According to the most recent estimates, more than 29 million Americans—or slightly more than 9% of the population—have diabetes. Nearly 2 million new cases of diabetes are diagnosed each year, highlighting the need for greater prevention efforts. When managing patients with diabetes and those at risk for the disease, the American Diabetes Association recommends that clinicians strive to provide patient-centered care, consider diabetes across the life span, and serve as advocates for patients with diabetes.
“A key management strategy for patients with diabetes is to recognize that one size does not fit all,” says Alka Kanaya, MD. “When following evidence-based guidelines for managing the disease, it’s important to adapt care based on each individual patient’s specific characteristics.” Because patients with diabetes are also at higher risk of heart disease, a patient-centered approach should be used. This includes a comprehensive plan to reduce cardiovascular risk by addressing blood pressure (BP) and lipid control, smoking cessation, weight management, and healthy lifestyle changes that include adequate physical activity.
Fragmented Care Delivery Systems
In addition to taking a patient-centered approach, improving coordination between clinical teams is critical as patients pass through different stages of life. “Ongoing efforts are needed to prevent the complications that can occur in patients with type 2 diabetes,” Dr. Kanaya says. “Studies suggest that there has been steady improvement in the proportion of patients achieving recommended levels of A1C, BP, and cholesterol in the last 10 years, but many patients still do not meet their personal targets. Variations in quality of diabetes care have persisted, indicating that there is potential to improve care delivery systems.”
A major barrier to optimizing care is a delivery system that is often fragmented, highlighting the need to use collaborative approaches to managing patients. The Chronic Care Model (CCM) has been shown to be an effective framework for improving the quality of diabetes care and is recommended by the American Diabetes Association (Table 1). The CCM model advocates moving from a reactive to a proactive care delivery system in which planned visits are coordinated through a team-based approach. The CCM also involves self-management support, decision support, and community resources, among other features. “It’s important to clearly define the roles of clinical staff and promote self-management practices,” adds Dr. Kanaya.
The National Diabetes Education Program’s 3 Key Objectives
The National Diabetes Education Program (NDEP) maintains an online resource to help clinicians design and implement more effective healthcare delivery systems for those with diabetes. The NDEP outlines three specific objectives for clinicians: 1) optimize provider and team behaviors, 2) support behavioral change for patients, and 3) change the care system (Table 2).
To optimize provider and team behavior, the care team should prioritize timely and appropriate intensification of lifestyle and/or pharmaceutical therapy for patients who have not achieved targeted A1C, BP, and cholesterol levels. Goals should be set explicitly with patients and language or cultural barriers to care should be identified and addressed.
A systematic approach should also be set to support and educate patients with regard to behavioral changes. “We should harness technology using text messages, applications, and the electronic health record as tools to help patients when they’re outside the care of their clinicians,” says Dr. Kanaya. “Technology can help with various aspects of diabetes care, including healthy lifestyle changes, self-management, and prevention of complications.” Attention should also be paid to the emotional concerns that patients with diabetes may experience.
To improve quality of diabetes care, the American Diabetes Association recommends that institutions redesign the care process to actively advocate for patients. “Patients should be educated about their disease and efforts should be made to remove potential financial barriers,” Dr. Kanaya says. “Reducing out-of-pocket costs for education, self-monitoring of diabetes-related complications, and medications is important. As a whole, we’re behind the curve with regard to optimizing diabetes management. We need to take a more organized, systematic approach and involve a coordinated team of dedicated professionals in which patient-centered, high-quality care is the top priority.”
Meeting Diabetes Treatment Goals
Despite the best efforts of healthcare providers, some patients may still not achieve desired treatment goals. When such cases occur, Dr. Kanaya says it is important to reassess treatment regimens to identify any potential barriers to reaching therapeutic goals. Potential barriers include income, health literacy, diabetes-related distress, depression, and other competing demands. It is also important to consider patients’ culture and tailor management strategies. In some cases, referral to a medical social worker for assistance with insurance coverage and behavior assessments may be helpful. “Ultimately, we need to take a holistic approach and make every effort to prevent diabetes complications before they emerge,” says Dr. Kanaya.
Readings & Resources (click to view)
American Diabetes Association. Strategies for Improving Care. Diabetes Care. 2015;38:S5-S7. Available at: http://care.diabetesjournals.org/content/38/Supplement_1/S5.full.
American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2014;38:S1-S93. Available at: http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/Documents/January%20Supplement%20Combined_Final.pdf.
Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999-2010. N Engl J Med. 2013;368:1613-1624.
Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:E26.