Mary L. O'Toole

Patient-Centered Goal Setting as a Tool to Improve Diabetes Self-Management

PURPOSE The purpose of this article is to describe the process of collaborative goal setting as a means to improve diabetes self-management in primary care. METHODS The Self-Management Goal Cycle framework illustrates a model of care for patients with diabetes. The Big Bad Sugar War is an approach to patient counseling that includes background, barriers, successes, willingness to change, action plan, and reinforcement. RESULTS Planned visits occur when a medical assistant performs routine health checks and laboratory tests prior to traditional individual appointments. Mini-group medical visits occur when a provider and medical assistant meet with 3 patients at one time. Open office group visits occur when 7 to 12 patients attend 2-hour sessions staffed by a provider. DISCUSSION Collaborative goal setting is a valuable tool for improving self-management skills among patients with diabetes. By implementing goal setting techniques, members of the patient care team are better equipped to help patients manage their chronic conditions by making them valued partners of the health care team.

Teaching How, Not What The Contributions of Community Health Workers to Diabetes Self-Management

PURPOSE The purpose of this study is to describe ways in which community health workers (CHWs) are used in various clinic and community settings to support diabetes self-management. METHODS Descriptive quantitative data were collected from logs completed by CHWs. Logs described mode, place, type, duration, and focus of individual contact between the CHW and the patient. Qualitative data were collected from semistructured interviews with patients. Interviews were conducted on site from June to August 2006. Interviewees included a purposeful sample of 47 patients who perceived being helped by CHWs. RESULTS CHWs reported providing assistance and teaching or practicing skills as the focus of most of the 1859 individual contacts. The assistance CHWs reported providing was most often in the form of encouragement/motivation. During interviews, patients shared that CHWs were helpful in demonstrating how to incorporate diabetes self-management (DSM) into their daily lives. The information patients shared also provided insight into what they perceived as encouragement/motivation from the CHWs. Quotes from interviews provide specific examples of how support from CHWs was different from that received from family and health care team members. CONCLUSIONS Both CHWs and patients perceived assistance being provided in similar ways, with consistent emphasis on encouragement/motivation. Interviews with the patients revealed that a personal connection along with availability and provision of key resources and supports for self-management made the CHW-patient interaction successful for DSM. Examples provide insight into the valuable contributions of CHWs to DSM. This insight should encourage guidelines that make CHWs a routine, standard part of the diabetes care team.

Integration of a promotora-led self-management program into a system of care

PURPOSE The purpose of this article is to describe the integration of a promotora-led self-management component into a system of care and assess the influence of this program on indicators of metabolic control over time. METHODS Gateway Community Health Center is a federally qualified health center in Laredo, Texas, that serves a predominantly Hispanic population. Gateway integrated self-management support into care for people with diabetes by incorporating promotora-led self-management services into the clinic structure, operations, and patient visits. The self-management program included education, goal setting, depression screening with symptom follow-up, and support groups after course end. Indicators of metabolic control, HbA1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were compared at baseline and at 12 months. RESULTS The integration of promotora-led self-management services into the system of care allowed for continual improvements of self-management services in response to patient needs. Patients enrolled in the self-management course showed improved indicators of metabolic control that were sustained over time, and they reported a high level of goal achievement. CONCLUSIONS The integration of the promotora-led self-management program into diabetes care at Gateway generated a system of referral, follow-up, feedback, and documentation that produced consistently high-quality clinical care.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

Move More Diabetes Using Lay Health Educators to Support Physical Activity in a Community-Based Chronic Disease Self-Management Program

PURPOSE The purpose of this article is to describe Move More Diabetes (MMD), which is used by Lay Health Educators (LHEs) to promote physical activity and improve diabetes self-management among individuals with type 2 diabetes. METHODS Move More Diabetes used social marketing strategies to choose and segment the target audience, develop messages, and determine message delivery. Based on market research results, MMD chose natural peer support from LHEs as the main intervention strategy. RESULTS Move More Diabetes built a sustainable volunteer network of 35 LHEs who recorded 1500 contacts with enrollees from 2004 to 2006. Participation improved when the program was not specific for diabetes. CONCLUSION The MMD program demonstrated benefits of partnership and natural peer support and the utility of social marketing in planning and implementing a community-based chronic disease self-management and physical activity promotion program. This low-cost program can serve as a model for other rural communities interested in increasing physical activity to address chronic disease.

Starting a Diabetes Self-Management Program in a Free Clinic

PURPOSE The purpose of this project is to develop and implement a system of care for people with type 2 diabetes in a free clinic setting. METHODS This project was conducted in the Homestead/Florida City community at the Open Door Health Center (a free clinic for the uninsured poor). Through a grant from the Robert Wood Johnson Foundation Diabetes Initiative, organizational and programmatic changes were made to improve care for patients with type 2 diabetes. Program participation and clinical data, incorporation of healthy practices and programs in other community organizations, and the success of collaborations were evaluated to judge program success. RESULTS Critical factors for providing health care for persons with type 2 diabetes in a free clinic setting were identified. These included reviewing and organizing medical records of patients with diabetes, developing a system that made efficient use of limited staff resources, finding an educational approach appropriate for the population served (ie, Popular Education), involving patients in self-management support roles by providing them the opportunity and training to become peer mentors, and developing strong community partnerships to complement and reinforce self-management. CONCLUSION Creation of a successful system of care for patients with diabetes in a free clinic setting is possible through innovative collaboration and creative program design.

The Business Case for a Diabetes Self-Management Intervention in a Community General Hospital

There is a growing and increasingly compelling body of evidence that self-management interventions for persons with type 2 diabetes can be both effective and cost-effective from a societal perspective. Yet, the evidence is elusive that these interventions can produce a positive business case for a sponsoring provider organization in the short term. The lack of a business case limits the enthusiasm for provider organizations to implement these proven quality-enhancing interventions more widely. This article provides a case example of a self-management intervention in a community general hospital targeting an underserved population who have significant barriers to receiving regular health care. The 3-component program sought to improve meaningful access to care, increase health literacy related to type 2 diabetes, and partner with the enrollees to make long-term lifestyle changes. The intervention not only resulted in significant improvements in HbA1c levels (-0.77%) but saved the hospital an average of

Use of the transtheoretical model to enhance resources and supports for diabetes self management: Lessons from the Robert Wood Johnson foundation diabetes initiative

551 per active patient per year, primarily by reducing hospital visits. With only 255 actively enrolled patients, the hospital can recover fully its total direct annual personnel and operating costs for the program. Because the program serves patients who would have been seen at other hospitals, it also enhanced care quality and reduced costs for the broader community in which the program is embedded.

Physical Activity Levels Among Participants in the Robert Wood Johnson Foundation Diabetes Initiative

PURPOSE The purpose of this article is to describe how Resources and Supports for Self Management (RSSM) and strategies of the transtheoretical model (TTM) intersect to produce a comprehensive approach resulting in cutting-edge diabetes programs. METHODS Specific components of RSSM, especially individualized assessment, collaborative goal setting, and enhancing skills, are reviewed in terms of contributions to the TTM. RESULTS Specific examples from the Diabetes Initiative of using TTM constructs from 5 projects are shown to illustrate the first 3 RSSM constructs: individualized assessment, collaborative goal setting, and skill building. CONCLUSION Diabetes Initiative grantees have demonstrated that the TTM enhances RSSM and facilitates the adoption of good diabetes self-management behaviors.

Ecological Approaches to Self-Management: The Case of Diabetes

Abstract Objective. The purposes of this study were to describe physical activity habits of individuals with type 2 diabetes participating in a self-management initiative conducted in real-world settings that was sponsored by the Robert Wood Johnson Foundation (RWJF); to assess changes in physical activity over time; and to identify factors associated with physical activity levels. Research design and methods. Clinical and community-based programs participating in the RWJF-funded Diabetes Initiative implemented comprehensive models for self-management, including supports to increase physical activity. A cohort of 622 largely lower-income and ethnic minority program participants (72% female, 85% overweight or obese) completed telephone surveys assessing self-reported physical activity levels at two times that were about 8 months apart. Results. Approximately 70% of participants who reported being inactive at Time 1 reported at least some physical activity at Time 2. Approximately 29% of participants who reported insufficient activity at Time 1 increased their activity enough to meet current public health guidelines at Time 2, whereas 28% of those who were sufficiently active no longer met the guidelines. Sufficient physical activity was associated with greater intervention intensity; being male, younger, and speaking English; and having greater self-efficacy, a lower BMI, and a health care provider who assisted in finding physical activity resources. Conclusions. Personal, behavioral, and program factors were related to physical activity levels among participants in these comprehensive self-management programs.