CDC - Centers for Disease Control and Prevention  NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases

NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations.

Provide Patient Education and Support

Diabetes self-management education and support are essential components of diabetes therapy because they can produce both behavioral and biological improvements. [1] However, clinicians should be sensitive to the reality that a patient’s actions not only reflect individual characteristics, but also the patient’s environment at home, work, and community, all of which should be considered in the education and support plan. [2]

“Self-management support is the assistance caregivers give to patients with chronic disease in order to encourage daily decisions that improve health-related behaviors and clinical outcomes.”[3] A summary of skills and tools to transform the patient/caregiver relationship into a collaborative partnership are available at www.IHI.org.

AHRQ provides resources for self-management support for people with chronic conditions at www.orau.gov/ahrq/sms_home.html.

Stages-of-Change

Identifying the patient's readiness to make changes can help the care team to determine an effective approach to help the patient assume responsibility for his or her disease management. Problem solving discussions can prepare the patient to deal effectively with self-management issues. Instruction should be individualized for persons of all ages, incorporating their cultural preferences, health beliefs, and preferred learning styles. The goal is to assist the person with diabetes discover how to manage their diabetes.

Stages-of-change assessment focuses on an individual's readiness to change. [4] Use of the simple tool below may help teams design interventions that are more effective and acceptable to patients. [5]

Stages-of-change assessment
Stage Statement of willingness to change[5]

Precontemplation

Negative response to all four statements.

Contemplation

I am intending to make changes in my diabetes management in the next six months.

Preparation

I am intending to make changes in my diabetes management in the next month.

Action

I have made changes in by diabetes management in the last six months.

Maintenance

My diabetes has been in good control for more than six months.

Reproduced with permission

A study of patients who were asked to select which statement they agreed with most, showed that patients in the action or preparation stages were able to reduce A1C levels significantly more quickly and to a greater degree that those patients in the contemplation or precontemplation stages. The reductions in A1C in the action and preparation groups persisted for at least 12 months. [5]

Self-efficacy and Patient Education

“Self-efficacy refers to the extent of an individual’s belief in his or her abilities. Because self-efficacy is based on feelings of self-confidence and control, it is a good predictor of motivation and behavior. Research has shown that health care professionals can have an impact on self-efficacy and that changes in self-efficacy are associated with changes in behavior. Some examples of ways to enhance a patient’s self-efficacy include:

  • Skills mastery
  • Modeling
  • Social persuasion”

For more information visit: www.euromedinfo.eu/patient-education-self-efficacy.html/

Additional sources that affect self-efficacy include:

  • Experience
  • Physiological factors

Self-Management Strategies

The diabetes management plan should involve the patient and family, the physician, and other members of the health care team. Any plan should incorporate diabetes self-management education and support. [6] The health care team may select from different strategies to provide adequate education and develop problem-solving skills in the various aspects of diabetes management according to comfort level, experience, and feasibility for use of the strategy in their practice setting.

  1. A five-step patient empowerment model helps the clinician effectively counsel patients about diabetes self-management:
    The 5-steps are:
    1. Step 1: Explore the problem or issue
    2. Step 2: Clarify feeling and meaning
    3. Step 3: Develop a plan
    4. Step 4: Commit to action
    5. Step 5: Experience and evaluate the plan [1]
  2. Motivational interviewing helps patients understand the intrinsic ambivalence they have towards certain behavioral changes. It can promote self-efficacy for behavior change. Investigators were able to help patients with diabetes make lifestyle changes using an individualized approach in which realistic manageable goals for lifestyle change and ways to overcome barriers were negotiated using brief motivational interviewing.

    Motivational interviewing uses open ended questions to understand the patient; reflective listening; and affirmations about what they do right to empower them.

    OARS for motivational interviewing:
    Often called micro counseling skills, OARS is a brief way to remember the basic approach used in motivational interviewing:

    • Open ended questions
    • Affirmations
    • Reflections
    • Summaries

    These are core counselor behaviors employed to move the process forward by establishing a therapeutic alliance and eliciting discussion about change.

    www.Motivationalinterviewing.org

    For videos demonstrating motivational interviewing go to:
    http://chsolutions.typepad.com/healthqualitynews/video-library/
    www.eatplay521.com/toolsForYourPractice.html
    http://pedsinreview.aappublications.org/content/33/9/e57.extract

Patient Education Materials

Many organizations offer free or low-cost diabetes patient education materials. The National Diabetes Education Program (NDEP) materials include a wide-range of easy-to-read materials that are tailored for groups at highest risk for diabetes and its complications. To help you find education materials that best fit your patients’ needs we have provided brief descriptions of available materials and links to some organizations for more details. Sources for culturally and linguistically appropriate patient education materials are in a box at the end. An online search would locate many more free or low-cost diabetes patient education resources.

Audiences for NDEP patient materials

Easy-to-read materials are tailored for groups at highest risk for diabetes and its complications– children and teens, older adults, African Americans, American Indians, Alaska Natives, Hispanics and Latinos, Asian Americans, and Pacific Islanders. Some items are available in 16 languages, from Spanish to Samoan. Small quantities are free and all may be reproduced or reprinted without copyright restrictions.

National Diabetes Educational Program (NDEP)
NDEP offers a wide range of resources aimed at diabetes prevention and control that you can use to reach out to people with diabetes, people at risk, and other health care providers. Order materials at ndep.nih.gov/publications/index.aspx.

NDEP's Diabetes HealthSense is an online library of resources to help patients with or at risk for diabetes make and sustain lifestyle changes and cope with the demands of diabetes.

Diabetes At Work Website provides lesson plans and fact sheets to serve a variety of health education activities, such as a lecture series, a diabetes support group curriculum, and "Lunch and Learn" forums.

American College of Physicians Patient and Provider Resources This link provides access to numerous patient education resources including health videos and information in English and Spanish.

American Diabetes Association provides numerous print materials for people with prediabetes and diabetes and a free one-year Living with Type 2 Diabetes Program and online materials including My Food Advisor.

CDC Diabetes Public Health Resource
www.cdc.gov/diabetes/prevention/index.htm
www.cdc.gov/diabetes
CDC's Division of Diabetes Translation translates diabetes research into daily practice to understand the impact of the disease, influence health outcomes, and improve access to quality health care.

Improving Chronic Illness Care www.improvingchroniccare.org/downloads/healthy_changes_plan.doc offers Healthy Changes Plan, a one-page tool for patients to document chosen healthy changes in terms of "what, when, how, where, and how often."

JDRF provides support via an Online Diabetes Support Team and has a website specifically for kids with diabetes, JDRF Kids Online: kids.jdrf.org.

Medicare provides specific information about coverage for Diabetes Supplies & Services, including Diabetes Self-Management Training and Medical Nutrition Therapy. For general information: www.medicare.gov or 1-800-MEDICARE, 1-800-633-4227, or 1-877-486-2048 for TTY users.

National Diabetes Information Clearinghouse (NDIC) provides numerous diabetes education materials; literature searches on numerous subjects related to diabetes; and Diabetes Dateline, a semiannual newsletter.

Culturally & Linguistically Appropriate Patient Education Materials
Some sources of free or low-cost culturally and linguistically appropriate patient education materials are below.

For African Americans; Asian Americans and Pacific Islanders (15 languages), Hispanics and Latinos; and American Indians and Alaska Natives:
ndep.nih.gov/publications/

For African Americans:
www.diabetes.org/communityprograms-and-localevents/africanamericans.jsp

For American Indians and Alaska Natives:
www.diabetes.org/communityprograms-and-localevents/nativeamericans.jsp
www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=resourcesPatientEduMat

For Asian Americans and Pacific Islanders:
ndep.nih.gov/publications/index.aspx?Ethnicity=Asian+American+and+Pacific+Islander
http://asianamericanhealth.nlm.nih.gov/chronic05.html

For Hispanics and Latinos:
ndep.nih.gov/publications/Publicaciones.aspx
www.diabetes.org/in-my-community/programs/latino-programs/
ndep.nih.gov/resources/index.aspx?Category=&Ethnicity=Hispanic%2FLatino+American


NIH Institute and Center Resources for Diabetes has a variety of diabetes resources (including some in Spanish) for consumers and patients from several NIH Institutes and Offices.

Poster – Tool Download (Spanish): Using this poster may serve to activate patients to become more involved in informed decision-making and patient-centered care. The National Diabetes Education Program (NDEP) obtained permission from Diabetes Nation, LLC to provide these resources.

References

1. Funnell MM, Anderson RM: Empowerment and self-management of diabetes. Clinical Diabetes 2004; 22(3): 123-127.

2. Marrero DG, Ard J, Delamater AM, et al. Twenty-fist century behavioral medicine: a context for empowering clinicians and patients with diabetes. A consensus report. Diabetes Care 2013; 36:463-470.

3. Schaefer J, Miller D, Goldstein M, Simmons L: Partnering in self-management support: a toolkit for clinicians. Cambridge, MA: Institute for Healthcare Improvement, 2009.

4. Parchman ML, Arambula-Solomon TG, Noel PH, Larme AC, Pugh JA: Stage of change advancement for diabetes self-management behaviors and glucose control. Diabetes Educ 2003; 29(1): 128-34.

5. Peterson KA: Readiness to change and clinical success in a diabetes educational program. J Am Board Fam Pract 2002; 15(4): 266-71.

6. Haas L, Maryniuk M, Beck J, et al. National Standards for Diabetes Self-management Education and Support. Diabetes Care 2012; 35:2393-2401.