Diabetese SELF management

Do you think your patients understand the difference in the medical care of an acute illness versus the medical care of a chronic illness?

I often begin my patient visit with these questions -- What made you decide to come to this visit? What do you hope to learn?

Too often, I will get a response such as "My doctor told me to come." , "I want you to tell me what I can eat."

To me, these responses indicate that the patient is still in an 'acute healthcare model'. These patients believe that if they are 'compliant' with directions, they will be well again. "Just tell me what to do"

So my first challenge is to help them understand that to live well with a chronic illness, the patient must become the expert. Diabetes is not black and white -- it will be a little different for each patient and even a little different on a day to day basis for any patient. I believe the patient must see himself as the owner and star player of the team -- the healthcare professionals are the coaching team that he hires and fires to help him develop the skills needed to be a successful player. In the end, the successful player will be the one who knows the rules of the game, the intricacies of the good game and practices the needed skills every day.

This is the message Jana and I are putting together for the presentation for the August/Sept patient support groups.

If you have additional analogies or ways you move your patients into the SELF management concept, I'd love to hear from you.

Re-inventing diabetes management

http://www.diabetesmine.com/designcontest

I don't really think of myself as a creative individual, but this contest has me thinking. What makes health promotion easy? What makes goal setting, learning new skills, marching to a different drummer --easy?

I haven't found it yet. I'm sure it is different strokes for different folks. It's fun to look at last year's entries. I'd love to come up with an idea to submit.

I'm thinking about it.

Mark April 18th on your calendar

Registration must be in by April 11 for the KCRADE Spring Conference. I hope you will be able to join us. Check the website for details...
www.kcrade.org

Tell me about....

I have started using this phrase more and more during my patient interactions. It is amazing to me the difference it makes in many of the interviews. Especially in women. It is almost as though they have been anxiously waiting to tell their story.

It takes a little more prodding when I use it with men.

I'll say tell me about your usual routine during the day.

A woman will begin reciting the time they get up, what they cook for breakfast, what the other family members are doing, etc. -- they simply seem to put all the details in the story that I need for the activity/food assessment.

A man will say, "What do you want to know?"

It is easy for me, at this point, to fall back into the question/answer format...
What time do you get up? --- I get up around_____
What do you eat for breakfast? --- I don't eat too much breakfast____
etc.

I've been trying to pause, and repeat... "I want you to describe your usual day -- from the time you wake up and get out of bed, what you do, what you eat, how stressful your day might be until the time you go to bed. Describe yesterday or what you think tomorrow might be."

Tell me about your day....

.... diabetes is not a 'one size fits all' condition...

Tell me about your day...

... because I want to know more about you...

Tell me about your day...

... because I want you to know I care.

Insulin Quote

"Insulin is not only the most powerful,
but also the most underutilized,
agent for the treatment of diabetes."

Anuj Bhargava, MD, MBA, CDE, FACP, FACE

Insulin, a Clinical Journal for Health Care Professionals
January 2009, pg 68

I told a Nurse Practitioner the other day that when she informs a patient about the new diagnosis of diabetes, she should take along an insulin syringe of normal saline and have the patient give a self injection -- remove the fear of insulin shots from the get go. She said she'd think about it.

I have 30 minutes for 'diabetes education' with my next scheduled patient. Her A1C is 8.4 -- do I take a syringe of normal saline in for my initial session? Hmmm.... that would be 'no'. But, I do mention the option and open it up for discussion. I throw in phrases like 'treat to target' and we don't want to follow the 'too little, too late' approach that was previously used regarding insulin for diabetes management. She's due for her next A1C in a month. I told her if it was still above 8, she should seriously consider adding insulin to her management plan.

I wonder if she will come back for her next scheduled visit with me.

Who should deliver diabetes education?......

... and how should they get paid?

What is the best setting for diabetes education -- hospital settings, physician offices, pharmacies, community settings?

As I nurse, I always wanted a dietitian on my team to help individualize the meal plan -- especially when the patient had concerns about concurrent health issues like severe diverticulitis, irritable bowel, crohn's disease and other GI problems that often made my advice of "you should eat more fresh fruits and vegetables" almost impossible to follow.

I also always advised my patients to take all of their medications to the pharmacist and make sure they were entered in their computer program so the pharmacist could review them at each visit and discuss any concerns.

I tell every patient that their diabetes team should include a podiatrist and ophthalmologist in addition to the doctor, nurse and dietitian. But, I have to confess -- I can't imagine the team without a nurse. (that would be me, of course). As I continue to fine tune my behavior modification efforts in teaching self-management, I can see a wide disparity in my initial didactic approach and my current more interactive, coach/mentor approach. I want every diabetes educator to be a CDE who is keeping up with the standards and practices of our national association. So, while there are many health professionals who can talk to the patient about diabetes, I think there are a select few who actually teach diabetes self management.

And now there is another wrinkle in the fabric of "Who teaches diabetes self-management?" Recently, I have been implementing the Diabetes Conversation Maps and watching how peer to peer education works. The facilitator guide puts "Cautions" on every page -- "Check -- are you talking too much?" When I can remember to be quiet and listen to them teach each other, I wonder how the future diabetes teams will look. The team will no doubt include lay members -- people who are living with diabetes -- engineers, school teachers, janitors, receptionists. Will they start their own business for 'diabetes education'? What's to stop them?

We need to define our "diabetes team" and clarify how we work together. The very best picture makes sure that the "Person with Diabetes" is the head of the team.

What do you think?

Health care reform

I just finished listening to the president's speech. He promises that health care will be reformed beginning this year. He stated that a large portion of the reform will go toward preventative health.

I was recently invited to give a one hour presentation on how to prevent diabetes. As I sat down to work on the presentation, I drafted an introduction that states "You prevent diabetes the same way you live well with diabetes
-- eat healthy,
--stay active,
--monitor your numbers,
--take your medications (even if it is just a daily vitamin - see previous blog about vitamin D)
--reduce risks (maintaining healthy weight, wearing good shoes, etc)
--healthy coping (stress management)
--problem solving (each individual should be responsible for promoting individual health and not waiting until illness becomes significant and expect the doctor to 'cure' them)

It seems like we should be able to send this message to our legislators and get some of the funds for health care reform directed toward diabetes education. We are well prepared to lead the way. We just need to let them know. As individual Diabetes Educators, we need to support the efforts of our National Association to advocate for the reimbursement of diabetes self management training. Now is the time. Do not remain silent.

Let me know

Brenda