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

AADE 7 - repeat - repeat - repeat

I've just been reading through the Scope of Practice for Diabetes Educators. I didn't realize that the AADE7 were published in 2002 -- We should celebrate! The AADE7 are 7 years old :)

The following statement in the Scope of Practice caught my eye today...

"It is the position of the AADE that all educators should measure the AADE7 Self-Care Behaviors...at least twice: preintervention and postintervention. These behaviors are...
- healthy eating
- being active
- monitoring
-taking medications
-problem solving
-healthy coping
-reducing risks"

In my previous blog, I mentioned 'information overload' as a risk for the patient's ability to feel confident in diabetes management. I offer them a choice of one of the AADE7 as a starting point.
Will I ask each patient to return 6 times after the initial visit so that each of the AADE7 can be addressed individually in a visit? Some insurance companies will actually pay for additional visits if the doctor orders it. How many physicians believe that it takes at least 7 patient visits to gain the basic understanding of the self-care behaviors? I don't think that is the reality we live in. If I could choose the one self-care behavior from the AADE7 to focus on during the first visit, I believe it would be "problem solving". The problem solving skill must address the importance of accessing ongoing resources, such as the wonderful support groups that are available -- in our community, online, through magazines. Let the patient know they are not alone, that it takes a great deal of time to comprehend it all, that they should prominently post the AADE7 and remember to take each - one - step - at - a - time.

In the short time that we have with the patient in the 'insurance provided" education time slot, we focus on the survival skills - monitoring, taking medications, problem solving. No matter how I try to put it in small, understandable, blocks of information. If I ask the question "Are you feeling overwhelmed?", a majority of the patients respond, "Yes." I reassure them that it will take time to process this information and encourage them to ask me enough questions to feel confident in just one aspect of diabetes management. It is usually very difficult, they most frequently just want to know 'what can I eat' . Regarding monitoring and medications, I still hear a great deal of "My doctor said..." reverting to the 'acute care' health model belief that if I do as my doctor says, the disease will be well treated. The 'chronic care' health model of patient self-management does not seem to be well promoted by all physicians. I'm afraid if the doctor does not plant the idea in the patient's head, it will be much harder for them to comprehend it when they begin hearing it from the other health care providers.

Still -- handing them a copy of the AADE7 -- informing them that the best managed diabetes is the self-managed diabetes is a good starting place. I believe it is a message that should be shared with all of our physicians and with every patient visit.

AADE7 - repeat - repeat -repeat

The AADE website - Patient Education section, offers a 2 minute video for each of the behaviors:

http://www.diabeteseducator.org/DiabetesEducation/Patient_Resources/

which also refers them to the website:

www.mydiabetespartner.org

The dLife website has a nice link to each of the 7 self-care habits. You can make a print out to give to your patients, or if they have computer access, refer them directly to the website...

http://www.dlife.com/dLife/do/ShowContent/7_Self-Care_Habits/7_Self-Care_Behaviors.html

dLife.com

What do you think? Do you have additional website links for the AADE7?

Brenda

Diabetes Superhighway of information

I feel like I could read all day every day and still not feel up to date with all the changes in managing diabetes. I'm reading 3 journals, 3 blogs, reviewing 2 websites, attending seminars and continuing education -- and with each interaction, I learn just a little more.

It certainly helps me feel empathetic to the patient who feels totally overwhelmed with information and doesn't know where to start -- so he doesn't.

As I try to determine what stage of change the patient is in -- pre-contemplative, contemplative, etc., I quite often seem to see a 'deer in the headlights' stage.

I really do believe that showing them an outline of the AADE 7 Self-Care Behaviors and letting them choose where they want to start, gives them an anchor and a sense of purpose and direction. Having a starting point and being given permission to start with just one takes some of the pressure off the need to learn it all. The first step is so often the hardest. Easing into the superhighway may give them the confidence to continue moving forward into the lifelong learning that managing diabetes will require.

What do you think?

Hyperglycemia and memory decline

This morning I read this link to an article in the NewYorkTimes:

http://www.nytimes.com/2009/01/01/health/31memory.html?_r=1&partner=permalink&exprod=permalink

"Blood Sugar Control Linked to Memory Decline, Study Says
By RONI CARYN RABIN Published: December 31, 2008

The study, by researchers at Columbia University Medical Center and funded in part by the National Institute on Aging, was published in the December issue of Annals of Neurology.

The study only had 240 subjects -- but the MRI of their brains consistently showed a correlation between elevated glucose and blood flow to the part of the brain that controls memory.

I think it is interesting that physicians and perhaps a great number of diabetes educators still believe that we can provide information to patients with diabetes regarding how to manage their diabetes -- and expect that they will remember the information and have the skills to implement the needed lifestyle changes. The amount of information that is provided to the patient in a one hour education session is truly overwhelming. I really have to believe that three 30 min sessions would provide a much better outcome for the patient. The question is always -- would they come back? If we think they might only remember one thing -- where would you start? -- showing them how to monitor their blood sugar or helping them set a realistic plan to start increasing their activity.

Dr. Scott Small was the lead investigator in the study showing the link between glucose and memory. His comment was...Since glucose regulation is improved with physical activity, Dr. Small said, “We have a behavioral recommendation — physical exercise.”

Catching up on my reading and blogging

My pile of "to read" is growing taller and taller. In today's issue of Endocrine today there was an article about medical blogs. How many blogs do you try to follow? Do you have them sent to your e-mail or just log on when you feel like reading them? I am adding blogs to my reading list -- perhaps they will be easier to keep up with than my periodicals have been -- at least the blogs won't take any surface space in my den, right?

I'll be looking at the ones listed in the Endocrine today:
www.endocrinetoday.com
www.kevinmd.com
www.epocrates.com
www.presentdiabetes.com

I also like to browse the websites of

www.diabeteseducator.org
www.dLife.com

Do you have any sites you would like to recommend?

Patient goal - my goal

How many times have I heard a patient say "I just want to stop taking all these medicines!"

I reply, "I can understand that goal, but will you also consider the goal - I will do what needs to be done to 'treat to target' so that I can live without complications?"

They sigh and say yes. And I wonder if I can come up with a better response. Maybe it would be better to recommend earlier insulin initiation at this point. If the patient is on Metformin, TZD, glypizide combination -- the MDI insulin could allow them to stop the TZD and glypizide, right?

It doesn't seem ethical to let them believe that with plenty of exercise and eating just right, they will eventually get off the medicine since I know that diabetes is a progressive disease.

The really sad part of each of the goals is that for many of the patients, we are not even close to reaching either one. If there is a way to bring the patient on board for 'treat to target', I'm sure it would increase the probability of reaching the goal. The patient could hold the healthteam accountable and ask for titration and adjustment of the medication to reach target. Maybe the medications would not seem like such a burden to the patient if he/she had a greater understanding of their impact and had more control of the adjustment of them to reach target.

I believe in the future, I will encourage my patients to become cheerleaders who chant "treat to target, treat to target, treat to target" and provide them information to participate in reaching that goal.

I will also seriously look at their medication list to assure that any combo drugs that are available are being used -- even reducing two pills to one combo pill would demonstrate that I heard their goal and want to help them achieve it.

Vitamin D - who knew?

If you are an AADE member, perhaps you've already read the article "Vitamin D and Diabetes. Let the Sunshine In" in the Nov/Dec 2008 issue of The Diabetes Educator.

I think the intro paragraph sums it up pretty well ... "This is an important area of study because many individuals with diabetes have decreased levels of vitamin D. And, evidence suggests that lack of vitamin D may be associated with hyperglycemia, increased hemoglobin A1c, insulin resistance, progression of diabetes, as well as hypertension, and cardiovascular disease. Treatment of low vitamin D by diet and oral supplements may be an easy and cost-effective method to improve metabolic control and prevent the serious complications associated with diabetes."

The conclusion states "It appears that diet alone will not provide sufficient amounts of vitamin D, and that treatment with supplements is probably necessary for most individuals with diabetes. However, given the possible benefit, it may be an easy and cost-effective therapy which could improve their long-term health outcomes as well as their quality of life."

Interesting article - 7 pages of information between the intro and conclusion I quoted above. Do you know your vitamin D level? Do you check your patient's levels of vitamin D?

Seems like I just read an article the other day about how much to supplement -- 1000-2000IU/day. Apparently at this dose it would be hard to become toxic. This article gave a wider range of recommendations. Have you read other recommendations. Are you currently recommending Vitamin D supplements. Why or why not?

Thanks for sharing

Publish Post

Chronic Care Model - 2

I've been thinking about an easy description to share with patients to help them understand the difference between acute care and chronic care. I'm not there yet. It is actually the topic for our support groups in September. Jana and I will be working on it between now and then. If you have any ideas you would like to share with us, please feel free to let me know. You can post on this blog or send an e-mail to me at
Brenda.09pres@gmail.com

Chronic Care Model

How do you bridge the health care you provide from 'acute care' to 'chronic care'?

I've been thinking about it. Do you agree with the theory that:

Acute Care is the healthcare professional 'fixing' the problem: i.e. prescribing medications, teaching self monitoring so that 'we can look at the numbers', prescribing food plans, exercise plans, etc.

Chronic Care is the healthcare professional learning to let go of the control and teaching the patient/family the life skills needed to live well with a chronic disease? What if the patient doesn't want to be in charge? What if we really are not willing to let go of the control or need to 'fix' things?

I'm not sure all health care providers give much thought to the different approach required for Chronic Care management. No wonder the patient doesn't get it.

Jesus taught with parables and I'm beginning to understand the importance of talking to patients in a language they might understand. I don't think that language is medical terminology. It might be fun if we could develop a large number of analogies that we think would help our patients understand diabetes in a language they can understand. I'll offer one tomorrow. Please feel free to offer one of your own as a 'post' to this blog.

Thanks for your time.

Brenda

Calling the meeting to order

How do you feel about reciting the Pledge of Allegiance at the beginning of a meeting?

It might be more fitting at more formal association meetings and less fitting at social meetings.

Is it a good transition between a social meeting and the business meeting?

If it does not work as the transition -- is there another transition to quiet the general conversation -- or does the president just keep saying "Hello? Hello? Can I have your attention? We're ready to start the meeting!" I think this approach works better for presidents who have strong, booming voices, but could possible work with the use of a good microphone.

I'm interested in your ideas. Thanks for sharing.

E-mails in January

I hope you are checking your e-mail address that you have provided to KCRADE. Webinar notices, job opportunities, KCRADE newsletter and board meeting minutes have been sent to all members.

Some e-mail notices have been returned that state a mail box is full and cannot recieve any additional e-mail at this time.

I did not receive minutes initially and had to request an update to the KCRADE yahoo list.

If you are not in the loop and would like to know what is going on in our Chapter, it is up to you to make sure you are connected.

KCRADE communications are a benefit of membership -- if you are an AADE member, you can join for free by just completeing a Chapter membership form. IF you are not an AADE member, you can join "Friends of KCRADE" for a $35 annual membership fee -- which adds you to the communication roster, and provides entrance to 6 meetings with a light supper and a 1hr continuing education session.

For more information, you can write to KCRADE@yahoo.com or Brenda.09pres@gmail.com

Happy reading.

Happy New Year

I'm looking forward to an exciting year in 2009 for KCRADE members. Hope to see you at the January 13th meeting!