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.
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? 
Community
Health Workers (CHWs) Can Play a Central Role