Diabetes Group Visit Toolkit

4. Core 4 - Self-Management

 

As health care providers we can encourage, support, and recommend strategies to improve the health and wellbeing of our patients. The responsibility of day to day care rests with the patient. Self-management strategies are difficult to maintain and require significant lifestyle changes across multiple targeted behaviors; diet, exercise, self-monitoring, and medication compliance are a few examples. There are multiple barriers to optimal self-management. These include difficulty maintaining motivation and confidence. The process of change is challenging and as providers we need to assess the patient’s awareness of the problem with their behaviors. It is important to explore possible solutions and help them see that the benefits outweigh the costs.

Stages of Change

Before we can talk about self-management we need to talk about the stages of change. The stages of change are precontemplation, contemplation, preparation, action, maintenance, and termination. Understanding these stages can help health care providers assess a patient’s readiness for change and use appropriate strategies to help them progress to the next stage. Each stage is described below along with processes that encourage progression to the next stage.

1. Precontemplation: “There is no problem, and therefore no need to change”

      • Consciousness-raising: increasing awareness and insight about oneself and the problem, and about the self-defeating defenses that get in one’s own way
      • Social liberation: providing social support for change (e.g., values statements, cultural norms)

2. Contemplation: “There is a problem – I’ll deal with it one day”

      • Emotional arousal: evoking positive feelings about the change you are contemplating.
      • Self-re-evaluation: taking stock of your current situation and recognizing that the change you are contemplating would substantially improve your life

3. Preparation: “There is a problem – and I’m going to deal with it soon – and I’ve even started to make small changes”

      • Commitment: choosing to act and to believe in your ability to change

4. Action: “I am changing my behavior, and managing the associated thoughts and feelings”

      • Rewards: rewarding yourself, or being rewarded by others, for changing
      • Helping relationships: enlisting the help of others

5. Maintenance: “I am solidifying new behaviors, and guarding against relapses”

      • Countering: finding and practicing new behaviors that replace problem behaviors
      • Environment control: avoiding situations that evoke problem behaviors and choosing those that encourage new behaviors

6. Termination: “My old way of behaving no longer holds any attraction for me”.

“It’s time for me to take my diabetes serious. I had an aunt that just passed and I don’t want to go through what she did. My life is important, I have 8 grandbabies.”

Patient Motivation

Motivation is a key factor in the success of self-management goals.

Key components to motivation are:

 

1. Patient Conviction

How can health care providers assess and support the patient’s belief in behavior change?

    • Ask questions such as:
        • On a scale of 1-10, with 10 being Very Important, how important is it to you that you (lower your A1C, get more exercise, quit smoking, etc.)?
        • Why a 4 and not a 1?
        • What would have to happen for you to see this as more important, to move from a 4 to a 7?
    • Be specific with what you see as the anticipated outcomes.
    • Discuss how outcomes align with values and what is important to the patient.
    • Help the patient see the pros/benefits and address concerns about cons/costs.
    • Have the patient make a public commitment.
    • Highlight positive results of the changes they are making.
2. Patient Confidence

How can health care providers support the patient’s confidence in achieving self-management goals?

    • Ask questions such as:
        • On a scale of 1-10, with 10 being Very Confident, how confident are you that you can (walk 30 minutes once a day, take your medicine each morning, etc.)?
        • Why do you say 3?
        • What would have to happen for you to feel more confident, to move from a 3 to a 6?
    • Take small steps initially.
    • Identify a short-term strategy that is attainable to promote success.
    • Encourage frequent self-monitoring and regular check-ins with the care team.
    • Use positive reinforcement and celebrate achievements.
    • Add steps to the goal as their confidence grows.
3. Patient Autonomy

 

Using patient-centered communication is more effective than giving advice or instructions. It shows respect for the patient’s autonomy and competence.

    • Patients are the experts on their own lives
    • Clinicians can provide guidance to help them set their own goals
    • More motivated to perform behaviors that are chosen rather than imposed
    • Leads to personal mastery and long-term change
    • Use open-ended questions, reflective listening, and expressions of empathy

Open-ended questions

    • Allows the patient to tell their own story, including barriers
    • Helps you understand the patient’s full experience, not just the “facts”
    • Examples:
      1. How did you exercise plan go?
      2. How are you doing today?
      3. What is your routine for an average weekday?

Reflective listening

    • Allows you to check your understanding, modify as needed, check again
    • Allows your patient to clarify, re-state, sometimes re-think
    • Examples:
      1. What I am hearing you say is…..
      2. So you feel…
      3. It sounds like you….
      4. You are wondering if…..
      5. For you, it’s like…..

Expressions of empathy

    • Shows that the patient is seen, heard, and accepted
    • Focused on the patient’s experience, not about sympathy or your feelings
    • Examples:
      1. It’s been hard for you to pass up the fast food, especially after a long day at work…
      2. With all that you have to do during the day, it’s easy to forget to go to the drugstore…
4. SMART Goals

 

The SMART goal framework can help patients clarify their goals and make sure they are realistic. They will have a better chance of success with clearly defined, attainable goals.

 

Specific: What specifically will you do? What actions will you take?

Measurable: What will you measure? How will you assess if you are achieving the goal?

Achievable: Is the goal doable? Do you have the necessary time, skills, resources, etc.?

Relevant: How does the goal relate to your overall health and diabetes care? Why is the result important?

Time-Bound: What is the time frame for accomplishing the goal?

 

Here is an example:

(S) I’m going to walk briskly…

(M) …for 30 minutes…

(A) …3 days a week …

(R) …to help lower my blood sugar….

(T) …for the next 30 days.

“Every patient experienced a gain at some point during the intervention. They know that they are capable of making progress and they are worth the effort of trying to improve their diabetes management.”

Summary

  • Self-management can be overwhelming to patients.
  • Confidence, conviction, and autonomy are keys to motivation.
  • SMART goals, self-monitoring, and review of progress help maintain self-management.
  • A patient-centered approach is essential to supporting autonomy and motivating self-management.
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