Extractado de: DIABETES CARE, ULTIMAS RECOMENDACIONES ADA
Critical Times to Provide Diabetes Education and Support
There are four critical times to
assess, provide, and adjust DSME/S : 1) with a new diagnosis of type 2 diabetes, 2) annually for health maintenance
and prevention of complications, 3) when new complicating factors influence self-management, and 4) when transitions in care occur .
Although four distinct time-related opportunities are listed, it is important
to recognize that type 2 diabetes is a chronic condition and situations can
arise at any time that require additional attention to self-management needs.
Whereas patient’s needs are continuous , these four critical times demand
assessment and, if needed, intensified reeducation and self-management planning
and support.
New
Diagnosis of Diabetes
The diagnosis of diabetes is often overwhelming .
The emotional response to the diagnosis can be a significant barrier for
education and self-management. Education at diagnosis should focus on safety
concerns (some refer to this as survival-level education) and “what do I need
to do once I leave the doctor’s office or hospital.” To begin the process of
coping with the diagnosis and incorporating self-management into daily life, a
diabetes educator or someone on the care team should work closely with the
individual and his or her family members to answer immediate questions, to
address initial concerns, and to provide support and referrals to needed
resources.
At diagnosis, important messages should be
communicated that include acknowledgment that all types of diabetes need to be
taken seriously, complications are not inevitable, and a range of emotional
responses is common. Educators should also emphasize the importance of
involving family members and/or significant others and of ongoing education and
support. The patient should understand that treatment will change over time as
type 2 diabetes progresses and that changes in therapy do not mean that the
patient has failed. Finally, type 2 diabetes is largely self-managed and DSME
and DSMS involve trial and error. The task of self-management is not easy, yet
worth the effort .
Other
diabetes education topics that are typically covered during the visits at the
time of diagnosis are treatment targets, psychosocial concerns, behavior change
strategies (e.g., self-directed goal setting), taking medications, purchasing
food, planning meals, identifying portion sizes, physical activity, checking
blood glucose, and using results for pattern management.
At
diagnosis of type 2 diabetes, education needs to be tailored to the individual
and his or her treatment plan. At a minimum, plans for nutrition therapy and
physical activity need to be addressed. Based on the patient’s medication and
monitoring recommendations, themes such as hypoglycemia identification and
treatment, interpreting glucose results, risk reduction, etc. may need to be
considered. Patients are supported when personalized education and
self-management plans are developed in collaboration with the patients and
their primary care provider. Depending on the qualifications of the diabetes
educator or staff member facilitating these steps, additional referrals to a
registered dietitian nutritionist for MNT, mental health provider, or other
specialist may be needed.
Individuals requiring insulin should receive
additional education so that the insulin regimen can be coordinated with the
patient’s eating pattern and physical activity habits . Patients presenting at
the time of diagnosis with diabetes-related complications or other health
issues may need additional or reprioritized education to meet specific needs.
Annual Assessment of Education, Nutrition, and
Emotional Needs
The health care team and
others can help to promote the adoption and maintenance of new diabetes
management tasks , yet sustaining these behaviors is frequently difficult.
Thus, annual assessments of knowledge, skills, and behaviors are necessary for
those who do meet the goals as well as for those who do not.
Annual visits for diabetes education are
recommended to assess all areas of self-management, to review behavior change
and coping strategies and problem-solving skills, to identify strengths and
challenges of living with diabetes, and to make adjustments in therapy . The
primary care provider or clinical team can conduct this review and refer to a
DSME/S program as indicated. More frequent DSME/S visits may be needed when the
patient is starting a new diabetes medication or experiencing unexplained
hypoglycemia or hyperglycemia, goals and targets are not being met, clinical
indicators are worsening, and there is a need to provide preconception
planning. Importantly, the educator is charged with communicating the revised
plan to the referring provider.
Family members are an underutilized resource
for ongoing support and often struggle with how to best provide this help .
Including family members in the DSME/S process on at least an annual basis can
help to facilitate their positive involvement .
Since the patient has now experienced living
with diabetes, it is important to begin each maintenance visit by asking the
patient about successes he or she has had and any concerns, struggles, and
questions. The focus of each session should be on patient decisions and
issues—what choices has the patient made, why has the patient made those
choices, and if those decisions are helping the patient to attain his or her
goals—not on perceived adherence to recommendations. Instead, it is
important for the patient/family members to determine their clinical,
psychosocial, and behavioral goals and to create realistic action plans to
achieve those goals. Through shared decision making, the plan is adjusted as
needed in collaboration with the patient. To help to reinforce plans made at
the visit and support ongoing self-management, the patient should be asked at
the close of a visit to “teach-back” what was discussed during the session and
to identify one specific behavior to target or prioritize .
Diabetes-Related
Complications and Other Factors Influencing Self-management
The
identification of diabetes complications or other patient factors that may
influence self-management should be considered a critical indicator for
diabetes education that requires immediate attention and adequate resources.
During routine medical care, the provider may identify factors that influence
treatment and the associated self-management plan. These factors may include
the patient’s ability to manage and cope with diabetes complications, other
health conditions, medications, physical limitations, emotional needs, and
basic living needs. These factors may be identified at the initial diabetes
encounter or may arise at any time. Such patient factors influence the
clinical, psychosocial, and behavioral aspects of diabetes care.
The diagnosis of additional health conditions
and the potential need for additional medications can complicate
self-management for the patient. Diabetes education can address the integration
of multiple medical conditions into overall care with a focus on maintaining or
appropriately adjusting medication, eating plan, and physical activity levels
to maximize outcomes and quality of life. In addition to the introduction of
new self-care skills, effective coping, defined as a positive attitude toward
diabetes and self-management, positive relationships with others, and quality
of life, can be addressed in DSME/S (29). Additional and focused emotional support may
be needed for anxiety, stress, and diabetes-related distress and/or depression.
Diabetes-related
health conditions can cause physical limitations, such as visual impairment,
dexterity issues, and physical activity restrictions. Diabetes educators can
help patients to manage limitations through education and various support
resources. For example, educators can help patients to access large-print or
talking glucose meters that benefit those with visual impairments and
specialized aids for insulin users that can help those with visual and/or
dexterity limitations.
Psychosocial and emotional factors have many
contributors and include diabetes-related distress, life stresses, anxiety, and
depression. In fact, these factors are often considered complications of
diabetes and result in poorer diabetes outcomes . Diabetes-related distress is
particularly common, with prevalence rates of 18% to 35% and an 18-month
incidence of 38% to 48% . It has a greater impact on behavioral and metabolic
outcomes than does depression . Diabetes-related distress is responsive to
intervention, including DSME/S and focused attention . Although the National
Standards for DSME/S include the development of strategies to address psychosocial
issues and concerns , additional mental health resources are generally required
to address severe diabetes-related distress, clinical depression, and anxiety.
Social factors, including difficulty paying
for food, medications, monitoring and other supplies, medical care, housing, or
utilities, negatively affect metabolic control and increase resource use . When
basic living needs are not met, diabetes self-management becomes increasingly
difficult. Basic living needs include food security, adequate housing, safe
environment, and access to medications and health care. Education staff can
address such issues, provide information about available resources, and
collaborate with the patient to create a self-management plan that reflects
these challenges.
If
complicating factors are present during initial education or a maintenance
session, the DSME/S educators can either directly address these factors or
arrange for additional resources. However, complicating factors may arise at
any time; providers should be prepared to promptly refer patients who develop
complications or other issues for diabetes education and ongoing support.
Transitional Care and Changes in
Health Status
Throughout
the life span, changes in age, health status, living situation, or health
insurance coverage may require a reevaluation of the diabetes care goals and
self-management needs. Critical transition periods include transitioning into
adulthood, hospitalization, and moving into an assisted living facility,
skilled nursing facility, correctional facility, or rehabilitation center.
DSME/S affords important benefits to patients
during a life transition. Providing input into the development of practical and
realistic self-management and treatment plans can be an effective asset for
successful navigation of changing situations. A written plan prepared in
collaboration with diabetes educators, the patient, family members, and
caregivers to identify deficits, concerns, resources, and strengths can help to
promote a successful transition. The plan should include personalized diabetes
treatment targets; a medical, educational, and psychosocial history; hypo- and
hyperglycemia risk factors; nutritional needs; resources for additional
support; and emotional considerations.
The health care provider can make a referral to a diabetes educator to
develop or provide input to the transition plan, provide education, and support
successful transitions. The goal is to minimize disruptions in therapy during
the transition, while addressing clinical, psychosocial, and behavioral needs
