Empowering
Your Patients to Tighter Control
Philip
Eager, M.Ed., N.C.C. Prevention/Intervention
Specialist
“I
Know what to do I just don’t do it.”
Who
hasn’t ever fallen into this common trap?
When it comes to home blood sugar monitoring the patient who just
fails to test his or her blood sugar as recommended is labeled
“non-compliant”. What
interventions or steps the doctor or diabetes educator can take to help
motivate this sort of patient to check their blood sugar with more
regularity is an important part of assisting patients to get the benefits
of tighter blood sugar control.
Not
Everyone Is a Candidate for Tighter Control
Before embarking on promoting tighter control and a routine of 3 or
more a day blood glucose monitoring it is important to decide if this is
really in the best interest of the patient who is hearing your
recommendation. Is the patient really motivated to follow this tight
intensive management? Do they understand the benefits and risks? You might
survey their knowledge.
Have
you taken the time to educate the patient about the Diabetes Control and
Complications Trial (DCCT)? Make
sure they understand it.
I recommend both talking to them and testing them to make sure they
understand the importance of good blood sugar control and their role in
it.
It
is important to ask the patient in both written and verbal form if they
agree with this and also to get their signature on a “letter of
agreement”
that
spells out the need to monitor blood sugars at least 3-4 times a day –
and when to check their blood sugars, including testing at 3AM at least
twice a month, if necessary. This will weed out people who clearly are not
ready to embark on the path to tighter control.
Persons who have a history of severe hypoglycemia or no sensation
of hypoglycemia may not be candidates for intensive blood glucose
management. Children under 13
and senior citizens also need to be closely evaluated before being put on
an intensive program.
Determining
if someone is a candidate for regular blood sugar monitoring
To help you determine who is a reliable candidate for home blood
glucose monitoring it is helpful to assess the patients level of
motivation by having them rate themselves on the following type questions:
On
a scale of 1 being least interested to 5 most interested rate yourself on
the following items:
1.
How interested are you in attaining a near normal HbA1c (6.0 -
7.0)?___.
2.
How interested are you in checking your sugar 4x or more a day?___.
3.
How interested are you in maintaining records of your blood
sugar?___.
4.
How interested are you in communicating with the diabetes care team
regarding your blood sugar results? ___.
5.
How interested are you in checking your sugars when you just
don’t feel
feel right? ___.
6.
How interested are you in feeling “good”? ___.
7.
How interested are you in avoiding diabetic complications? ___.
8.
How interested are you in gaining and maintaining good control
of your blood sugar?___.
9.
How interested are you in being in control of your diabetes?___.
10.
How interested are you in following your doctor’s advice?___.
Scoring
A.
0 -10 = Very low motivation to complete blood glucose monitoring.
B.
11- 20 = Low motivation to complete blood glucose monitoring.
C.
21 - 30 = Medium motivation to complete blood glucose monitoring.
D.
31 - 40 = High motivation to complete blood glucose monitoring.
E.
41- 50 = Very high
motivation to complete glucose monitoring.
By assessing which category A - E that the patient is in we get a
better understanding of the level of care necessary to help the patient
become motivated to perform the regular blood glucose monitoring that is
the cornerstone of a good diabetes management plan.
Plan
of Action
Before beginning to address the needs of a patient to become
“motivated” it is important to determine if they are even close to
being motivated. For Persons
in category A, it is
important to have a frank talk about the DCCT and how the patient feels
about their future? If they
are very fatalistic I would strongly suggest they seek a professional
consult with a psychiatrist, licensed psychologist, certified counselor or
diabetes educator. If they “just don’t get it”, it would be
important to have them read and see videos of people who are in good
control as a demonstration of the fact that it can be achieved.
I would also suggest a membership in a diabetes support group that
allows them the opportunity to meet with people who have gone from “poor
control” to “in control”, much
like AA affords alcoholics the chance to learn and gain meaningful support
from others who are going from “out of control” to “in control”.
Persons who are in categories B, C, or D are the primary targets of
your interventions. These
represent the majority of patients who can benefit
from
your interventions and from each others insights into glucose testing.
Those
who are in category A probably need counseling or psychological
intervention by a specialist to help them along.
Those in category E probably are doing fine already and just need
some minor suggestions (these are the sort of patients that know
themselves very well and that you can often learn a lot from).
Working with those who have low, medium, and high motivation will
help them learn from each other. How
to set this up is to schedule a regular once a month meeting,
where they can all attend - say on a Saturday.
At this meeting you will review in an open and supportive
environment a discussion on what challenges people face when it comes to
blood sugar testing. On a
wall paper page write them all down and then get some themes like - “It
is a real inconvenience”, “I don’t like other’s seeing me test in
public”, “I don’t have
the place or time”. Then
ask others to share what strategies they have used to overcome these
obstacles. The goal is get
them to learn from each other and to allow you to slip in the secrets your
expertise in a manner that says “how about this” rather than “do it
this way - I am the expert after all”.
In this class which should be no shorter than an hour and no longer
than two hours. You can go
over the benefits of good control the negative impact of poor control and
ways people feel when the have to deal with various facets of diabetes.
An educational blood sugar testing event is to have a
representative from one of the monitor companies visit to demonstrate and
calibrate meters. Or use your
own calibrated meters for this exercise.
Ask all persons to guess where their blood sugar is and to write it
on a piece of paper with their name on it.
Let them know the person with the nearest guess will win a prize
(perhaps a meal donated by a kind hearted merchant).
This demonstrates how far off people can guess. In the case of a
tie ask trivia questions about diabetes until someone misses.
Conclusion
The significance of frequent blood glucose monitoring in achieving
blood glucose control is indisputable.
It is important to determine if someone is a candidate for frequent
monitoring and tight control. By
giving the patient a survey to assess their level of motivation to test
their blood you can rule out those that either are too unmotivated or
motivated to the degree that they may not profit from your intervention(s).
Once you’ve identified common barriers it is helpful to get group
input and to offer your insights. By
having a fun blood glucose experiment that tests peoples accuracy in
guessing their blood sugar you can prove that testing is needed to make
sure your clients know where they are.
Giving much positive feedback to the patients for their efforts is
important. Letting them know
they are capable of gaining and maintaining control through consistent
testing is something that must be striven for even if it is not totally
achieved.
To learn
more, please review the feature “Motivation and Diabetes by going to
http://www.diabetesincontrol.com/feature26.htm
If
you would like to hold a Diabetes Day to address these issues and have it
sponsored by a meter company, drop us an email at diabetesincontrol@home.com
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