Building Competency in Diabetes Education THE ESSENTIALS

Building Competency in Diabetes Education THE ESSENTIALS

Copyright ©2019 Canadian Diabetes Association. All rights reserved. 1300-522 University Avenue, Toronto, Ontario, M5G 2R5

ACKNOWLEDGEMENTS |

ACKNOWLEDGEMENTS

Fifth edition revised and updated by Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada

Barbara Cleave RN MN CDE

Violeta Nikolova RN MscHQ CDE

Karen Gorecki RN MN CDE

Christine Opsteen NP-Adult MN CDE

Christie Hamilton RD CDE

Jennifer Sampson RD CDE

Gail MacNeill BNSc RN MEd CDE

Expert Reviewers The authors wish to acknowledge and thank the following expert reviewers for their contributions:

Lori Berard RN CDE

Henry Halapy BScPhm PharmD ACPR

Nancy Cardinez MN-NP CDE

Stephanie Henry NP MN CDE CFT

Carolyn Christo RD CDE

Arlene Kuntz BSP CDE

Darcy Dowsett RN CDE

Janelle Lopez RN MScN (pending) CDE

Marcelo Falappa CRC

Sarah Moore BScN MN RN(EC) CDE

Denice Feig MD MSc FRCPC

Rema Sanghera RD MA CDE

Celia Fredericks RN MScN CDE

Diana Sherifali RN PhD CDE

Jeremy Gilbert MD FRCPC

Bernard Zinman CM MD FRCPC FACP

Diabetes Canada Staff Erin Bankes BSc (Hon.) Tracy Barnes MA MJ Stephanie Boutette RD MPH

TABLE OF CONTENTS

TABLE OF CONTENTS

CHAPTER 1: Introduction

CHAPTER 2: Foundations for Diabetes Self-Management Education & Support

CHAPTER 3: Pathophysiology

CHAPTER 4: Changes Across the Lifespan

CHAPTER 5: Treatment Modalities - Lifestyle

CHAPTER 6: Treatment Modalities - Pharmacological Therapies

CHAPTER 7: Monitoring Glycemic Management

CHAPTER 8: Acute Complications of Diabetes

CHAPTER 9: Chronic Complications

CHAPTER 10: Gestational Diabetes Mellitus

CHAPTER 11: Self-Management Education & Support – Program Development

CHAPTER 12: Basal-Bolus Insulin Therapy

Chapter 1

INTRODUCTION

• Diabetes management: The Essentials

• Background

• Statement of purpose of The Essentials

• Objectives of The Essentials

• How to use The Essentials

• Content in The Essentials

• Discussion forum

INTRODUCTION| 1-3

DIABETES MANAGEMENT: THE ESSENTIALS

Diabetes is now considered a world health challenge. In 2017, the International Diabetes Federation estimated that 425 million people were living with diabetes worldwide and projected that, by 2045, there will be 629 million people living with diabetes (1). Canada is contributing to this challenge with an estimated 44% increase expected in the prevalence of diabetes from 2015 to 2025. This translates into an estimated 3.4 million Canadians or 9.3% living with diabetes in 2015 to over 5 million or 12.1% living with diabetes in 2025 (2). The estimated prevalence rate for prediabetes is also expected to increase with 6.4 million Canadians or 23.2% of the population living with prediabetes by 2025 (2). The impact of these statistics on the Canadian population and health-care system cannot be ignored. People with diabetes are three times more likely to be hospitalized with cardiovascular disease, 12 times more likely to be hospitalized with end stage renal disease and over 20 times more likely to be hospitalized with non-traumatic lower limb amputation (2). However, as daunting as these statistics are, research continues to inform us that we can make a difference. The Diabetes Control and Complications Trial, the United Kingdom Prospective Diabetes Study and the Diabetes Prevention Program are three landmark studies that demonstrate how lifestyle changes and blood glucose in target range can prevent or delay the progression of diabetes and its complications (3-5). Recently, we are particularly encouraged with the results of several cardiovascular outcome trials showing a clear benefit of some newer oral diabetes medications in preventing cardiovascular death and all-cause mortality in patients with type 2 diabetes (6-8). With these promising research results, one wonders why the prevalence of diabetes continues to increase. The answer lies in the chronic nature of diabetes and the essential elements for treatment. When we realize that the patient with diabetes spends less than 5% of their time with a health-care professional, we begin to understand that a key element necessary for successful diabetes treatment lies in the informed practice of self-management (9). Working with a collaborative, interdisciplinary, patient-centred approach, diabetes educators have the responsibility to teach their patients the knowledge and skills necessary to engage in self management (10,11). We also have the responsibility to support the patient as they engage in their care. The ultimate goal is to effectively facilitate each patient’s informed decision making process resulting in the best possible management of their diabetes. The educator is required to translate research findings, use effective communication strategies and use appropriate educational tools to educate and support the patient in their individualized care.

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The Building Competency in Diabetes Education: The Essentials (The Essentials) manual was developed to assist the educator in this endeavour. It is intended to inform the educator of the basics involved in self-management education (SME) and self-management support (SMS), emphasizing that although knowledge is a necessity, how this knowledge is transferred by the educator and implemented by the patient is the ultimate challenge. The content in this manual supports the integration of the Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (2018 Guidelines) into every day practice. Welcome to the art and science of diabetes management.

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BACKGROUND

This manual is supported by the members of the Professional Section Executive of Diabetes Canada (formerly the Canadian Diabetes Association) who support excellence in the practice of SME and SMS. Over the past several decades, Diabetes Canada and the Diabetes Educator Section (now part of the Professional Section of Diabetes Canada) have initiated and participated in a range of projects to support excellence in the practice of SME and SMS. These include, but are not limited to, the following: • The Canadian diabetes educator certification process was developed between 1989 and 1991. It is now a self-regulating body administered through the Canadian Diabetes Educator Certification Board (CDECB) and offers both an examination for initial certification and a credit portfolio option for recertification. • Standards for Diabetes Education in Canada (12) were developed through an extensive consensus-building process from 1991 to 1995 and culminated in a full recognition program (the Diabetes Education Standards Recognition Program), which was launched in 1997. This program was revised in 2001, 2008 and 2014 to reflect changes in the recognition process (13). • The Framework for Diabetes Education for Health Professionals (a core curriculum for workshop development) was published in 1997 (14). • The annual professional conference, held in partnership by Diabetes Canada and the Canadian Society of Endocrinology and Metabolism (CSEM) brings together educators, clinicians and scientists to share their expertise, ideas and experiences with other health care professionals. The conference provides the latest information regarding diabetes and related research. Diabetes Canada and the CSEM have also previously partnered with the International Diabetes Federation and with the Canadian Vascular Society for their respective annual conferences, providing a comprehensive program for all health-care professionals involved in the field of diabetes management. • Professional publications and journals, such as the Canadian Journal of Diabetes, are supported by the Professional Section Executive of Diabetes Canada. o The Canadian Journal of Diabetes is Canada’s only indexed, diabetes-oriented, peer reviewed, interdisciplinary journal for diabetes health-care professionals. It is published eight times a year by Elsevier.

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o The Diabetes Communicator is a newsletter that provides information on the activities of Diabetes Canada professional members and disseminates relevant, practice based information to the Professional Section members across Canada. It is published four times a year. This manual, The Essentials , was first added to this group of initiatives in 2001. It originated from the previous resource for professional education, The Framework for Diabetes Education for Health Professionals (14). We are grateful to the original authors of this framework and trust that they will approve of our modifications and additions. The learning objectives for each chapter were established collaboratively by the original Professional Development Committee, and then reviewed by the authors and the Professional Development Committee. They have also been compared to the International Curriculum for Diabetes Health Professional Education published by the International Diabetes Federation (15). We are grateful to those who contributed their feedback and whose suggestions have been incorporated in these revisions. This 5 th edition of The Essentials manual has been updated to reflect new evidence and the changes made in the Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (2018 Guidelines). How these changes will affect the delivery of our care is a question that will need to be answered by every diabetes educator as they engage in their practice. In this edition, we have also incorporated and updated some information previously found in the Building Competency in Diabetes Education: Advancing Practice manual. The Advancing Practice manual will no longer be published as a separate entity, but modules will be developed for more intensive review of some topics previously found in the Advancing Practice manual. It is our sincere hope that you will find the information in this 5th edition of The Essentials manual invaluable as you engage in the journey of learning the essence of diabetes self-management education and support. Diabetes Canada 2018 Clinical Practice Guidelines Canada has been a leader in the development of evidence-based clinical practice guidelines since the initial publication of Diabetes Canada’s 1992 clinical practice guidelines (2). These guidelines represent the results of a stringent, interdisciplinary effort to ensure excellence in the care of persons with diabetes. New this year in the 2018 Guidelines is the expanded harmonization with several other sets of guidelines which impact the treatment of patients with diabetes, particularly in regard to co-morbidities or special circumstances. This addition also draws authors from more diverse backgrounds, including informed people living with diabetes. Also, for the first time, key messages for people with diabetes have been included in each chapter. The 2018 Guidelines include specific information on:

INTRODUCTION| 1-7

• Diagnosis and assessment • Organization of care • Healthy lifestyle management • Complications • Special issues in the treatment of: o Children: type 1 and type 2 o Adolescents: type 1 and type 2 o Indigenous peoples o The elderly

o Diabetes in pregnancy o Driving and diabetes

These guidelines reflect the ethnocultural diversity in Canada and demonstrate the concern for the rights and responsibilities of all persons living with diabetes. They emphasize the need for an effective working relationship between the diabetes health-care (DHC) team and the person with diabetes and stress that patients should be fully informed about their condition and its potential complications. Diabetes SME and SMS are accepted as the primary means for achieving these goals (9-11,16). It is recognized that the care and support for people living with diabetes also requires an entire organized system that incorporates the person, the health-care professionals, the community and the government. The Chronic Care Model is endorsed in the 2018 Guidelines and in this manual as a systematic organization of care which reflects and articulates the many facets involved in the management of chronic disease (17,18).

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STATEMENT OF PURPOSE OF THE ESSENTIALS

This manual is designed to provide education for the novice diabetes educator and for health care professionals seeking to increase their knowledge and skills related to diabetes SME and SMS. 1. This manual is intended to be a self-study manual and resource. It is designed to be complementary to courses, programs, workshops and other sources of diabetes SME and SMS — not a complete, encyclopedic resource. 2. This manual is not intended as a textbook or a study guide for certification for the experienced educator; it has not been developed in collaboration with the CDECB. However, the authors have attempted to address most of the competencies listed for Certified Diabetes Educator (CDE) status, and members of the board of the CDECB have previously acted as peer reviewers for these manuals. Many educators have reported using The Essentials to assist them in preparing for the CDE exam.

INTRODUCTION| 1-9

OBJECTIVES OF THE ESSENTIALS

Completion of this manual should enable the learner to: 1. Develop a basic competency in the knowledge and skills necessary to educate patients in the self-management of their diabetes. 2. Identify key strategies to facilitate the patient’s behaviour change process. 3. Identify appropriate resources for further knowledge and skill development in diabetes SME and SMS.

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HOW TO USE THE ESSENTIALS

• This self-study manual is designed for independent learning and takes into account the principles of adult learning. • Specifically, it must be assumed that readers will be self-directed and prepared to engage in this independent process. Readers’ self-assessment or perceived “need to know” will guide their progress through the manual. Practical applications, based on real-life situations from clinical practice, are presented in each chapter. • A comprehensive final evaluation accompanies the manual. Readers may complete this evaluation and send it to guidelines@diabetes.ca, as evidence that they have achieved the specified learning objectives. A certificate of completion will be awarded to demonstrate successful completion of this course of study. • Every effort has been made to provide the most current information in as complete a form as possible. However, this manual is not intended to be a textbook on diabetes. The reader must assume responsibility for obtaining recommended reading references to augment the information included here. • Updates to the 2018 Guidelines are available on the Diabetes Canada guidelines website (guidelines.diabetes.ca). Please check this site regularly for any interim updates. We hope this manual will help novice educators acquire the skills essential to this complex process and start them off well on the road to expertise.

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CONTENT IN THE ESSENTIALS

The authors hope to build on the current level of knowledge and skill that readers bring from their past experience. The content is organized in logical sequence from simple to more complex and this manual follows the traditional order of many diabetes texts. Critical core behaviours required for SME and SMS for people with diabetes and their support systems are traditionally grouped into the following topics: • Information that answers the questions: “What is diabetes?” and “What does diabetes mean to me?” • How to identify and treat symptoms of high blood glucose and low blood glucose. • How to monitor glycemic control and other health parameters. • Nutrition for healthy living. • Activity and exercise for healthy living. • Pharmacological interventions. • Information on screening, prevention and treatment for chronic complications. • Information on diabetes through the lifespan. • How diabetes is experienced in special populations, i.e. pregnancy, elderly. • Psychosocial adjustment and stress management. • How to find and use health-care resources for effective diabetes management. Chapters 2 to 9 contain the learning content essential to beginning a career in SME, while the remaining chapters build on this information at a more advanced level. It is now recognized that the goals and strategies of intensive diabetes therapy are the gold standard for diabetes practices throughout Canada. This may be better labelled advanced self management , but it is now the standard we all must strive for — educator and patient alike. It may not be feasible or appropriate for all persons with diabetes to achieve all of the goals of optimal diabetes care, but all educators must be prepared to engage in this process. Optimal diabetes care should not be for a select few; it should be patient-centered and individualized for everyone affected by diabetes. As diabetes educators, we acknowledge that there are many components to the successful delivery of care. We can advocate for, and with our patients, for inclusion of these elements. However, we also realize that our primary responsibility, and where we can really make a

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difference, is in helping our patients work towards informed self-care. If we do our part with dedication, perseverance and passion, it will be the foundation from which to build. Please use the information in this manual to help inform your decisions. In any clinical practice, there must also be the realization that decisions are not solely based on one aspect of care, i.e. knowledge. The ingredient of ‘clinical judgement’ must be added to make an informed decision. As Dr. Hertzel Gerstein has stated: “ Neither evidence nor clinical judgement alone is sufficient. Evidence without judgement can be applied by a technician. Judgement without evidence can be applied by a friend. But the integration of evidence and judgement is what the health-care provider does in order to dispense the best clinical care” (19).

INTRODUCTION| 1-13

DISCUSSION FORUM

Reflection is an essential ingredient for best practice. As you begin your learning journey, please take a moment to reflect on where you are beginning. 1. What areas have you found to be the most difficult when educating your patients about their diabetes? a. What skills and/or tools do you feel would help you improve in this area? 2. What do you feel is the most significant barrier your patients are experiencing in dealing with their diabetes self-management? a. How do you feel you can most effectively help patients in overcoming their barriers? 3. What are your goals as you begin working with this manual?

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REFERENCES

1. International Diabetes Federation. IDF Diabetes Atlas, 8th ed. Brussels: International Diabetes Federation, 2017. http://www.idf.org/diabetesatlas. Accessed August 13, 2018. 2. Houlden RL. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Introduction. Can J Diabetes 2018;42(Suppl 1):S1-S5. 3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86. 4. United Kingdom Prospective Diabetes Study (UKPDS). Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes. (UKPDS 34). Lancet 1998;352:54-865. 5. Diabetes Prevention Program Research Group. 10 year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:77-1686. 6. Cefalu WT, Kaul S, Gerstein HC, et al. Cardiovascular outcome trials in type 2 diabetes: Where do we go from here? Reflections from a Diabetes Care editors’ expert forum. Diabetes Care 2018;41:14-31. 7. Schnell O, Rydén L, Standl E, Ceriello A, D&CVD EASD Study Group. Updates on cardiovascular outcome trials in diabetes. Cardiovasc Diabetol 2017;16:128. 8. Paneni F, Lüscher TF. Cardiovascular protection in the treatment of type 2 diabetes: A review of clinical trial results across drug classes. Am J Med 2017;130(Suppl 6):S18-S29. 9. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Care 2013;36(Suppl 1):S100-S108. 10. Sherifali D, Berard L, Gucciardi, E, MacDonald B, MacNeill G. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Self Management Education and Support. Can J Diabetes 2018;42(Suppl 1):S36-S41. 11. Rasekaba TM, Graco M, Risteski C, et al. Impact of a diabetes diseases management program on diabetes control and patient quality of life. Popul Health Manag 2012;15:12-9. 12. Diabetes Educator Section, Canadian Diabetes Association. Standards for Diabetes Education in Canada. Toronto: Canadian Diabetes Association, 2008. 13. Diabetes Canada. Diabetes Education Standards Recognition Program Manual: A Quality Assessment Tool for Diabetes Education Programs. 2014.

INTRODUCTION| 1-15

14. Canadian Diabetes Association, Diabetes Educator Section. Framework for Diabetes Education for Health Professionals. Toronto: Canadian Diabetes Association, 1997. 15. International Diabetes Federation. International Curriculum for Diabetes Health Professional Education. Brussels: International Diabetes Federation, 2008. 16. Clement M, Filteau P, Harvey B, et al. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Organization of Care. Can J Diabetes 2018;42(Suppl 1):S27-S35. 17. Coleman K, Austin B, Brach C, et al. Evidence on the chronic care model in the new millennium. Health Aff 2009;28:75-85. 18. Baptista DR, Wiens A, Pontarolo R, et al. The chronic care model for type 2 diabetes. A systematic review. Diabetol Metab Syndr 2016;8:7. 19. Cheng A. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Introduction. Can J Diabetes 2013;37(Suppl 1):S1-S3.

Chapter 2

FOUNDATIONS FOR DIABETES SELF MANAGEMENT EDUCATION & SUPPORT

• Introduction to educational principles and strategies

• Discussion of self-management education and support in the context of diabetes management

• Definitions of concepts involving self-management education and support

• Introduction to learning principles

• Introduction to behaviour change theory

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OBJECTIVES

Completion of this chapter should enable the learner to do the following: 1. State the value of self-management education and support in the treatment of diabetes. 2. Describe the key concepts of self-management education and support in the treatment of chronic disease. 3. Compare and contrast empowerment and compliance-based approaches to education. 4. Define the terms education, learning and teaching . 5. Describe the taxonomy of educational objectives as it relates to levels of self-management education. 6. Define selected theories underlying the practice of self-management education and support. 7. Demonstrate how such theories apply to the practice of self-management education and support. 8. Describe how the recommendations in the “Self-Management Education and Support” chapter in the Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (2018 Guidelines) can apply to your practice.

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EDUCATIONAL PRINCIPLES AND STRATEGIES

The overriding aim of this manual is to provide novice diabetes educators with the essential knowledge, skills and motivation to participate in educational interventions that meet the Standards for Diabetes Education in Canada (1) and the recommendations contained in the 2018 Guidelines. With the increasing complexity of chronic disease management, the practice of SME (self-management education) and SMS (self-management support) has grown exponentially. The educators’ skills must increase accordingly. To meet this need, relevant information from the previous Building Competency in Diabetes Education: Advancing Practice manual has been updated and included in this workbook, making this manual a valuable resource for the more experienced educator, as well as the novice. Since 2008, the Diabetes Canada (formerly the Canadian Diabetes Association) clinical practice guidelines have included a full chapter on the design and application of SME.

New to the 2018 guidelines is the recognition that self management education needs to be reinforced and supported on an ongoing basis in order for the person with diabetes to truly initiate and integrate any behaviour change. This chapter is now entitled: “ Self-Management Education and Support”.

The discussion and exploration of the many complex SME and SMS issues is presented in two parts, beginning in this chapter and continuing in Chapter 11: Self-Management Education and Support: Program Development. This division is intended to facilitate learning of this challenging topic, beginning with definitions and concepts of SME and SMS, leading into behaviour change theories and the basic objectives of educational interventions. Chapter 11 continues with educational strategies and the constructs essential for the development of programs and services supporting diabetes management.

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SME and SMS interventions may take many forms, from public lectures to coping-skills counselling; from self-injection skills to multimedia technology. They may be designed for population health (targeting an entire population at risk) or an individual living with diabetes (2).

Throughout all the chapters, there will be reference to the activities and strategies of SME and SMS that are unique or most relevant to the topic. This reinforces the concept that knowledge is a valuable tool, but how this knowledge is translated and applied by the person with diabetes is the most important process. We will start our discussion by briefly reviewing the context within which we are facilitating SME and SMS. As stated previously, there are many factors involved in the successful management of chronic disease. The 2018 Guidelines highlight the Chronic Care Model (CCM) as a framework for an organized approach to population health and public health initiatives in diabetes care (3). It is necessary for all educators to understand how SME and SMS contribute to this evolving model and how collaboration with as many elements as possible leads to the greatest chance of success (4-9). Further exploring the essentials of SME and SMS, this chapter introduces several major educational and psychosocial models that seek to explain human behaviour and learning; they form the foundation for the development of diabetes SME and SMS interventions and services. We hope you will keep these models and principles in mind as you work through this manual, reflecting on how you can facilitate your patient’s learning of the same material. Definitions For the purposes of this manual, we will use the following definitions to guide the discussion. Patient-centered care : Care provided in a manner that respects and reflects the individual’s needs, preferences and values; a patient’s values direct decisions (10). Self-management : The active participation of individuals in achieving their best health and wellness. This involves gaining the confidence, knowledge and skill to manage physical, social, and emotional aspects of life in partnership with health-care teams and community supports (11). Self-management education : A systematic intervention that involves active patient participation in self-monitoring of health parameters and/or decision making (managing). It involves the ongoing process of facilitating the knowledge, skills and ability necessary to

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develop self-care behaviours. It is recognized that a collaborative patient-provider approach with the application of problem solving skills is an essential component in this process (2,12). Self-management support: A range of activities offered by organizations, communities and providers that support self-management behaviours across the lifespan and are not necessarily specific to educational processes. These may include behavioural, educational, psychosocial and/or clinical strategies (2,10-13). Self-management training: Teaching the skills necessary to manage diabetes.

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CHRONIC DISEASE MANAGEMENT

The diagnosis of diabetes has a ‘ripple effect’. Although education and support for patient centered care is the primary focus for this manual, it is recognized that there are many other components which influence the ability to successfully manage diabetes. Over the past several decades, it has become evident that we cannot use the same methods to treat chronic disease as we have been using to treat acute disease. Within the wider scope of practice, we need to consider the way we are delivering our health services, how we are supporting and communicating with our health-care providers, and how electronic information systems can add value to our practice (14,15). Beyond this, there are community factors and government health policies which have the ability to help or hinder successful management. We now realize that chronic disease management requires “multi-pronged strategies” in order to be effective (9,15-17). It is a slow process to adapt our provincial health systems to chronic disease management. The clinical aspect in the delivery of chronic care needs should be revamped for sustainability and coordination, and other elements that have a greater influence on prevention and population health must be reviewed. Several models have been proposed, each with a different focus yet the same goal: to improve chronic care management using an integrated systems approach (18,19). The most robust of these models and the one that has more evidence-based outcomes is the CCM (9,20-22). This model clearly identifies the relationship between the various elements involved in chronic disease management (15). Of particular note is the key message that ‘diabetes care should be delivered using as many elements as possible of the Chronic Care Model’ (15,23). The “Organization of Diabetes Care” chapter in the 2018 Guidelines clearly outlines how the: CCM model as a multifaceted, interdependent framework to improve health-care delivery from prevention to advanced management can be used in diabetes care (14,15). An original model proposed by Wagner et al. illustrates how chronic disease is best managed by productive interactions between informed, activated patients and prepared, proactive health teams (24). Barr et al. expanded this original model, enhancing the elements of community participation and incorporating the social determinants of health (15). This expanded CCM model highlights the need for partnerships between health systems and communities which provide a core element to the successful management of chronic disease (9,15,21,25). The essential elements of the CCM model are illustrated in Figure 1.

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Figure 1. The Expanded Chronic Care Model: Integrating Population Health Promotion

Reprinted from Diabetes Canada 2018 Clinical Practice Guidelines (14)

With its current application to chronic disease management, the CCM is considered not only an organization of care model, but also a quality improvement strategy (14). Evidence to date suggests that when the CCM has been used as a template to redesign practice, there have been significant improvements in health outcomes (7,9,21). Studies have found reduced rates of cardiovascular disease, better processes for delivery of care, higher levels of patient satisfaction, lower health care utilization and improved clinical outcomes when elements of the CCM model have been introduced in diabetes management (7,21,23,26,27). There is, however, a need for further research to evaluate the cost effectiveness of the model, the time frame for implementation and the process outcomes. Although it has been noted that not all the elements of the model have had the same success, evidence supports the fact that the self-management component has been the most effective element in improving outcomes (8,19).

As educators, our main task is to work within a prepared, proactive practice team to help develop productive interactions and relationships which result in an informed and activated patient (15,24) .

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Viewing the comprehensive design of the CCM, diabetes educators can understand that SME alone is not sufficient to ensure success. However, we can also see that this is an excellent starting point where we can use our knowledge, skills and collaborative practice approach to engage our patients to become active agents in their own health (28).

Table 1. Core elements of the expanded chronic care management model

1. Delivery-system design/reorient health services

• Multidisciplinary teams, expanding roles of educators, case management, system navigators • Cluster visits, shared care linking providers • Technology support, telehealth, reminder systems

2. Self-management/ develop person skills

• “Behaviorally sophisticated self-management support that gives priority to developing patients’ confidence and skills so that they can be the ultimate

manager of their condition” (7) • Delivery focused around SME • Individual portals, websites, interactive technology

3. Decision support

• Prompted access to clinical practice guidelines, decision algorithms

4. Information systems

• Shared clinical information among all care providers through electronic medical records, registries • Reminders, tracking systems

5. Health system organization of health care

• Provincial strategies, funding policies • Outcome evaluation systems, accreditation • Standards

6. Strengthen

• Resources available • Community supporters • Community partnerships

community action

7. Build healthy public policy

• Provincial strategies, funding policies • Outcome evaluation systems, accreditation • Standards

8. Create supportive environments

• Parks available with bicycle paths • Green space for safe walking

Adapted from Barr et al. (15)

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COLLABORATIVE PRACTICE

With the increasing complexity of health-care needs for people with diabetes, it is becoming more evident that patients require multiple services delivered by a coordinated health-care team (29,30). Terms, such as “multidisciplinary”, have been used for many years to describe

the use of health-care professionals (HCP) from different disciplines working with the patients. A newer initiative that implies a much greater degree of interaction and a more integrated team is referred to as interprofessional collaborative practice (ICP). ICP has been shown to improve health outcomes through a partnership between a team of health-care providers and a client in a participatory, collaborative and coordinated approach to

“Collaborative practice happens when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care” (35).

“shared decision making” (29,31-34,27-30). Previously, we had been delivering fragmented care; each HCP doing “their part” (35). In collaborative practice, we work together. We see patients together, we share our knowledge, our skills and respect the contribution of each discipline, working towards a mutually decided upon goal. Descriptions, such as “synergistic influence of grouped knowledge and skills”, and “blending of professional cultures” have been used to explain the integrated approach in ICP (31-36).

The benefits to ICP include (32,33,35,36): • More accessible care. • Improved outcomes for people with chronic illness. • Less conflict with caregivers and care teams.

• Better use of clinical resources. • Easier recruitment of caregivers. • Greater staff satisfaction.

Collaborative practice may be introduced and developed differently for each health-care system. However, there is agreement that interprofessional education (IPE) is a starting point to foster the growth and acceptance of collaborative practice (34-36). The Canadian Interprofessional Health Collaborative has outlined six competency domains they consider essential in all IPE (34):

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Figure 2. Core competencies for collaborative care (34)

Person- centered care

IP conflict resolution

Role clarification

COLLABORATIVE CARE

IP communication

Team functioning

Collaborative leadership

Examples of IPE recently introduced are cross professional mentoring programs, multiple professional group education and ‘team’ rather than ‘discipline’ training. The concept that those who train together stay together is resulting in a more integrated, collaborative approach to care.

“Interprofessional education occurs when two or more professions learn about, from, and with each other to enable effective collaboration” (35).

Health Force Ontario engaged in an interprofessional care project and wrote an extensive report entitled a “Blueprint for Action” (32). In this report, it is suggested that IPE should be an integral part of the foundation for the integration of interprofessional care into existing infrastructures (32). Building on this education, professions need to review their standards of

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practice to develop support for the sharing of responsibility. The task force emphasizes that we need to reassess our systems, processes and tools to identify and, if necessary, create systemic enablers. With these approaches, we can then lead sustainable cultural change where the nature and value of IPC will be integrated into all aspects of health care (32,37).

A paradigm that shifts towards partnership care, consisting of two main components collaborative care and self-management education that are conceptually similar but clinically separable would facilitate better clinical outcomes (38).

Note: As you continue to read through this chapter and this manual, please consider how you can change your practice to embrace and engage in interprofessional collaborative care for the benefit of your patients.

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COMPLIANCE VS. EMPOWERMENT

In diabetes self-management, the empowerment approach to care and education has gained widespread support among educators. It has become a hallmark of all chronic disease management models being widely implemented, as provincial and/or managed care organizations attempt to develop strategies that help society and patients cope effectively with the growing and chronic burden of diabetes (26,39-42). Traditionally, individual education programs were usually based on a compliance model of care where a patient is expected to follow a prescription supplied by a health-care provider (43). In the same way, diabetes education was typically organized around structured content designed by an expert provider and delivered using didactic teaching methods. The compliance model is based on the principle that the health-care provider is responsible for a patient’s health choices, and the patient is responsible for following the health-care provider’s recommendations and/or decisions. It has since become obvious that people do not necessarily act, learn or change their behaviour simply because a health professional prescribes a therapy. Actual behaviour change is much more complex, and the self-care behaviours associated with chronic conditions, such as diabetes, are even more so (10,12). Not only are self-care prescriptions imperfect and complicated, but: Clinicians often estimate that more than 99% of care decisions are made outside of the practice/office setting, where independent patient decision-making is essential (12) .

Compliance

• A prescription defined by a health-care provider must be followed. • “This is what you need to do” … and it is done … and it should work. • It is implied that if it doesn’t work, it’s the patient’s fault.

As the need for advanced self-management skills gained recognition, the “empowerment” approach has evolved, which is now the driving philosophy behind SME and SMS (10-12,42,43). The techniques of persuasion, traditional education and advice-giving, which have been shown to have limited effectiveness when it comes to chronic health issues, are no longer the tools of choice. Using an empowerment approach, a person is able to make informed decisions and

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take action based on his or her awareness of possible consequences (30,43-45). This approach is based on the understanding that adult learners: • Are self-directed and responsible for themselves. • Have an inherent drive for growth and health. • Possess self-awareness.

Empowerment

• “Process designed to facilitate self-directed behaviour change”. • Helping patients discover and develop the inherent capacity to be responsible for one’s own life. • Philosophy: Patients have choices, control and consequences. • Goal: Informed choice (44,45).

Empowerment is not so much a type of intervention as it is a philosophy and process that guides an educator’s perspective regarding interventions (12,45). It involves a fundamental shift in the roles and responsibilities of both the patient and the health-care provider. The health-care provider must see the patient as an equal partner and be willing to accept that the patient has the ultimate control and power over decision-making. This shared decision- making approach ensures a greater individualization of goals, an equal exchange of information, and advocates for patient involvement in all aspects of their care (45,48). Adults are more likely to make and maintain behaviour changes if changes are personally meaningful and freely chosen (46). An empowering conversation has a very different approach recognizing that it is the person’s internal drive to change that must be nurtured. The key features of empowering interventions include the 5 As (47): • A cceptance (unconditional, positive regard)

• A ffect (exploring the emotional content of a problem) • A utonomy (decision-making by the person with diabetes)

• A lliance (providing help and information for informed decision-making) • A ctive participation (participation and active listening by both/all parties)

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Initially, the superiority of the empowerment approach was challenging to demonstrate via traditional research methods. However, as it was implemented and trialled, it became evident that the empowerment approach is essential for successful diabetes management (12,30,32,47,49). Programs using this approach have resulted in more patients achieving the target A1C of less than 7%, decreased utilization of outpatient services and improved quality of care (42). Patients need to be knowledgeable and proactive in their decision-making and understand the consequences of their informed choice. This can best be achieved through the empowerment approach. Currently, it is the gold standard of practice and has been widely adopted (3,10,12). The patient/family-centred care movement rests on this key principle: collaboration through the empowerment approach with patients and families to form true partnerships is essential (42,50,51).

Table 2. Paradigm Shift

Medical Model

Self-Management Model

Health professional authority

Patient is in charge

•

•

Patient education is prescriptive

Patient is self-directed

•

•

Goals set by professional

• Goals set by patient in collaboration with HCP

•

Education designed for compliance

• Education to facilitate informed decision making

•

Choice, control and consequences

•

Adapted from Anderson & Funnell (45)

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SELF-MANAGEMENT EDUCATION AND SUPPORT

Essential concept of SME and SMS Diabetes presents many challenges to patients and their families. Through studies, such as DAWN (Diabetes Attitudes, Wishes and Needs) and DAWN2, the burden of diabetes on the patient, their family and their community has been better understood (51,52). We realize that living well with diabetes requires a positive psychological approach and considerable stamina. Since diabetes is a chronic illness, it continues to present new challenges and changing requirements over time so patients need to be flexible and be able to adapt to change (10,12). To be successful, they are required to learn a body of knowledge, coping skills and essential self-management skills which require ongoing reinforcement and support (3,12). SME and SMS are processes that can be used to achieve the goal of living well with diabetes (12,35,53-56). SME involves the teaching-learning process designed to help patients, families and groups gain the knowledge, behaviours, attitudes and skills required for self-management. Planned educational experiences with a strong patient-provider collaborative approach have proven to be most effective in supporting the SME process (3,38,55,56). A diagnosis of diabetes generally involves significant changes in lifestyle behaviours and patients view such changes through unique perspectives. The development of behaviour change goals and their implementation is one of the most difficult tasks in learning to live well with diabetes. Patients require ongoing support as they make changes towards a healthier lifestyle. SMS is the integral component necessary to achieve and sustain behaviour change with the ultimate goal being successful self-management (12). SMS can include many diverse activities involving the extended community and beyond which influence the ability of the person with diabetes to continue in their self-management behaviours (3). SME and SMS for persons affected by diabetes takes place in many different settings and formats and is facilitated by individuals from many different disciplines. Each profession brings a unique perspective and contribution to the educational and support process.

In all circumstances, SME and SMS should be individualized, taking into consideration the type of diabetes, the patient’s ability, the patient’s motivation for learning and change, their cultural and literacy level and their preferences (3).

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Educational interventions should be a collaborative effort designed with an interactive approach to facilitate person-centered goals (3). Likewise, SMS should reflect the patient’s specified needs to support their self-management behaviour (3). Both SME and SMS should meet the standards of practice set forth by Diabetes Canada, specifically from the Standards for Diabetes Education in Canada (1) and the 2018 Guidelines (2). Timing of SME and SMS Given that diabetes is a chronic disease, it is understandable that education and support requirements may change over the course of the disease. However, the timing of the education and support is critical as proven by studies which show that patients who attend an education class within one year of their diagnosis have a greater decrease in A1C (2,57). Patients have reported that their education at the time of diagnosis was extremely important in their success in their self-management (57). To add to this, research has identified four critical points where patients are most likely to require an assessment, reassessment and/or significant change in their treatment plan; at time of: 1. Diagnosis 2. Annual assessment 3. Development of complications 4. Transition period (pregnancy, insulin initiation, etc.) (10) Each of these time periods may require a different focus or message embedded in the education and support given. For example, at the time of diagnosis, the educator is emphasising adjustment and the beginning development of coping skills. During the annual assessment, the need for screening is reviewed and the prevention of complications is a focus. If complications have developed, the discussion may center on psychosocial support. Throughout the life cycle of living with diabetes, the educator has the responsibility to assess the timely need for education and support, to collaborate with the patient as to their priorities, and to facilitate the development of self management behaviours to improve outcomes (40).

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SELF-MANAGEMENT EDUCATION

History and practice One of the most perplexing issues in chronic disease management and educational literature is a lack of standardization as to what is involved in self-management, SME, SMS, self management training . We have defined these entities, but we need to go further. Since education is at the heart of our profession, we must be clear as to how we are applying the standards to practice. The evolution of terminology follows the evolution of the empowerment approach. Self management itself refers to the involvement of the patient in his/her care, and this is not in debate (13); it is who provides the education, where, when and how that remains inconsistently defined in the various chronic disease self-management publications and models. It has also been difficult to articulate the benefits of this education, as the studies are often comparing very heterogeneous programs. In 1991, the Canadian Diabetes Association (now Diabetes Canada) Diabetes Educator Section (DES) belief statement noted that diabetes education “enables individuals with diabetes to make choices and take actions based on informed judgement and understanding of possible consequences”. This definition incorporated the essential characteristics of empowerment, but remained provider-focused. The term SME became more widely used in practice in the place of diabetes education as we moved away from a compliance approach. However, the term remains poorly understood and is used interchangeably with self-management training and SMS (which often refers to peer-led support programs for type 2 diabetes, diabetes registries or electronic patient portals). A major challenge for educators and their associations is to gain consensus and clarity on the essential components of SME. In the initial “Self-Management Education” chapter in the Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management for Diabetes in Canada , SME refers to a comprehensive educational behaviour change program that provides intervention(s) over a lifetime of living with diabetes and combines both educational and psychological interventions delivered by a multidisciplinary team, including peer members (58).