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Treat to target: Utilizing a patient-centered team approach
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Much time and effort has been spent on determining which HbA1c target best fits the population with diabetes. Evidence-based practice suggests that reaching HbA1c levels ≤6.5% to 7% results in improved long-term outcomes. As diabetes educators, this discussion has limited merit given that most patients with diabetes are unable to reach any given target without support.
The American Diabetes Association’s clinical guidelines state that treatment goals need to be individualized. However, individualization requires a patient-focused team approach. Regardless of which target level the provider selects — 6.5%, 7% or another — patient input in goal-setting is critical. Attaining target goals is only possible if the patient has full participation in self-management. Self-management requires the application of knowledge and skills; therefore, the cornerstone of diabetes care and treatment is education.
Two standard setting organizations have defined diabetes education. The National Standards for Diabetes Self-Management Education (2007) defines education as the “ongoing process of facilitating the knowledge, skill and ability necessary for diabetes self-care. This process incorporates the needs, goals and life experiences of the person with diabetes and is guided by evidence-based standards. The objectives are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status and quality of life.”
Additionally, the American Association of Diabetes Educators states that “Diabetes self-management education and training is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions. DSME/T is an interactive, ongoing process involving the person with diabetes (or the caregiver or family) and a diabetes educator(s). The intervention aims to achieve optimal health status, better quality of life and reduce the need for costly health care. DSME/T focuses on the AADE7 Self-Care Behaviors, which are essential for improved health status and improved quality of life.”
 Donna Rice |
 Mary M. Austin |
Communication, collaboration
Education is not only about acquiring knowledge but acting on the knowledge. It is difficult to take action without a target or goal. Often, patients come in for diabetes education and have no idea what HbA1c is — let alone know what their HbA1c goal should be. Much of this stems from a lack of communication between the health care team and the patient. Increased communication is required to evaluate each patient individually and work toward patient-centered goals. By doing so, the individual receives consistent messages and has opportunities to change or improve.
It is very difficult in a 10-minute provider visit, once a quarter or less, to have any in-depth time with a patient to set or review progress on goals. Collaboration within a team — diabetes educators, physicians, pharmacists, dietitians, cardiologists and family members, to name a few — can help the patient establish meaningful goals, monitor progress and provide necessary support. Diabetes educators’ experience and training make them the ideal team member to explore individualized behavior strategies and to help set customized goals.
Collaboration does not happen by accident. In today’s changing health care environment, we need to recognize the unique roles that other providers can bring to diabetes care. A starting point is to evaluate how you are currently providing care and to what extent you recognize other team members’ contribution to patient-centered care. Establishing relationships and a referral mechanism is necessary if patient needs are to be met.
Patient-centered care
Historically, the AADE has embraced patient-centered care as the most important aspect of health care. In 2006, it adopted the Chronic Care Model, which strongly supports self-management as integral to improving outcomes. The AADE7 Self-Care Behaviors provide the framework for goal-setting and self-management and provide the common language and reference for behavior change used by the team.
The self-care behaviors include healthy eating, being active, taking medications, monitoring, problem-solving, healthy coping and risk reduction. These self-care behaviors are both the goals and outcomes of successful diabetes management.
The AADE7 is a tool that can be used to promote the discussion of healthy goal-setting. People set goals to reach desired outcomes. If a patient has an HbA1c level of 7.5%, you may want to discuss barriers to medication adherence before increasing or changing medications. Various team members bring unique perspectives and contributions to help individuals meet their goals. For example, the pharmacist may help the patient simplify the medication regimen, the dietitian may uncover inconsistent carbohydrate intake and the nurse may identify psychosocial issues that affect medication adherence — all of which need to be communicated among the team.
Start by looking at your practice. Have you defined your team? Are you really working to individualize care around patients’ goals? With collaborative care, you cannot continue to practice like you have practiced in the past. Be proactive in establishing the team that best serves your patients. A multidisciplinary team approach is essential for improved outcomes.
Mary M. Austin, MA, RD, CDE, is Owner and President of The Austin Group, LLC, and Donna Rice, RN, CDE, is President of the Diabetes Health and Wellness Institute, Baylor Health Care System.