Overview and Framework
Research shows that self management programs improve diabetes care. Most of this research has been in academic medical centers, but will these programs work in the real world?
To answer this question, the Diabetes Initiative of The Robert Wood Johnson Foundation demonstrated that self management programs can be implemented successfully in primary care and community sites around the country. The 14 sites of the Initiative include urban, rural, frontier, and Indian Country settings; Latino, African American, American Indian, and white populations – all representing groups experiencing substantial health disparities.
The Task of Self Management
Managing diabetes is a “24/7” job for the rest of an individual's life. Practice guidelines recommend 3–-4 medical appointments a year – about two hours for the average patient. For the remaining 8,764 hours a year, an individual with diabetes is responsible for managing his/her disease – taking medicines as prescribed, measuring blood sugar and adjusting medications accordingly, eating a healthy diet, getting regular physical activity, and avoiding or managing stress and negative emotions. All of this needs to be incorporated into the complex routines of family, workplace, and daily life.
What Individuals Need
To accomplish this, they need Resources & Supports for Self Management:
- Continuity of quality clinical care
- Individualized assessment
- Collaborative goal-setting
- Key skills both for disease management and healthy behaviors such as healthy eating, physical activity, and healthy coping
- Ongoing follow-up and support to help people adjust their plans as problems arise, stay motivated, and see their providers when they need to
- Community resources, e.g., for purchasing healthy foods or getting physical activity in safe, attractive environments
Key Lessons Learned
Self Management Is Central to Diabetes Management Resources & Supports for Self Management encourage healthy eating, physical activity, and healthy coping, which are critical to diabetes management. That is why they need to be central to diabetes care, not just an add-on if time and resources permit.
The individual who receives only updated medications and tests from a physician a few times a year is receiving care that is far less than state-of-the-art.
Many Good Practices Rather than Few Best Practices
Individuals receiving very little or no care is a major problem in diabetes. Reaching and engaging people with diabetes require offering a variety of ways to learn skills and receive follow-up and support. Choice is key!
As do individuals, healthcare settings and communities have different resources, needs, capacities, and challenges. Resources & Supports for Self Management can be implemented in ways that fit their settings and their populations–through physicians and nurses, group classes, community health workers or promotoras, interactive e-health interventions, or community organizations and partnerships.
Regardless of specifics, what is important is that those to be served must be able to choose among a variety of appealing, easily available ways in which they can learn the skills they need in order to carry out their diabetes self management.
Attention to Stress, Depression, and Healthy Coping are Key Parts of Self Management
Managing negative emotions is important in diabetes management. A range of strategies to address these include support groups, self management classes, supportive community health workers, counselors on the diabetes care team, medication, and as-needed referral care. But healthy coping isn’t just for the few. All individuals can benefit from improving their coping skills, and all 14 Diabetes Initiative grantees are incorporating this aspect of self management into their programs.
Ongoing Follow-Up and Support
Ongoing follow up and support for when patients have questions about their diabetes they need convenient access to someone they can talk to. At the same time, they need to be contacted periodically to see how they are doing, even if they haven’t checked in with their diabetes team. Thus, routine contacts by the healthcare team as well as “as needed” options for patients are key to sustained self management. Again, choice is key!
Infrastructure Needs to Support Self Management
Programs for self management will not prosper if they rely on the heroic efforts of a few staff members. Rather, organizational factors and system features need to facilitate consistent and high-quality provision of self management services. The Diabetes Initiative has developed a tool, Assessment of Primary Care Resources and Supports for Chronic Diseases Self Management, that can be used by teams wishing to improve self management supports in their settings.
Community Health Workers (CHWs) Can Play a Central Role
Called by a number of names (“promotora,” “coach,” “lay health worker,” etc.), CHWs play a variety of roles in diabetes care. These include (a) instruction in key skills for self management and problem-solving to apply self management plans in daily life, (b) emotional support and encouragement, and (c) facilitating effective communication among patients and their healthcare teams. They offer unique services and functions not provided by traditional healthcare teams. To date, CHWs are used primarily in programs that serve underserved populations. Their contributions to high-quality diabetes care would be beneficial to all adults with diabetes.
Clinic-Community Partnerships
Clinics, community organizations, and other groups can develop partnerships to extend the range and variety of opportunities and supports for self management. These reflect the reality that diabetes management takes place in daily life, not in clinics. Grantees have identified key characteristics of effective partnerships and tools for assessing their benefits.
Read more about our Lessons Learned
