2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S24 support for evidence-based practice change. J Nurs Care Qual. 2006;21:110-113. 55. Bodenheimer T,Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775- 1779. 56. Bodenheimer T,Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288:1909-1914. 57. Bodenheimer T, Wang MC, Rundall TG, et al. What are the facilitators and barriers in physician organizations’ use of care management process? Jt Comm J Qual Saf. 2004;30:505-514. 58. Battersby M. Health reform through coordinated care: SA HealthPlus. BMJ. 2005;330:662-665. 59. Singh D, Surrey and Sussex Primary Care Trust Alliance. Transforming chronic care: a systematic review of the evidence. Evid Based Cardiovasc Med. 2005;8:91-94. 60. Wellingham J, Tracey J, Rea H, et al. The development and implementation of the Chronic Care Management Program in Counties Manukau. N Z Med J. 2003;116:U327. 61. Government of British Columbia, Ministry of Health website. Available at: http://www.healthservices.gov.bc.ca/cdm. Accessed September 1, 2008. 62. Barr VJ, Robinson S, Marin-Link B, et al. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the chronic care model. Hosp Q. 2003;7:73-82. 63. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511-544. 64. Groves T,Wagner EH. High quality care for people with chronic diseases. BMJ. 2005;330:609-610. 65. Baquet CR, Carter-Pokras O, Bengen-Seltzer B. Healthcare disparities and models for change. Am J Manag Care. 2004;10: SP5-SP11. 66. World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Global Report. Geneva, Switzerland: World Health Organization; 2002. Available at: http://www.who.int/diabetesactiononline/about/icccglobal report.pdf. Accessed September 1, 2008. 67. Piatt GA, Orchard TJ, Emerson S, et al.Translating the chronic care model into the community. Diabetes Care.2006;29:811-817. 68. Tsai AC, Morton SC, Mangione CM, et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11:478-488. 69. Ansari Z, Ackland MJ, Carson NJ, et al. Small area analysis of diabetes complications: opportunities for targeting public health and health services interventions. Aust J Primary Health. 2005;11:72-78. 70. Smith S, Bury G, O’Leary M, et al. The North Dublin randomized controlled trial of structured diabetes shared care. Fam Pract. 2004;21:39-45. 71. Diabetes Integrated Care Evaluation Team. Integrated care for diabetes: clinical, psychological, and economic evaluation. BMJ. 1994;308:1208-1212.
Self-management Education Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Helen Jones RN MSN CDE, Lori D. Berard RN CDE and Heather Nichol RN MScN CDE KEY MESSAGES • Self-management education (SME) that incorporates knowledge and skills development, as well as cognitivebehavioural interventions, should be implemented for all individuals with diabetes. • The content of SME programs must be individualized according to the individual’s type of diabetes, current state of metabolic stability, treatment recommendations, readiness for change, learning style, ability, resources and motivation. • SME is a fundamental component of diabetes care and is most effective when ongoing diabetes education and comprehensive healthcare occur together. INTRODUCTION The objectives of diabetes self-management education (SME) are to increase the individual’s involvement in, confidence with and motivation for control of their diabetes, its treatment and its effect on their lives (1).The term “SME,” rather than “diabetes education,” emphasizes the importance of including a variety of client-centred strategies and interventions that address the physical, psychological and social management of living with a chronic illness. SME goes beyond a focus on adherence to guidelines and treatment prescriptions; it incorporates didactic and nondidactic (e.g. active, participatory) education, as well as social, behavioural and psychological interventions (2). ELEMENTS OF SME SME, which includes skills training, coping strategies, problem-solving and case management, has been demonstrated to improve the individual’s ability to engage in effective selfcare, lower glycated hemoglobin (A1C) levels and enhance quality of life (3-6). The essential components of SME are hypothesized to include: education tailored to individual needs Table 1. Levels of learning (11) Survival/ basic level and circumstances; a group setting with others who share the same condition; feedback following an intervention; psychological emphasis in the intervention; and involvement of medical providers in providing the intervention (4). Long-term education with scheduled follow-up has also been shown to enhance the effect of education on glycemic control (7). Didactic programs alone are not advocated (3). Motivational interviewing, added to a behaviour-change program, may have greater impact (1,8). The content and skill training components of SME programs must be individualized according to the type of diabetes, current state of metabolic stability, treatment recommendations, learning ability, ability to change, resources and motivation. Education should be offered in a timely and needs-based manner (5,9,10). Interventions that include face-to-face delivery, a cognitive-reframing teaching method and practical application content are more likely to improve glycemic control (9).The following basic knowledge areas are generally accepted as essential to an SME program (11,12), and each topic should include a problem-solving component; monitoring of relevant health parameters; healthy eating; physical activity; pharmacotherapy; hypo- and hyperglycemia prevention and management; and prevention and surveillance of complications and comorbid conditions. Suggested learning objectives for each topic area have been developed at basic, intermediate and advanced levels (Table 1) (11). Skill training during SME should include self-monitoring of blood glucose (SMBG), making dietary choices, incorporating an exercise regimen, using medications as recommended and possible medication adjustment (5,9,10). For example, individuals with diabetes should be taught to interpret their own blood glucose (BG) meter results and make appropriate changes (5,13). Additional information regarding dietary choices, physical activity and BG levels before and after meals is frequently required to guide treatment decisions (13). • The knowledge, skills and motivation required for self-care to prevent, identify and treat the acute short-term complications of hyperglycemia or severe hypoglycemia • The person may or may not wish and/or need or be able to progress beyond this level Intermediate level • The knowledge, skills and motivation required for self-care to achieve recommended metabolic control, reduce the risk of long-term complications and facilitate the adjustment to living with diabetes Advanced level • The knowledge, skills and motivation required for self-care to support intensive diabetes management for optimal metabolic control, and full integration of care into the individual’s life activities and goals S25 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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