/Screen early

Prevent diabetes among people at

highest risk

Group support programs that help people with pre-diabetes develop better eating habits, improve their coping skills, and increase their physical activity level have been proven to be effective 12

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Deliver Evidenced Based Diabetes Care and Treatments Decrease disability and pre-mature death

by providing/prescribing/recommending physical activity and dietary interventions, self-management training, ongoing support, and, when necessary, medications to help control the effects of diabetes 13

Diabetes Education in your Practice

What is Diabetes Self Management?Diabetes education, also known as diabetes

self-management training (DSMT) or diabetes self-management education

(DSME), is defined as a collaborative process through which people with or at risk for

diabetes gain the knowledge and skills needed to modify behavior and successfully self-

manage the disease and its related conditions 14

Diabetes Education in your Practice

Diabetes Education focuses on seven self-care behaviors that are essential for improved health status and greater quality of life 15 Healthy eating

Being active

Monitoring

Taking medication

Problem solving

Healthy coping

Reducing risks

Diabetes Education in your Practice

How are patients with diabetes self managing their health?

The Achievement of Goals in U.S. Diabetes

Care 1999–2010 Report, surveyed patients

with diabetes to see how they felt that they

doing with their diabetes self management and care 16

Diabetes Education in your Practice

Data reviewed pertained to a patients self care practices: Daily glucose monitoring and A1C levels

Blood pressure and LDL cholesterol

Tobacco use and Coronary Artery Disease

Eye and Dental exams

Foot exams

Flu shots and Pneumococcal vaccinations

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The Results …….

The United States is not doing very

well in meeting goals for diabetes

care 17

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Why?

Diabetes Education in your Practice

Patient Adherence….

What is that?

Adherence has been defined as the “active, voluntary, and collaborative involvement of

the patient in a mutually acceptable course of behavior to produce a therapeutic result”18

Diabetes Education in your Practice

Fact Patient self-reports conclude that ~40% of

patients feel confident that they can successfully make behavioral changes 19

Research has demonstrated that patients who are satisfied with their relationship

with their health care providers have better adherence to diabetes regimens 20

Diabetes Education in your Practice

Patient Adherence Identified Barriers to adequate self care:

Demographic/ Health care provider and

medical system- Access to Care

Psychological-Beliefs about health and care

Financial-No Insurance/Cost of Care

Disease and treatment-related factors-

Aggressive/Hard to follow treatment regimen21

Diabetes Education in your Practice

The majority of patients can recall only about 50% of the information communicated to them by their physician 22

Patients prefer that their Physician use The “Tell Back-Collaborative Inquiry” TBCIinformational sharing method, in which, the doctor asks the patient to describe his or her understanding of their conditions and treatments 23

Diabetes Education in your Practice

TBCI Methodology also involves the physician sharing any additional information with the patient and then asks what the patient understands and feels about the information that was given 24

Diabetes Education in your Practice

Physician Barriers to effective Diabetes Education: 25

Physicians have a lack of:

Time

Resources

Financial incentives

Diabetes Education in your Practice

In the United States, more than 90% of physician visits of patients with diabetes are to

primary care providers

Average time of patient visits with a general or family practice provider is~ 16 minutes

Research has shown that PCPs may be offering advice on risk reduction rather than specific

education and skills to affect behavior change 26

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“Clinical inertia” or inadequate intensification of diabetes treatment therapy in primary care is a real issue

Developing billing and payment strategies for DSME in primary care has been a challenging process 27

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Three Key Objectives to Improve Diabetes Care 28

Enact provider and team behavior changes

Facilitate patient behavior changes

Redesign the system of care

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Implementing the Chronic Care Model (CCM)

Move from a reactive to a proactive

care delivery system, where

planned visits are

coordinated through Team-Based approaches 29

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Facilitate patient behavior changes

Patient-centered, High-quality diabetes care involves The Primary Care

Physician’s ability to:

Diabetes Education in your Practice

Assess behavioral and motivational status

Help patients build motivation for change

Collaboratively select a plan of action

Negotiate realistic goals

Tailor treatment plans to patients' situations

Provide ongoing follow-up and support 30

Diabetes Education in your Practice

Help patients build motivation for change

Motivational Interviewing (MI) is an effective approach to helping patients

build motivation and confidence to undertake the behavioral changes

necessary for effective diabetes self-management 31

Diabetes Education in your Practice

Guiding Principles of Motivational

Interviewing

Diabetes Education in your Practice

MI Communication Skills in Practice

Physicians should:

Express empathy (show compassion and understanding)

Use open-ended questions (rather than closed yes-no questions)

Practice Reflective Listening-Reflections (rephrasing what patients have said)

Nonverbal communication (i.e., body language, appearance, tone of voice) 32

Diabetes Education in your Practice

Empathy

“Empathy is a specifiable and learnable skill

for understanding another’s meaning through

the use of reflective listening…It requires

sharp attention to each new client statement,

and the continual generation of hypotheses as

to the underlying meaning”

(Miller and Rollnick, 1991)

Diabetes Education in your Practice

Open-Ended Questions and eliciting “Change Talk”

Change Talk elicits self-motivational statements.

(The goal is to get patients talking about reasons for making changes and

to uncover their efficacy for change and, when possible, to solve their own

barriers to change) 33

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Effective CommunicationPhysicians promote effective

communication by:Establishing patient rapport by asking

permission to provide information and/or advice

In individual studies, effective physician communication skills have been correlated to positive outcomes as adherence to diabetes

therapies 34

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Reflective Listening

Reflections convey that the provider is actively trying to understand and accepts in a nonjudgmental way what patients are

experiencing. Reflections, even if inaccurate, encourage patients to further clarify and

explain their experiences and feelings.

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Non Verbal Communication

Direct eye contact

Relaxed Body Posture

Non rushed atmosphere 35

Diabetes Education in your Practice

Patient Behavioral Change is contingent upon the Physician and

Patient being able to:

Collaboratively select a plan of action

Negotiate realistic goals

Diabetes Education in your Practice

Plan of action and Goal setting

An action step is a targeted, concrete activity that patients propose to

undertake, with the “what, where, how, and when” clearly outlined (e.g., “I will walk around the block after lunch on Monday, Wednesday, and Friday.”) 36

Diabetes Education in your Practice

Plan of action and Goal setting

Physician and Patient Explore possible barriers to implementing the action plan and ways the patient can over-

come these barriers 37

Diabetes Education in your Practice

Provide ongoing follow-up and support

Set follow up appointments to address patient selected behavior

goals

Use a variety of means for follow up-In person, telephone, email 38

Diabetes Education in your Practice

On-Going Support

Refer to community resources, including referral to a Nationally Recognized Diabetes Outpatient Program and/or other Specialty

Services 39

Diabetes Education in your PracticeIn Conclusion

Diabetes is a chronic disease that continues to increase in prevalence in the United States. As

people will continue to seek healthcare from many venues, healthcare providers are expected to be

prepared to delivery patient centered, cost effective care. Primary Care Providers have a

great opportunity to assist patients with diabetes in effective self management by empowering

patients. Motivational Interviewing is one technique that can help facilitate optimal diabetes

management.

Diabetes Education in your Practice

Please enjoy this short video on Motivational Interviewing

http://www.youtube.com/watch?v=7999_0E3BpU

http:// www.youtube.com/watch?v=7999_0E3BpU

http://www.bing.com/videos/search?q=bob+nehart+motivational+interviewing+skills&view=detail&mid=04872008E50EE5395F7904872008E50EE5395F79&first=0&FORM=NVPFVR&qpvt=bob

+nehart+motivational+interviewing+skills

Diabetes Education in your Practice

Questions?

Thank you for your attention!!

Diabetes Education in your Practice

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Diabetes Education in your Practice

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Diabetes Education in your Practice

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Diabetes Education in your Practice

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