REVIEW
Partnering with patients to promote holistic diabetes management: Changing paradigms Lenora Lorenzo, DNP, APRN-RX, BC-FNP/GNP/ADM, CDE, FAANP (Nurse Practitioner)1,2 1 2
Department of Veterans Affairs, Pacific Island Health Care System, Spark Matsunaga Center, Honolulu, Hawaii School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, Hawaii
Keywords Nurse practitioners; diabetes; behavioral health; coaching; empowerment; health promotion; Motivational Interviewing. Correspondence Lenora Lorenzo, DNP, APRN-RX, BC-FNP/GNP/ADM, CDE, FAANP, Department of Veterans Affairs, Pacific Island Health Care System, Spark Matsunaga Center, 459 Patterson Rd, Honolulu, Hawaii 96783. Tel: 808-433-2704; Fax: 808-433-7864; E-mail: [email protected] Received: July 2011; accepted: January 2012 doi: 10.1111/1745-7599.12004
Abstract Purpose: To provide a review of best practice for clinical management of diabetes mellitus (DM) for nurse practitioners (NPs) and accelerate incorporation of key findings into current practice. Data source: A search was conducted in Pub Med, Ovid, CINAHL, and Cochrane’s Database of Systematic Reviews. Conclusions: There are many challenges for DM care identified in the current health system. There is a great need to change care paradigms to engage patients in partnership for enhanced management and self-management in DM. A review of the best practice evidence revealed numerous models of care, strategies, and tools available to enhance diabetes care and promote health and well-being. The primary focus of this article is to engage NP clinicians to incorporate new strategies to augment management and improve clinical outcomes. Implications for practice: Incorporation of best practice for DM management may accelerate the paradigm shift to more patient-focused care. Engaged, informed, and activated patients along with clinicians working in partnerships may enhance clinical outcomes.
The diabetes mellitus (DM) pandemic has inundated many countries affecting millions of people worldwide. DM is now a major public health concern globally. America’s growing rate of unrecognized prediabetes is estimated to rise to 52% by 2020, thus earning the title of “The United States of Diabetes” (Vojta et al., 2010). There is no doubt that as the prevalence of DM increases at unparalleled rates, so will the complications and burden of the disease. The American Diabetes Association (ADA; 2008) estimated that the average cost of caring for a patient with DM is twice the cost of caring for patients with other conditions. DM is the leading cause of cardiovascular disease, stroke, renal failure, nontraumatic lower limb amputations, and new cases of blindness in the United States (Centers for Disease Control [CDC], 2011). Diabetes also imposes costs in terms of lost productivity and loss of economic growth because of missed work days. The burden of diabetes significantly impacts quality of life as well as economics for persons with diabetes and the healthcare industry. This article reviews challenges and opportunities, best practice evidence, and concludes with strategies and tools to enhance DM management in primary care.
Challenges and opportunity for changing paradigms The Institute of Medicine (IOM, 2002) recognized the importance of DM as having unusual eminent risk for increased mortality and morbidity despite the enormous capability for risk reduction with health promotion and preventative care. The IOM (2001, 2002) also identified numerous gaps in the quality and safety of health care. These identified gaps led to the IOM’s call to action for health care providers to redesign and incorporate more patient-centered methods with a focus on population management of chronic conditions like DM.
Biomedical, acute care model impact on diabetes The present healthcare system’s (HCS’) propensity for acute care models is divergent from complex care needs of chronic conditions like DM, resulting in suboptimal care and outcomes. Although DM requires lifestyle changes and complex treatment regimens, the present biomedical model of care does not focus on patients needs for health promotion, or self-management support. The biomedical model focuses heavily upon
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disease, pathology, and treatment, failing to identify individual differences (Stewart et al., 2003). This focus on treatment of disease may work well for traditional medical and physical care; however, it does not attend to the psychological, sociocultural, or economic differences of individuals. The biomedical model essentially views patients with the same disease as having the same problem regardless of religion, culture, or ethnicity (Stewart et al., 2003). In the biomedical model, patients are frequently uninformed and unengaged in their care and labeled noncompliant. Providers are also unprepared to deal with the individual psychosocial needs of patients. These phenomena result in frustration and unproductive interactions between patients and providers. In contrast to the biomedical model, holistic models of nursing place emphasis on changes that can be made in society with regard to behavior and lifestyles resulting in a healthier population (Pender, Murdaugh, & Parsons, 2005). Nurse practitioners (NPs) are educated in health promotion, disease prevention, and evidencebased health care. Thus, NPs are ideal change agents in this paradigm shift from the biomedical model to holistic system change and patient focused care. Selfmanagement and patient centeredness are considered critical and essential components of appropriate diabetes care (Funnell et al., 2010).
Compliance versus therapeutic alliance Compliance is crucial to ensure the success of therapeutic and preventative health care and high-quality health outcomes. Medical sociologist Barofsky (Cramer, 2004; Madden, 1990) coined the term “therapeutic alliance” to describe the importance of the collaborative and interactive relationship of the clinician with the patient. Barofsky characterized the relationship as a continuum where compliance suggests coercion, adherence suggests conformity, and therapeutic alliance suggests negotiation (Cramer, 2004; Madden, 1990). This continuum varies in the degree to which the patients or clinicians make decisions and is thought of as a process to improve compliance. Through this continuum process, a therapeutic alliance between the patients and clinicians can be crafted with the ultimate goal of good outcomes. This model is consistent with patient-centered care and has great potential to address the priorities of care advocated by the IOM (2001, 2002). The therapeutic alliance is a complex, sophisticated process that requires respect for the patients’ autonomy, health beliefs, and life circumstances. All too often life gets in the way of a patients’ desire to achieve better outcomes. Taking the time to understand and begin treatment where the patients “are” builds a therapeutic al352
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liance upon which manageable and realistic common goals guide the process. NPs are expert in the practice of therapeutic alliance, skilled at listening to patient concerns and contribute greatly to improving health outcomes and thus are well respected by patients (Bauer, 2010; IOM, 2010; Newhouse et al., 2011).
Systematic reviews of diabetes management Search methodology An evidence-based search for systematic reviews (SRs) was conducted in Pub Med, Cochrane Database of Systematic Reviews, and CINHAL. Keywords for searches included: SRs (AND), type 2 diabetes, adult, organizational intervention, chronic care, management, intervention, self-management, self-management training, diabetes education, or glycemic control. The results of the SR can guide NPs to better understand and make decisions about program planning and implementation in order to enhance the provision of holistic evidence-based health care for persons with diabetes and thus assure best outcomes.
SRs of clinical interventions Evidence from these SRs corroborates multifaceted practice changes are needed to improve diabetes outcomes. Four critical components were identified: (a) patient empowerment/self-management support; (b) structured team-based delivery systems; (c) increased clinician expertise; and (d) organizational support with information systems (Glazier, Bajcar, Kennie, & Willson, 2006; Magwood, Zapka, & Jenkins, 2008; Peek, Cargill, & Huang, 2007; Shojania et al., 2004, 2006). A rigorous SR and meta-regression analysis was completed by Shojania et al. (2004, 2006) and sponsored by the Agency for Healthcare Research and Quality (AHQR). They completed a technical review of 58 articles reporting a total of 66 trials. The most common interventions deployed were organizational change (40 trials), patient education (28 trials), and provider education (24 trials). Fifty-two trials involved interventions deploying more than one quality improvement (QI) strategy, with a median of two strategies per trial and a maximum of five. Multifaceted trials reported a median reduction in glycosylated hemoglobin A1C (A1C) of 0.60%, compared to a median reduction of 0.0% for trials of a single intervention (p = .01) (Shojania et al., 2006, 2006). The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials. The investigators did not find any specific type of QI strategy to be more effective, and they suggested that employing at least two strategies provides a greater chance of success than single-faceted interventions in terms of improving
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glycemic control and adherence. Magwood et al. (2008) completed a review of nine SRs with a total of 231 studies and also found evidence that multicomponent approaches incorporating both disease- and case management had shown the best improved outcomes of A1C. Overall SRs and meta-analyses identified multifaceted disease management and organizational interventions that enhance frequent, structured clinical contacts were effective in improving the clinical outcomes of A1C and adherence (Glazier et al., 2006; Magwood et al., 2008; Peek et al., 2007; Shojania et al., 2006, 2006). Disease management changes in organizational practice such as enhancing the role of the nurse to include medication adjustment, diabetes education, and use of Clinical Practice Guidelines (CPG) resulted in better outcomes. Organizational change that includes use of diabetes registries, health information systems for tracking and monitoring, and clinical visit reminders improve delivery of care and outcomes (Shojania et al., 2006, 2006). Most studies did not determine which one strategy was clearly better than others (Magwood et al., 2008; Peek et al., 2007; Shojania et al., 2006, 2006).
SRs of diabetes self-management education (DSME) Researchers found a majority of DSME programs reviewed provided primarily informative education (didactic) without opportunities to develop self-management skills (Duke, Colagiuri, & Colagiuri, 2009; Leeman, 2006; Lirussi, 2010; Loveman, Frampton, & Clegg, 2008; Magwood et al., 2008; Wens et al., 2008). These SRs reported evidence that informational education does improve diabetes knowledge, dietary changes, and self-monitoring of blood glucose for the short term only with no substantive changes in clinical outcomes. Furthermore these SRs also reported a majority of the DSME programs evaluated did not clearly identify components of the curriculum, an aspect that is important to evaluate and compare for DSME programs and results (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2003; Magwood et al., 2008; Wens et al., 2008). Researchers also reported a positive relationship between social support, self-management behavior and the quality of life (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Lirussi (2010) conducted a significant review of 10 SRs from four different countries and found evidence for improved A1C control with DSME when it occurred in community settings, was group based and of high intensity delivered over a longer period, and aimed at improving self-management skills. Leeman (2006) identified issues of integration of DSME into HCSs to include lack of reimbursement for
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DSME and human resource requirements. However, Gagliardino et al. (2011) found evidence that DSME strategies are an efficient way to improve clinical outcomes without major impact on healthcare costs. An analysis by Bridges to Excellence estimated that a consistent A1C of 7.0 saves $279 a year in health costs per person (Rosenthal, 2008). Researchers found DSME has evolved from informative education only to education plus behavioral and empowerment models (Lirussi, 2010; Magwood et al., 2008). Educational and behavioral interventions combined with educational strategies such as group sessions achieve higher knowledge gains and compliance (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Magwood et al., 2008; Wens et al., 2008). Enhanced DSME. Prior to 1990, DM education was primarily a hospital-based, informative process for individuals (Brown, 1999). Since then, DSME has evolved into a specialty with a curriculum that includes behavioral strategies for self-management and problemsolving skills to promote behavioral changes that enhance self-management skills (Funnell et al., 2010). This is consistent with the ADA DSME curriculum and supports holistic, person-focused care (Funnell et al., 2010). Effective DSME is very different from merely informing patients of what needs to be done. In self-management, patients have a central role in determining their care and therefore, foster responsibility for their health. Research validates that informative education alone does not lead to behavioral change (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Fortunately, there have been many changes in the DSME curriculum and programs that clearly identify the components and self-management skills required (Funnell et al., 2010). SRs validate programs incorporating behavioral and psychosocial strategies as well as demonstrate improved outcomes (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Today, DSME includes a continuous process of facilitating the knowledge, and self-management skills essential to empower diabetes self-care. This process integrates person-cenered needs, goals, and life experiences and is supported by evidence-based standards (Funnell et al., 2010). The purpose of DSME includes facilitation for informed decision-making, self-management skills, problem-solving and active collaboration with the healthcare team with the goal of improve clinical outcomes, and quality of life (Funnell et al., 2010). All of these enhancements of DSME are consistent with IOM (2001, 2002) recommendations. R
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Table 1 Helpful resources for organizational models Chronic Care Model: Agency for Health Care Research and Quality Clinical Microsystem: Materials, workbooks, and guides Patient-Focused Medical Home Guidelines by the National Alliance of Quality Care Custom program of evaluations, training, and metrics
https://www.cahps.ahrq.gov/ QIGuide/content/interventions/ chroniccaremodel.aspx http://clinicalmicrosystem.org/ materials/ http://www.transformed.com/ PPC/NCQA/contactForm-PPC ncqa.cfm?refPage=%2FPPC% 2FNCQA%2FPPC%5Fncqa2a% 2Ecfm+facilitation
SRs of structured delivery systems with organizational support The SRs support multifaceted approaches at the organizational level to better serve the chronic care needs for persons with DM. The complex nature of diabetes itself requires holistic multifaceted approaches by primary care clinicians, which require an integration of the patient into a health system that promotes long-term management. NPs providing primary care may want to consider choosing a model that best fits their present system (Table 1). Three primary examples of structured delivery systems for primary care redesign identified in the literature are the Chronic Care Model (CCM), the Patient-Centered Medical Home (PCMH), and Clinical Microsystems (CMs; Carrier, Gourevitch, & Shah, 2009a; Friedberg, Lai, Hussey, & Schneider, 2009; Nutting et al., 2007; Wasson et al., 2005). A brief description of these models and the evidence follows.
The CCM The CCM was first identified in the 1990s and is also known as the Wagner CCM (Coleman, Austin, Brach, & Wagner, 2009; Siminerio et al., 2006; Sunaert et al., 2009). Researchers claim that deployment of the CCM addresses the major issues required in chronic care and the gaps identified by the IOM (Coleman et al., 2009; Siminerio et al., 2006; Sunaert et al., 2009). The premise of the model is that quality care is not delivered in isolation but (a) interfaces with the community and its resources, (b) includes self-management support, (c) shifts how care is delivered within the HCS, (d) is based on decision support and evidence, (e) is driven by clinical information systems, and (f) is offered in settings and/or organizations that value chronic care (Figure 1). The result of this shift in the focus of care is a productive interaction between a proactive practice team and prepared activated person with diabetes that drives clinical care and improves the quality of life (Tsai, Morton, Mangione, & Keeler, 2005). Sunaert et al. (2009) reported that incor354
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porating even a few components of the CCM into an HCS or clinic may serve to enhance care of chronic conditions. The conceptual framework of the CCM exemplifies an entire system change by providing patient-centered chronic care (Sunaert et al., 2009; Wagner et al., 2005). The model shifts care from the biomedical model of disease orientation to whole person integration of biological, psychological, and sociological factors. The CCM patient centeredness focal point seeks to develop a therapeutic alliance to understand the patients’ experience and readiness to incorporate health promotion. The end result is informed activated patients and providers engaged in health promotion and self-management (Wagner et al., 2005). CCM evidence. The Health Resources and Services Administration, Health Disparities Collaboration (HDC), and the Improving Chronic Illness Care Collaborative provide information about implementation challenges and the sustainability of the CCM (Coleman et al., 2009). Improved patient care and short-term process outcomes were noted and sustainable over 1 year, however no statistically significant intermediate outcomes were reported (Coleman et al., 2009). Coleman et al. (2009) reported that expanding the studies to 3 years, showed significant improvements in intermediate outcomes such as A1C and the cholesterol low-density lipoprotein. The HDC included more than 700 community health centers serving a population of 9.6 million and demonstrated average reductions of A1C level from 10.5% to 8.6%. Although these internal organizations self-reports do not meet rigorous research standards, they did report positive results that impacted a significant number of patients (Coleman et al., 2009). Nutting et al. (2007) reported on small independent primary care practices where clinicians employed elements of CCM. These practices were able to demonstrate significantly lower A1C values (p = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (p = .02). For every unit increase in clinician-reported CCM use (e.g., from “rarely” to “occasionally”), there was an associated 0.30% reduction in A1C value and 0.17 reduction in the lipid ratio. Thus clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care (Nutting et al., 2007).
The CM The CM model includes an improvement framework that also responds to the IOM call for systems redesign.
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Leadership At Multiple Levels Community resources and linkages Partnerships to develop and support tailored interventions for diabetes management Vision and ability to promote and manage diabetes interventions Advocacy for public policy change Performance standards for diabetes education and management Financing for diabetes education and management training Collaborative/coordination philosophy Quality control/improvement philosophy
Delivery System Design Service arrangements/contracts Methods for referral to DSMT Team members and roles Case/Care/Demand management Centralized/decentralized services Appointments, follow up, other procedures Coordination and methods for referral to community resources and assistance programs Quality control/improvement processes
Clinician/Team Characteristics
Prepared, Proactive Practice Team Productive Interactions and Encounters
Clinical Decision Support Guideline selection and development (ADA recognized DM education program, ADA clinical recommendations for care, AADE basic 7 and others) Guideline tailoring, updating, dissemination, and education of team Cultural competence Certification, continuing education of staff Protocols/critical pathways/prompts Access to specialists, referrals Expert support
Informed, Activated, Patients Patient and Family Characteristics
Clinical Information Systems Performance data related to desired outcomes Methods for documenting and tracking care and self-management Reminder systems for patients and providers Facilitate individual care planning with flow charts, algorithms
Patient Self-Management & Decision Support Education and activation about health issues Assessment of assets and resources for selfmanagement Goal setting, action planning, problem solving Information about service arrangements and resources Reminders of service needs, goal progress Reminders to bring needs to the attention of clinicians (proactivity) Tracking and follow-up for adherence and control of diabetes Patient held records for tracking care and outcomes Updates for patients on new guidelines for care
Outcomes
Figure 1 Strategies to improve outcomes. (Used with permission of Sage Publications. From Magwood, G. S., Zapka, J., & Jenkins, C. (2008). A review of systematic reviews evaluating diabetes interventions: Focus on quality of life and disparities. The Diabetes Educator, 34(2), 242–265.)
The microsystem has been defined as small groups of clinicians that collaborate to provide care to a specific population of patients (Nelson et al., 2002, 2008). This CM often has similar clinical and business aims, interrelated processes, and common information systems with clinical performance measures. The CM may be part of a larger HCS (macrosystem) or a unique independent clinic. The CM (or clinic) is considered the hub of the critical framework for building larger health systems (Nelson et al., 2008; Wasson et al., 2008). The CM design includes the four Ps: (a) patient population served, (b) clinicians who collaborate (providers), (c) processes used to provide care, and (d) functional structure of the clinic (program) (Nelson et al., 2008). Similar to the CCM, the CM multifaceted approach includes support for self-management, clinical decision support, delivery system design, and clinical information systems. The focal point of a microsystem is productive interaction between an informed, activated patient and prepared, activated clinical staff (Nelson et al., 2008). Again, self-management support is deemed essential and is enhanced by the therapeutic alliance and collaborative partnerships between patients and clinicians.
The CM framework includes QI methods, theories, tools, and techniques and can be easily accessed online (Table 1; Dartmouth Institute, 2011). Utilization of process maps to evaluate healthcare practice for improvement is essential to the CM design. An increasing number of providers are adopting the CM model because of the helpful and accessible templates and tools for patients with DM. CM evidence. There is a paucity of research on the CM, perhaps due in part to the ease of transforming the model templates for deployment into private practice and microsystems within larger organizations as QI projects, which are not reported. One multisite clinical research trial, the Spine Patient Outcomes Research Trial (SPORT), modeled on the Spine Center microsystem has demonstrated improvement in the standards of care for SCI (Ditunno et al., 2003).
Patient-Centered Medical Homes The PCMH model has existed since 1967 and has recently become the focus of healthcare reform discussion 355
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(Carrier et al., 2009b; Rosenthal, 2008). The PCMH original focus was a primary healthcare team, lead by a physician. This has evolved to be more inclusive with NPs now recognized as primary care providers (PCPs) and team leaders (National Alliance for Quality Care, 2005 Symposium, 2005; Rothman, Hansen-Turton, & Valdez, 2011). The PCMH is a provider guided, patient-centered model of health care constructed to revitalize primary care practices and improve patient care. The framework of the PCMH includes: (a) holistic patient-focused proactive care; (b) a relationship with a consistent long-term PCP; (c) a team providing primary care provided lead by the PCP; (d) clinical excellence enhanced by the integration of information technology, CPG and QI tracking; and (e) enhanced patient access with expanded hours; enhanced communication and care via the internet and telephonic follow-up care. Teamwork is a cornerstone of the PCMH and the team typically includes the PCP; registered nurse; clinical associate, such as a licensed practice nurse or medical assistant; and clerical support person. The model is proactive as each team member looks ahead of upcoming appointments and plans needed actions to assure optimal care. For example, a team member evaluates the medical record prior to visits to assure all diagnostics and patient follow-up phone calls are completed. The model enables care to focus on prevention steps to improve health and prevent disease. The focal point of the PCMH is productive interaction between an informed, activated patient and prepared, activated clinical staff. PCMH evidence. A majority of studies on the PCMH were found to incorporate different components making evaluation difficult (Carrier et al., 2009b; Rosenthal, 2008). The National Demonstration Project and Pennsylvania initiative for diabetes population provide information about implementation challenges and the sustainability of the PCMH (Crabtree et al., 2010; Gabbay, Bailit, Mauger, Wagner, & Siminerio, 2011). The statewide Pennsylvania initiative for diabetes population was implemented to include the PCMH guided by the CCM in a multipayer insurance system (Gabbay et al., 2011). A total of 105 practices, representing 382 PCPs, were included and demonstrated significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors; Gabbay et al., 2011). There were also statistically significant improvements in clinical outcomes for blood pressure and cholesterol levels, with the highest-risk patients demonstrating the greatest improvement (Gabbay et al., 2011). Rosenthal (2008) reviewed more than 200 publications and several books, which included original research, meta-analysis, or pro356
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gram evaluations and concluded the greatest challenges to implementation is the resulting increased costs for collection of outcome data and the lack of reimbursement for increased access and communication modes.
Provider strategies and tools There are numerous strategies and tools to deploy when building holistic partnerships with patients for enhanced DM care. Three evidence-based organizational models of care and DSME have been described to assist NPs toward program development to enhance patientcentered health care in their practices. It is beyond the scope of this article to review all strategies and tools. Strategies such as self-monitoring of blood glucose, dietary and physical activity are recognized as cornerstones of diabetes control and key components in present DSME programs and thus were not included in this review. Herein is an overview of a few of the holistic behavioral and educational strategies and tools with suggestions for application into clinical practice. Some of the major barriers to implementation or the translation of evidence into practice include lack of time to research methods, resources needed for planning and implementation, and training needs for staff skill development (Jennings, 2004). Recall that QI is a continuous process that includes adjustments leading to improvements for better outcomes. The same skills used to help patients change their behavior can also be used to change clinical practice. One suggestion is to begin small by choosing one action plan at a time and trial it with a pilot group. Use of Deming’s (2000) Model of Improvement, called the Plan Do Study Act (PDSA) is a sequence of team formation, aim setting, planning, and change implementation to guide QI. Weekly team huddles and monthly evaluations augment the PDSA process. Investing in enhancing staff and team members’ skills will also ensure success. Another concern might be intervention costs. When viewed in the context of pay-for-performance and accountable care organizations this becomes a moot consideration as it is well known that evidence-based, quality care results in good outcomes. For example, a 1% drop in A1C has been associated with a 10% reduction in diabetes-related deaths and a 25% reduction in microvascular endpoints (Turner, Cull, & Holman, 1996). The Trust for America’s Health (2008) found that investing in prevention programs saved $9.90 for every dollar spent when compared to treatment programs. These numbers were achieved by analytically factoring in diseases in several chronic conditions secondary to implementing preventative health programs. Clearly, mitigating or ameliorating DM complications would increase the
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value of healthcare dollars while simultaneously decreasing the amount spent on acute care.
Diabetes self-management skill building and patient engagement It is important for patients to learn to manage their disease but the ultimate goal of DSME is to support the adoption of healthy behaviors. DM requires major changes in behaviors and self-management skills to prevent complications and improve outcomes. The most significant difference between health promotion and disease or illness prevention is the motivation for the behavior (Pender et al., 2005). In this case, health promotion is motivated by the need to function optimally and to feel well. Disease prevention includes the desire to avoid illness or prevent complications of disease. NPs are knowledgeable in health promotion, education, and use of behavioral models for change and empowerment.
The Healthy Interactions Conversation Map Program. The Healthy Interactions (Healthy I) Conversation Map program and education tools are one strategy easily deployed for DSME. This program engages people in meaningful conversation about their health (Healthy Interactions, 2009). The methods of deployment include group sessions where learners focus on topics they are interested in with open discussions, which lead to the integration of life experiences in an interactive process. The Conversation Maps include five colorful interactive fun topic game maps on (a) diet, (b) disease process, (c) blood glucose monitoring, (d) gestational DM, and (e) complications (i.e., acute and chronic). The curriculum is approved by the ADA and based on CPGs (Funnell et al., 2010). The Healthy I theoretical underpinnings include the Health Belief Model, the Common Sense Model of Health and Illness Self-Regulation, the Social Learning Self-efficacy Theory, and Adult Learning Principles (Healthy Interactions, 2009). The training for the maps and curriculum can be found online (Table 2) for nurses, pharmacist, and dieticians. Once training is completed, the box of maps and facilitator guide books and game cards are mailed to the facilitator free of charge. NPs are already skilled in health promotion and prevention and can easily deploy this program within their practices for DSME in group visits. The end result is informed activated patients empowered with self-management skills, which ultimately lead to improved outcomes.
Group visits Group visits are another strategy for system redesign based on the CCM. Shared medical appointments and group visits appear synonymous as described in the lit-
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Table 2 Helpful resource for provider strategies Healthy Interactions Conversation Map: education tools and program The Stanford Chronic Disease Self-Management Program Motivational Interviewing: resources Group Visits: California Association of Family Physicians Group Visits: Transformed
http://www.healthyinteractions. com/conversation-mapprograms http://patienteducation.stanford. edu/programs/cdsmp.html http://motivationalinterview.net/ clinical/index.html http://www.familydocs.org/newdirections-diabetes-care/toolsand-resources/group-visits.php http://www.transformed.com/ Perspectives/GroupVisits-E. Shahady.cfm
erature and will be referred to in this article as “group visits” (Clancy, Huang, Okonofua, Yeager, & Magruder, 2007; Jaber, Braksmajer, & Trilling, 2006; Kirsh et al., 2007; Riley & Marshall, 2010). In group visits, several patients (6–20) are seen by a multidisciplinary team in 1–2 h appointments. The team can include a minimum of the provider and one other team members such as (a) medical assistant, (b) RN, (c) Certified Diabetes Educator (CDE), (d) dietitian, (e) behavioral specialist, (f) pharmacist, or (g) a peer lay support leader. Group visit agendas vary and may include DSME sessions, group discussion on topics of interest, foot exams, and a review of recent laboratory results. The Conversation Map program is another strategy that can be implemented during group visits. Group visits require patients’ consent for confidentiality concerns (Table 2). Group visits include individual visits with the provider in order to meet requirements for reimbursement. Group visits allow providers to efficiently meet with groups of patients with similar conditions to provide information, peer support, and lead open discussions about the chronic condition for self-management skill building (Bartley & Haney, 2004).
Diabetes teams No one clinician can provide all the care needs for patients, therefore working in teams may enhance patient care. Teams and “teamlets” are discussed extensively in CCM, CM, and PCMH models (Friedberg et al., 2009). A team consists of a group of clinical staff who work together with the common goal of helping patients achieve improved health. The core team or teamlet include the provider and a medical assistant and/or a nurse. Teams can integrate many other consultants and experts as needed or as available, such as a pharmacist, CDE or a podiatrist (Figure 2). The team meets and communicates regularly about the care of a defined group of patients (i.e., huddles). The focus of the team includes holistic 357
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Diabetes Health Care Team
Primary Care Provider (NP or MD)
Patient (and family)
Health Coach
Community
Partners Church, Support Groups,
CDE, RN or LPN
Consultants
Medical Assistant
Nephrology
Podiatry
Neurology
Psychology
Cardiology
Social Worker
Vascular
Health Educator
Ophthalmology Optometry
Exercise Physiologist
Dentist/ Hygienist
Physical Therapy
Lay Peer Leader
Employer Groups
Diabetologist Advanced Diabetes Management (ADM)NP/Pharmacist
Endocrinologist
Figure 2 Diabetes health care team.
integration of biological, psychological, and sociological factors to enable a therapeutic alliance with patients, which will help to empower and enhance selfmanagement skills. Team members assume the responsibility as the “health coach.” Health coach core skills often include (a) setting the agenda, (b) discussing DM care, (c) teaching about medication reconciliation, (d) closing the loop by follow-up phone calls or visits, (e) using 358
behavior action plans (MacGregor et al., 2006) and supportive encouragement for self-management.
Motivational Interviewing Motivational Interviewing (MI) is a counseling strategy that has demonstrating success (Spahn et al., 2010). MI is a communication health coaching technique that serves
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to empower, motivate, and help move patients through the stages of change toward making a healthy behavior change (Miller & Rollnick, 2002). Theoretical underpinnings of MI include the Trans Theoretical Model (TTM) of behavior change (Prochaska & Norcross, 2001) and social cognitive theory (Bandura, 2004). The TTM is a cyclic evolutionary process where individuals may recognize a need for change (knowledge) and based on readiness stage may act, prepare, or contemplate action. Individuals that do not identify the problem are not aware and thus do not intend to change. These individuals are considered to be in the precontemplation stage of change (Prochaska & Norcross, 2001). However, even in the stage of precontemplation, one may wish to change, but has not identified the need to do so. In this case, the use of “conscious rising” as a process may help to move individuals to the stage of contemplation (Prochaska & Norcross, 2001). MI techniques use understanding of TTM to help move patients through these stages to action. The spirit of MI is (a) empathetic, with active listening to understand the patients view; (b) evocative, to guide and support self-efficacy with a focus on success building skills; and (c) collaborative, to support autonomy and goal building skills. Nurses often use components of MI techniques such as open-ended questions, affirmation, reflection, summaries (OARS) in their daily practice. Patients and groups of patients respond to MI techniques (Spahn et al., 2010).
Behavioral action plans Behavioral actions plans are a means of working with patients for agreement to make healthy changes. Behavioral action plans are used to negotiate behavioral changes to focus on, using your expertise and the patients’ desires. Behavioral action plans focus on one or two actions goals. They are used as a contract or planning guide for specific, measurable, time frame goals. They require exploring barriers and challenges to success and are often used for benchmarking to stimulate action planning. Behavioral action plans are incorporated as a tool to implement health promotion change behavior (MacGregor et al., 2006).
Conclusion The complex treatment regimens for DM require integration of best practice, behavioral as well as biomedical strategies and tools. Several organizational models of care as well as health promotion behavior strategies were introduced for application into DM healthcare partnerships with patients. Ultimately, it is the patients who have a right to accept or refuse whatever care is offered (Cody,
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2006). Holistic care includes respect for individual rights to autonomy and use of evocation guidance and support for self-efficacy with a focus on success building skills. There is a critical need for NPs to translate the evidence into practice and champion holistic health care to evolving paradigms and thus significantly improve our nation’s health. As the prevalence of DM continues to escalate, the HCS and providers are challenged to provide best practice care to meet the IOM aims. NPs have demonstrated excellent outcomes (Bauer, 2010; Newhouse et al., 2011) and are well positioned to make important contributions to shift the paradigm of care toward more holistic patient-centered methods. Challenged to become the healthcare providers patients choose, NPs must embrace and translate evidence-based cutting edge psychosocial healthcare strategies and tools. This care must engage patients in therapeutic partnerships (alliances) with emphasis on empowering to develop self-management skills, which promotes health.
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Partnering with patients to promote holistic diabetes management: Changing paradigms Lenora Lorenzo, DNP, APRN-RX, BC-FNP/GNP/ADM, CDE, FAANP (Nurse Practitioner)1,2 1 2
Department of Veterans Affairs, Pacific Island Health Care System, Spark Matsunaga Center, Honolulu, Hawaii School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, Hawaii
Keywords Nurse practitioners; diabetes; behavioral health; coaching; empowerment; health promotion; Motivational Interviewing. Correspondence Lenora Lorenzo, DNP, APRN-RX, BC-FNP/GNP/ADM, CDE, FAANP, Department of Veterans Affairs, Pacific Island Health Care System, Spark Matsunaga Center, 459 Patterson Rd, Honolulu, Hawaii 96783. Tel: 808-433-2704; Fax: 808-433-7864; E-mail: [email protected] Received: July 2011; accepted: January 2012 doi: 10.1111/1745-7599.12004
Abstract Purpose: To provide a review of best practice for clinical management of diabetes mellitus (DM) for nurse practitioners (NPs) and accelerate incorporation of key findings into current practice. Data source: A search was conducted in Pub Med, Ovid, CINAHL, and Cochrane’s Database of Systematic Reviews. Conclusions: There are many challenges for DM care identified in the current health system. There is a great need to change care paradigms to engage patients in partnership for enhanced management and self-management in DM. A review of the best practice evidence revealed numerous models of care, strategies, and tools available to enhance diabetes care and promote health and well-being. The primary focus of this article is to engage NP clinicians to incorporate new strategies to augment management and improve clinical outcomes. Implications for practice: Incorporation of best practice for DM management may accelerate the paradigm shift to more patient-focused care. Engaged, informed, and activated patients along with clinicians working in partnerships may enhance clinical outcomes.
The diabetes mellitus (DM) pandemic has inundated many countries affecting millions of people worldwide. DM is now a major public health concern globally. America’s growing rate of unrecognized prediabetes is estimated to rise to 52% by 2020, thus earning the title of “The United States of Diabetes” (Vojta et al., 2010). There is no doubt that as the prevalence of DM increases at unparalleled rates, so will the complications and burden of the disease. The American Diabetes Association (ADA; 2008) estimated that the average cost of caring for a patient with DM is twice the cost of caring for patients with other conditions. DM is the leading cause of cardiovascular disease, stroke, renal failure, nontraumatic lower limb amputations, and new cases of blindness in the United States (Centers for Disease Control [CDC], 2011). Diabetes also imposes costs in terms of lost productivity and loss of economic growth because of missed work days. The burden of diabetes significantly impacts quality of life as well as economics for persons with diabetes and the healthcare industry. This article reviews challenges and opportunities, best practice evidence, and concludes with strategies and tools to enhance DM management in primary care.
Challenges and opportunity for changing paradigms The Institute of Medicine (IOM, 2002) recognized the importance of DM as having unusual eminent risk for increased mortality and morbidity despite the enormous capability for risk reduction with health promotion and preventative care. The IOM (2001, 2002) also identified numerous gaps in the quality and safety of health care. These identified gaps led to the IOM’s call to action for health care providers to redesign and incorporate more patient-centered methods with a focus on population management of chronic conditions like DM.
Biomedical, acute care model impact on diabetes The present healthcare system’s (HCS’) propensity for acute care models is divergent from complex care needs of chronic conditions like DM, resulting in suboptimal care and outcomes. Although DM requires lifestyle changes and complex treatment regimens, the present biomedical model of care does not focus on patients needs for health promotion, or self-management support. The biomedical model focuses heavily upon
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disease, pathology, and treatment, failing to identify individual differences (Stewart et al., 2003). This focus on treatment of disease may work well for traditional medical and physical care; however, it does not attend to the psychological, sociocultural, or economic differences of individuals. The biomedical model essentially views patients with the same disease as having the same problem regardless of religion, culture, or ethnicity (Stewart et al., 2003). In the biomedical model, patients are frequently uninformed and unengaged in their care and labeled noncompliant. Providers are also unprepared to deal with the individual psychosocial needs of patients. These phenomena result in frustration and unproductive interactions between patients and providers. In contrast to the biomedical model, holistic models of nursing place emphasis on changes that can be made in society with regard to behavior and lifestyles resulting in a healthier population (Pender, Murdaugh, & Parsons, 2005). Nurse practitioners (NPs) are educated in health promotion, disease prevention, and evidencebased health care. Thus, NPs are ideal change agents in this paradigm shift from the biomedical model to holistic system change and patient focused care. Selfmanagement and patient centeredness are considered critical and essential components of appropriate diabetes care (Funnell et al., 2010).
Compliance versus therapeutic alliance Compliance is crucial to ensure the success of therapeutic and preventative health care and high-quality health outcomes. Medical sociologist Barofsky (Cramer, 2004; Madden, 1990) coined the term “therapeutic alliance” to describe the importance of the collaborative and interactive relationship of the clinician with the patient. Barofsky characterized the relationship as a continuum where compliance suggests coercion, adherence suggests conformity, and therapeutic alliance suggests negotiation (Cramer, 2004; Madden, 1990). This continuum varies in the degree to which the patients or clinicians make decisions and is thought of as a process to improve compliance. Through this continuum process, a therapeutic alliance between the patients and clinicians can be crafted with the ultimate goal of good outcomes. This model is consistent with patient-centered care and has great potential to address the priorities of care advocated by the IOM (2001, 2002). The therapeutic alliance is a complex, sophisticated process that requires respect for the patients’ autonomy, health beliefs, and life circumstances. All too often life gets in the way of a patients’ desire to achieve better outcomes. Taking the time to understand and begin treatment where the patients “are” builds a therapeutic al352
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liance upon which manageable and realistic common goals guide the process. NPs are expert in the practice of therapeutic alliance, skilled at listening to patient concerns and contribute greatly to improving health outcomes and thus are well respected by patients (Bauer, 2010; IOM, 2010; Newhouse et al., 2011).
Systematic reviews of diabetes management Search methodology An evidence-based search for systematic reviews (SRs) was conducted in Pub Med, Cochrane Database of Systematic Reviews, and CINHAL. Keywords for searches included: SRs (AND), type 2 diabetes, adult, organizational intervention, chronic care, management, intervention, self-management, self-management training, diabetes education, or glycemic control. The results of the SR can guide NPs to better understand and make decisions about program planning and implementation in order to enhance the provision of holistic evidence-based health care for persons with diabetes and thus assure best outcomes.
SRs of clinical interventions Evidence from these SRs corroborates multifaceted practice changes are needed to improve diabetes outcomes. Four critical components were identified: (a) patient empowerment/self-management support; (b) structured team-based delivery systems; (c) increased clinician expertise; and (d) organizational support with information systems (Glazier, Bajcar, Kennie, & Willson, 2006; Magwood, Zapka, & Jenkins, 2008; Peek, Cargill, & Huang, 2007; Shojania et al., 2004, 2006). A rigorous SR and meta-regression analysis was completed by Shojania et al. (2004, 2006) and sponsored by the Agency for Healthcare Research and Quality (AHQR). They completed a technical review of 58 articles reporting a total of 66 trials. The most common interventions deployed were organizational change (40 trials), patient education (28 trials), and provider education (24 trials). Fifty-two trials involved interventions deploying more than one quality improvement (QI) strategy, with a median of two strategies per trial and a maximum of five. Multifaceted trials reported a median reduction in glycosylated hemoglobin A1C (A1C) of 0.60%, compared to a median reduction of 0.0% for trials of a single intervention (p = .01) (Shojania et al., 2006, 2006). The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials. The investigators did not find any specific type of QI strategy to be more effective, and they suggested that employing at least two strategies provides a greater chance of success than single-faceted interventions in terms of improving
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glycemic control and adherence. Magwood et al. (2008) completed a review of nine SRs with a total of 231 studies and also found evidence that multicomponent approaches incorporating both disease- and case management had shown the best improved outcomes of A1C. Overall SRs and meta-analyses identified multifaceted disease management and organizational interventions that enhance frequent, structured clinical contacts were effective in improving the clinical outcomes of A1C and adherence (Glazier et al., 2006; Magwood et al., 2008; Peek et al., 2007; Shojania et al., 2006, 2006). Disease management changes in organizational practice such as enhancing the role of the nurse to include medication adjustment, diabetes education, and use of Clinical Practice Guidelines (CPG) resulted in better outcomes. Organizational change that includes use of diabetes registries, health information systems for tracking and monitoring, and clinical visit reminders improve delivery of care and outcomes (Shojania et al., 2006, 2006). Most studies did not determine which one strategy was clearly better than others (Magwood et al., 2008; Peek et al., 2007; Shojania et al., 2006, 2006).
SRs of diabetes self-management education (DSME) Researchers found a majority of DSME programs reviewed provided primarily informative education (didactic) without opportunities to develop self-management skills (Duke, Colagiuri, & Colagiuri, 2009; Leeman, 2006; Lirussi, 2010; Loveman, Frampton, & Clegg, 2008; Magwood et al., 2008; Wens et al., 2008). These SRs reported evidence that informational education does improve diabetes knowledge, dietary changes, and self-monitoring of blood glucose for the short term only with no substantive changes in clinical outcomes. Furthermore these SRs also reported a majority of the DSME programs evaluated did not clearly identify components of the curriculum, an aspect that is important to evaluate and compare for DSME programs and results (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2003; Magwood et al., 2008; Wens et al., 2008). Researchers also reported a positive relationship between social support, self-management behavior and the quality of life (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Lirussi (2010) conducted a significant review of 10 SRs from four different countries and found evidence for improved A1C control with DSME when it occurred in community settings, was group based and of high intensity delivered over a longer period, and aimed at improving self-management skills. Leeman (2006) identified issues of integration of DSME into HCSs to include lack of reimbursement for
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DSME and human resource requirements. However, Gagliardino et al. (2011) found evidence that DSME strategies are an efficient way to improve clinical outcomes without major impact on healthcare costs. An analysis by Bridges to Excellence estimated that a consistent A1C of 7.0 saves $279 a year in health costs per person (Rosenthal, 2008). Researchers found DSME has evolved from informative education only to education plus behavioral and empowerment models (Lirussi, 2010; Magwood et al., 2008). Educational and behavioral interventions combined with educational strategies such as group sessions achieve higher knowledge gains and compliance (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Magwood et al., 2008; Wens et al., 2008). Enhanced DSME. Prior to 1990, DM education was primarily a hospital-based, informative process for individuals (Brown, 1999). Since then, DSME has evolved into a specialty with a curriculum that includes behavioral strategies for self-management and problemsolving skills to promote behavioral changes that enhance self-management skills (Funnell et al., 2010). This is consistent with the ADA DSME curriculum and supports holistic, person-focused care (Funnell et al., 2010). Effective DSME is very different from merely informing patients of what needs to be done. In self-management, patients have a central role in determining their care and therefore, foster responsibility for their health. Research validates that informative education alone does not lead to behavioral change (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Fortunately, there have been many changes in the DSME curriculum and programs that clearly identify the components and self-management skills required (Funnell et al., 2010). SRs validate programs incorporating behavioral and psychosocial strategies as well as demonstrate improved outcomes (Duke et al., 2009; Leeman, 2006; Lirussi, 2010; Loveman et al., 2008; Magwood et al., 2008; Wens et al., 2008). Today, DSME includes a continuous process of facilitating the knowledge, and self-management skills essential to empower diabetes self-care. This process integrates person-cenered needs, goals, and life experiences and is supported by evidence-based standards (Funnell et al., 2010). The purpose of DSME includes facilitation for informed decision-making, self-management skills, problem-solving and active collaboration with the healthcare team with the goal of improve clinical outcomes, and quality of life (Funnell et al., 2010). All of these enhancements of DSME are consistent with IOM (2001, 2002) recommendations. R
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Table 1 Helpful resources for organizational models Chronic Care Model: Agency for Health Care Research and Quality Clinical Microsystem: Materials, workbooks, and guides Patient-Focused Medical Home Guidelines by the National Alliance of Quality Care Custom program of evaluations, training, and metrics
https://www.cahps.ahrq.gov/ QIGuide/content/interventions/ chroniccaremodel.aspx http://clinicalmicrosystem.org/ materials/ http://www.transformed.com/ PPC/NCQA/contactForm-PPC ncqa.cfm?refPage=%2FPPC% 2FNCQA%2FPPC%5Fncqa2a% 2Ecfm+facilitation
SRs of structured delivery systems with organizational support The SRs support multifaceted approaches at the organizational level to better serve the chronic care needs for persons with DM. The complex nature of diabetes itself requires holistic multifaceted approaches by primary care clinicians, which require an integration of the patient into a health system that promotes long-term management. NPs providing primary care may want to consider choosing a model that best fits their present system (Table 1). Three primary examples of structured delivery systems for primary care redesign identified in the literature are the Chronic Care Model (CCM), the Patient-Centered Medical Home (PCMH), and Clinical Microsystems (CMs; Carrier, Gourevitch, & Shah, 2009a; Friedberg, Lai, Hussey, & Schneider, 2009; Nutting et al., 2007; Wasson et al., 2005). A brief description of these models and the evidence follows.
The CCM The CCM was first identified in the 1990s and is also known as the Wagner CCM (Coleman, Austin, Brach, & Wagner, 2009; Siminerio et al., 2006; Sunaert et al., 2009). Researchers claim that deployment of the CCM addresses the major issues required in chronic care and the gaps identified by the IOM (Coleman et al., 2009; Siminerio et al., 2006; Sunaert et al., 2009). The premise of the model is that quality care is not delivered in isolation but (a) interfaces with the community and its resources, (b) includes self-management support, (c) shifts how care is delivered within the HCS, (d) is based on decision support and evidence, (e) is driven by clinical information systems, and (f) is offered in settings and/or organizations that value chronic care (Figure 1). The result of this shift in the focus of care is a productive interaction between a proactive practice team and prepared activated person with diabetes that drives clinical care and improves the quality of life (Tsai, Morton, Mangione, & Keeler, 2005). Sunaert et al. (2009) reported that incor354
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porating even a few components of the CCM into an HCS or clinic may serve to enhance care of chronic conditions. The conceptual framework of the CCM exemplifies an entire system change by providing patient-centered chronic care (Sunaert et al., 2009; Wagner et al., 2005). The model shifts care from the biomedical model of disease orientation to whole person integration of biological, psychological, and sociological factors. The CCM patient centeredness focal point seeks to develop a therapeutic alliance to understand the patients’ experience and readiness to incorporate health promotion. The end result is informed activated patients and providers engaged in health promotion and self-management (Wagner et al., 2005). CCM evidence. The Health Resources and Services Administration, Health Disparities Collaboration (HDC), and the Improving Chronic Illness Care Collaborative provide information about implementation challenges and the sustainability of the CCM (Coleman et al., 2009). Improved patient care and short-term process outcomes were noted and sustainable over 1 year, however no statistically significant intermediate outcomes were reported (Coleman et al., 2009). Coleman et al. (2009) reported that expanding the studies to 3 years, showed significant improvements in intermediate outcomes such as A1C and the cholesterol low-density lipoprotein. The HDC included more than 700 community health centers serving a population of 9.6 million and demonstrated average reductions of A1C level from 10.5% to 8.6%. Although these internal organizations self-reports do not meet rigorous research standards, they did report positive results that impacted a significant number of patients (Coleman et al., 2009). Nutting et al. (2007) reported on small independent primary care practices where clinicians employed elements of CCM. These practices were able to demonstrate significantly lower A1C values (p = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (p = .02). For every unit increase in clinician-reported CCM use (e.g., from “rarely” to “occasionally”), there was an associated 0.30% reduction in A1C value and 0.17 reduction in the lipid ratio. Thus clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care (Nutting et al., 2007).
The CM The CM model includes an improvement framework that also responds to the IOM call for systems redesign.
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Leadership At Multiple Levels Community resources and linkages Partnerships to develop and support tailored interventions for diabetes management Vision and ability to promote and manage diabetes interventions Advocacy for public policy change Performance standards for diabetes education and management Financing for diabetes education and management training Collaborative/coordination philosophy Quality control/improvement philosophy
Delivery System Design Service arrangements/contracts Methods for referral to DSMT Team members and roles Case/Care/Demand management Centralized/decentralized services Appointments, follow up, other procedures Coordination and methods for referral to community resources and assistance programs Quality control/improvement processes
Clinician/Team Characteristics
Prepared, Proactive Practice Team Productive Interactions and Encounters
Clinical Decision Support Guideline selection and development (ADA recognized DM education program, ADA clinical recommendations for care, AADE basic 7 and others) Guideline tailoring, updating, dissemination, and education of team Cultural competence Certification, continuing education of staff Protocols/critical pathways/prompts Access to specialists, referrals Expert support
Informed, Activated, Patients Patient and Family Characteristics
Clinical Information Systems Performance data related to desired outcomes Methods for documenting and tracking care and self-management Reminder systems for patients and providers Facilitate individual care planning with flow charts, algorithms
Patient Self-Management & Decision Support Education and activation about health issues Assessment of assets and resources for selfmanagement Goal setting, action planning, problem solving Information about service arrangements and resources Reminders of service needs, goal progress Reminders to bring needs to the attention of clinicians (proactivity) Tracking and follow-up for adherence and control of diabetes Patient held records for tracking care and outcomes Updates for patients on new guidelines for care
Outcomes
Figure 1 Strategies to improve outcomes. (Used with permission of Sage Publications. From Magwood, G. S., Zapka, J., & Jenkins, C. (2008). A review of systematic reviews evaluating diabetes interventions: Focus on quality of life and disparities. The Diabetes Educator, 34(2), 242–265.)
The microsystem has been defined as small groups of clinicians that collaborate to provide care to a specific population of patients (Nelson et al., 2002, 2008). This CM often has similar clinical and business aims, interrelated processes, and common information systems with clinical performance measures. The CM may be part of a larger HCS (macrosystem) or a unique independent clinic. The CM (or clinic) is considered the hub of the critical framework for building larger health systems (Nelson et al., 2008; Wasson et al., 2008). The CM design includes the four Ps: (a) patient population served, (b) clinicians who collaborate (providers), (c) processes used to provide care, and (d) functional structure of the clinic (program) (Nelson et al., 2008). Similar to the CCM, the CM multifaceted approach includes support for self-management, clinical decision support, delivery system design, and clinical information systems. The focal point of a microsystem is productive interaction between an informed, activated patient and prepared, activated clinical staff (Nelson et al., 2008). Again, self-management support is deemed essential and is enhanced by the therapeutic alliance and collaborative partnerships between patients and clinicians.
The CM framework includes QI methods, theories, tools, and techniques and can be easily accessed online (Table 1; Dartmouth Institute, 2011). Utilization of process maps to evaluate healthcare practice for improvement is essential to the CM design. An increasing number of providers are adopting the CM model because of the helpful and accessible templates and tools for patients with DM. CM evidence. There is a paucity of research on the CM, perhaps due in part to the ease of transforming the model templates for deployment into private practice and microsystems within larger organizations as QI projects, which are not reported. One multisite clinical research trial, the Spine Patient Outcomes Research Trial (SPORT), modeled on the Spine Center microsystem has demonstrated improvement in the standards of care for SCI (Ditunno et al., 2003).
Patient-Centered Medical Homes The PCMH model has existed since 1967 and has recently become the focus of healthcare reform discussion 355
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(Carrier et al., 2009b; Rosenthal, 2008). The PCMH original focus was a primary healthcare team, lead by a physician. This has evolved to be more inclusive with NPs now recognized as primary care providers (PCPs) and team leaders (National Alliance for Quality Care, 2005 Symposium, 2005; Rothman, Hansen-Turton, & Valdez, 2011). The PCMH is a provider guided, patient-centered model of health care constructed to revitalize primary care practices and improve patient care. The framework of the PCMH includes: (a) holistic patient-focused proactive care; (b) a relationship with a consistent long-term PCP; (c) a team providing primary care provided lead by the PCP; (d) clinical excellence enhanced by the integration of information technology, CPG and QI tracking; and (e) enhanced patient access with expanded hours; enhanced communication and care via the internet and telephonic follow-up care. Teamwork is a cornerstone of the PCMH and the team typically includes the PCP; registered nurse; clinical associate, such as a licensed practice nurse or medical assistant; and clerical support person. The model is proactive as each team member looks ahead of upcoming appointments and plans needed actions to assure optimal care. For example, a team member evaluates the medical record prior to visits to assure all diagnostics and patient follow-up phone calls are completed. The model enables care to focus on prevention steps to improve health and prevent disease. The focal point of the PCMH is productive interaction between an informed, activated patient and prepared, activated clinical staff. PCMH evidence. A majority of studies on the PCMH were found to incorporate different components making evaluation difficult (Carrier et al., 2009b; Rosenthal, 2008). The National Demonstration Project and Pennsylvania initiative for diabetes population provide information about implementation challenges and the sustainability of the PCMH (Crabtree et al., 2010; Gabbay, Bailit, Mauger, Wagner, & Siminerio, 2011). The statewide Pennsylvania initiative for diabetes population was implemented to include the PCMH guided by the CCM in a multipayer insurance system (Gabbay et al., 2011). A total of 105 practices, representing 382 PCPs, were included and demonstrated significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors; Gabbay et al., 2011). There were also statistically significant improvements in clinical outcomes for blood pressure and cholesterol levels, with the highest-risk patients demonstrating the greatest improvement (Gabbay et al., 2011). Rosenthal (2008) reviewed more than 200 publications and several books, which included original research, meta-analysis, or pro356
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gram evaluations and concluded the greatest challenges to implementation is the resulting increased costs for collection of outcome data and the lack of reimbursement for increased access and communication modes.
Provider strategies and tools There are numerous strategies and tools to deploy when building holistic partnerships with patients for enhanced DM care. Three evidence-based organizational models of care and DSME have been described to assist NPs toward program development to enhance patientcentered health care in their practices. It is beyond the scope of this article to review all strategies and tools. Strategies such as self-monitoring of blood glucose, dietary and physical activity are recognized as cornerstones of diabetes control and key components in present DSME programs and thus were not included in this review. Herein is an overview of a few of the holistic behavioral and educational strategies and tools with suggestions for application into clinical practice. Some of the major barriers to implementation or the translation of evidence into practice include lack of time to research methods, resources needed for planning and implementation, and training needs for staff skill development (Jennings, 2004). Recall that QI is a continuous process that includes adjustments leading to improvements for better outcomes. The same skills used to help patients change their behavior can also be used to change clinical practice. One suggestion is to begin small by choosing one action plan at a time and trial it with a pilot group. Use of Deming’s (2000) Model of Improvement, called the Plan Do Study Act (PDSA) is a sequence of team formation, aim setting, planning, and change implementation to guide QI. Weekly team huddles and monthly evaluations augment the PDSA process. Investing in enhancing staff and team members’ skills will also ensure success. Another concern might be intervention costs. When viewed in the context of pay-for-performance and accountable care organizations this becomes a moot consideration as it is well known that evidence-based, quality care results in good outcomes. For example, a 1% drop in A1C has been associated with a 10% reduction in diabetes-related deaths and a 25% reduction in microvascular endpoints (Turner, Cull, & Holman, 1996). The Trust for America’s Health (2008) found that investing in prevention programs saved $9.90 for every dollar spent when compared to treatment programs. These numbers were achieved by analytically factoring in diseases in several chronic conditions secondary to implementing preventative health programs. Clearly, mitigating or ameliorating DM complications would increase the
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value of healthcare dollars while simultaneously decreasing the amount spent on acute care.
Diabetes self-management skill building and patient engagement It is important for patients to learn to manage their disease but the ultimate goal of DSME is to support the adoption of healthy behaviors. DM requires major changes in behaviors and self-management skills to prevent complications and improve outcomes. The most significant difference between health promotion and disease or illness prevention is the motivation for the behavior (Pender et al., 2005). In this case, health promotion is motivated by the need to function optimally and to feel well. Disease prevention includes the desire to avoid illness or prevent complications of disease. NPs are knowledgeable in health promotion, education, and use of behavioral models for change and empowerment.
The Healthy Interactions Conversation Map Program. The Healthy Interactions (Healthy I) Conversation Map program and education tools are one strategy easily deployed for DSME. This program engages people in meaningful conversation about their health (Healthy Interactions, 2009). The methods of deployment include group sessions where learners focus on topics they are interested in with open discussions, which lead to the integration of life experiences in an interactive process. The Conversation Maps include five colorful interactive fun topic game maps on (a) diet, (b) disease process, (c) blood glucose monitoring, (d) gestational DM, and (e) complications (i.e., acute and chronic). The curriculum is approved by the ADA and based on CPGs (Funnell et al., 2010). The Healthy I theoretical underpinnings include the Health Belief Model, the Common Sense Model of Health and Illness Self-Regulation, the Social Learning Self-efficacy Theory, and Adult Learning Principles (Healthy Interactions, 2009). The training for the maps and curriculum can be found online (Table 2) for nurses, pharmacist, and dieticians. Once training is completed, the box of maps and facilitator guide books and game cards are mailed to the facilitator free of charge. NPs are already skilled in health promotion and prevention and can easily deploy this program within their practices for DSME in group visits. The end result is informed activated patients empowered with self-management skills, which ultimately lead to improved outcomes.
Group visits Group visits are another strategy for system redesign based on the CCM. Shared medical appointments and group visits appear synonymous as described in the lit-
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Table 2 Helpful resource for provider strategies Healthy Interactions Conversation Map: education tools and program The Stanford Chronic Disease Self-Management Program Motivational Interviewing: resources Group Visits: California Association of Family Physicians Group Visits: Transformed
http://www.healthyinteractions. com/conversation-mapprograms http://patienteducation.stanford. edu/programs/cdsmp.html http://motivationalinterview.net/ clinical/index.html http://www.familydocs.org/newdirections-diabetes-care/toolsand-resources/group-visits.php http://www.transformed.com/ Perspectives/GroupVisits-E. Shahady.cfm
erature and will be referred to in this article as “group visits” (Clancy, Huang, Okonofua, Yeager, & Magruder, 2007; Jaber, Braksmajer, & Trilling, 2006; Kirsh et al., 2007; Riley & Marshall, 2010). In group visits, several patients (6–20) are seen by a multidisciplinary team in 1–2 h appointments. The team can include a minimum of the provider and one other team members such as (a) medical assistant, (b) RN, (c) Certified Diabetes Educator (CDE), (d) dietitian, (e) behavioral specialist, (f) pharmacist, or (g) a peer lay support leader. Group visit agendas vary and may include DSME sessions, group discussion on topics of interest, foot exams, and a review of recent laboratory results. The Conversation Map program is another strategy that can be implemented during group visits. Group visits require patients’ consent for confidentiality concerns (Table 2). Group visits include individual visits with the provider in order to meet requirements for reimbursement. Group visits allow providers to efficiently meet with groups of patients with similar conditions to provide information, peer support, and lead open discussions about the chronic condition for self-management skill building (Bartley & Haney, 2004).
Diabetes teams No one clinician can provide all the care needs for patients, therefore working in teams may enhance patient care. Teams and “teamlets” are discussed extensively in CCM, CM, and PCMH models (Friedberg et al., 2009). A team consists of a group of clinical staff who work together with the common goal of helping patients achieve improved health. The core team or teamlet include the provider and a medical assistant and/or a nurse. Teams can integrate many other consultants and experts as needed or as available, such as a pharmacist, CDE or a podiatrist (Figure 2). The team meets and communicates regularly about the care of a defined group of patients (i.e., huddles). The focus of the team includes holistic 357
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Diabetes Health Care Team
Primary Care Provider (NP or MD)
Patient (and family)
Health Coach
Community
Partners Church, Support Groups,
CDE, RN or LPN
Consultants
Medical Assistant
Nephrology
Podiatry
Neurology
Psychology
Cardiology
Social Worker
Vascular
Health Educator
Ophthalmology Optometry
Exercise Physiologist
Dentist/ Hygienist
Physical Therapy
Lay Peer Leader
Employer Groups
Diabetologist Advanced Diabetes Management (ADM)NP/Pharmacist
Endocrinologist
Figure 2 Diabetes health care team.
integration of biological, psychological, and sociological factors to enable a therapeutic alliance with patients, which will help to empower and enhance selfmanagement skills. Team members assume the responsibility as the “health coach.” Health coach core skills often include (a) setting the agenda, (b) discussing DM care, (c) teaching about medication reconciliation, (d) closing the loop by follow-up phone calls or visits, (e) using 358
behavior action plans (MacGregor et al., 2006) and supportive encouragement for self-management.
Motivational Interviewing Motivational Interviewing (MI) is a counseling strategy that has demonstrating success (Spahn et al., 2010). MI is a communication health coaching technique that serves
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to empower, motivate, and help move patients through the stages of change toward making a healthy behavior change (Miller & Rollnick, 2002). Theoretical underpinnings of MI include the Trans Theoretical Model (TTM) of behavior change (Prochaska & Norcross, 2001) and social cognitive theory (Bandura, 2004). The TTM is a cyclic evolutionary process where individuals may recognize a need for change (knowledge) and based on readiness stage may act, prepare, or contemplate action. Individuals that do not identify the problem are not aware and thus do not intend to change. These individuals are considered to be in the precontemplation stage of change (Prochaska & Norcross, 2001). However, even in the stage of precontemplation, one may wish to change, but has not identified the need to do so. In this case, the use of “conscious rising” as a process may help to move individuals to the stage of contemplation (Prochaska & Norcross, 2001). MI techniques use understanding of TTM to help move patients through these stages to action. The spirit of MI is (a) empathetic, with active listening to understand the patients view; (b) evocative, to guide and support self-efficacy with a focus on success building skills; and (c) collaborative, to support autonomy and goal building skills. Nurses often use components of MI techniques such as open-ended questions, affirmation, reflection, summaries (OARS) in their daily practice. Patients and groups of patients respond to MI techniques (Spahn et al., 2010).
Behavioral action plans Behavioral actions plans are a means of working with patients for agreement to make healthy changes. Behavioral action plans are used to negotiate behavioral changes to focus on, using your expertise and the patients’ desires. Behavioral action plans focus on one or two actions goals. They are used as a contract or planning guide for specific, measurable, time frame goals. They require exploring barriers and challenges to success and are often used for benchmarking to stimulate action planning. Behavioral action plans are incorporated as a tool to implement health promotion change behavior (MacGregor et al., 2006).
Conclusion The complex treatment regimens for DM require integration of best practice, behavioral as well as biomedical strategies and tools. Several organizational models of care as well as health promotion behavior strategies were introduced for application into DM healthcare partnerships with patients. Ultimately, it is the patients who have a right to accept or refuse whatever care is offered (Cody,
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2006). Holistic care includes respect for individual rights to autonomy and use of evocation guidance and support for self-efficacy with a focus on success building skills. There is a critical need for NPs to translate the evidence into practice and champion holistic health care to evolving paradigms and thus significantly improve our nation’s health. As the prevalence of DM continues to escalate, the HCS and providers are challenged to provide best practice care to meet the IOM aims. NPs have demonstrated excellent outcomes (Bauer, 2010; Newhouse et al., 2011) and are well positioned to make important contributions to shift the paradigm of care toward more holistic patient-centered methods. Challenged to become the healthcare providers patients choose, NPs must embrace and translate evidence-based cutting edge psychosocial healthcare strategies and tools. This care must engage patients in therapeutic partnerships (alliances) with emphasis on empowering to develop self-management skills, which promotes health.
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