1. Strategies for Improving Care

• A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used. B

• Treatment decisions should be timely and founded on evidence-based guidelines that are tailored to individual patient preferences, prognoses, and comorbidities. B

• Care should be aligned with components of the Chronic Care Model (CCM) to ensure productive interactions between a prepared proactive practice team and an informed activated patient. A

• When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. B

In the following sections, different components of the clinical management of patients with (or at risk for) diabetes are reviewed. We highlight the following three themes that are woven throughout these sections that clinicians, policymakers, and advocates should keep in mind:

1. Patient-Centeredness: Practice recommendations, whether based on evidence or expert opinion, are intended to guide an overall approach to care. The science and art of medicine come together when the clinician is faced with making treatment recommendations for a patient who would not have met eligibility criteria for the studies on which guidelines were based. Recognizing that one size does not fit all, these Standards provide guidance for when and how to adapt recommendations (e.g., see Section 10. Older Adults and Fig. 6.1. Approach to the Management of Hyperglycemia). Because patients with diabetes are also at greatly increased risk of cardiovascular disease, a patient-centered approach should include a comprehensive plan to reduce cardiovascular risk by addressing blood pressure and lipid control, smoking cessation, weight management, and healthy lifestyle changes that include adequate physical activity.

2. Diabetes Across the Life Span: An increasing proportion of patients with type 1 diabetes are adults. Conversely, and for less salutary reasons, the incidence of type 2 diabetes is increasing in children and young adults. Finally, patients both with type 1 diabetes and with type 2 diabetes are living well into older age, a stage of life for which there is little evidence from clinical trials to guide therapy. All these demographic changes highlight another challenge to high-quality diabetes care, which is the need to improve coordination between clinical teams as patients pass through different stages of the life span or the stages of pregnancy (preconception, pregnancy, and postpartum).

3. Advocacy for Patients With Diabetes: Advocacy can be defined as active support and engagement to advance a cause or policy. Advocacy in the cause of improving the lives of patients with (or at risk for) diabetes is an ongoing need. Given the tremendous toll that lifestyle factors such as obesity, physical inactivity, and smoking have on the health of patients with diabetes, ongoing and energetic efforts are needed to address and change the societal determinants at the root of these problems. Within the more narrow domain of clinical practice guidelines, the application of evidence level grading to practice recommendations can help identify areas that require more research investment (1). This topic is explored in more depth in Section 14. Diabetes Advocacy.

There has been steady improvement in the proportion of diabetic patients achieving recommended levels of A1C, blood pressure, and LDL cholesterol in the last 10 years (2). The mean A1C nationally has declined from 7.6% in 1999–2002 to 7.2% in 2007–2010 based on the National Health and Nutrition Examination Survey (NHANES) data (E.W. Gregg, Centers for Disease Control and Prevention, personal communication). This has been accompanied by improvements in lipids and blood pressure control and has led to substantial reductions in end-stage microvascular complications in patients with diabetes. Nevertheless, between 33 and 49% of patients still do not meet targets for glycemic, blood pressure, or cholesterol control, and only 14% meet targets for all three measures and nonsmoking status (2). Evidence also suggests that progress in cardiovascular risk factor control (particularly tobacco use) may be slowing (2,3). Certain patient groups, such as young adults and patients with complex comorbidities, financial or other social hardships, and/or limited English proficiency, may present particular challenges to goal-based care (4–6). Persistent variation in quality of diabetes care across providers and across practice settings even after adjusting for patient factors indicates that there remains potential for substantial system-level improvements in diabetes care.

Although numerous interventions to improve adherence to the recommended standards have been implemented, a major barrier to optimal care is a delivery system that too often is fragmented, lacks clinical information capabilities, duplicates services, and is poorly designed for the coordinated delivery of chronic care. The CCM has been shown to be an effective framework for improving the quality of diabetes care (7). The CCM includes six core elements for the provision of optimal care of patients with chronic disease: 1) delivery system design (moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach, 2) self-management support, 3) decision support (basing care on evidence-based, effective care guidelines), 4) clinical information systems (using registries that can provide patient-specific and population-based support to the care team), 5) community resources and policies (identifying or developing resources to support healthy lifestyles), and 6) health systems (to create a quality-oriented culture). Redefining the roles of the clinic staff and promoting self-management on the part of the patient are fundamental to the successful implementation of the CCM (8). Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients’ self-management (9–12).

The National Diabetes Education Program (NDEP) maintains an online resource (www.betterdiabetescare.nih.gov) to help health care professionals design and implement more effective health care delivery systems for those with diabetes. Three specific objectives, with references to literature that outlines practical strategies to achieve each, are delineated below.

The care team should prioritize timely and appropriate intensification of lifestyle and/or pharmaceutical therapy for patients who have not achieved beneficial levels of blood pressure, lipid, or glucose control (13). Strategies such as explicit goal setting with patients (14); identifying and addressing language, numeracy, or cultural barriers to care (15–18); integrating evidence-based guidelines and clinical information tools into the process of care (19–21); and incorporating care management teams including nurses, pharmacists, and other providers (22–24) have each been shown to optimize provider and team behavior and thereby catalyze reductions in A1C, blood pressure, and LDL cholesterol.

Successful diabetes care requires a systematic approach to supporting patients’ behavior change efforts, including 1) healthy lifestyle changes (physical activity, healthy eating, tobacco cessation, weight management, and effective coping), 2) disease self-management (taking and managing medication and, when clinically appropriate, self-monitoring of glucose and blood pressure), and 3) prevention of diabetes complications (self-monitoring of foot health; active participation in screening for eye, foot, and renal complications; and immunizations). High-quality diabetes self-management education (DSME) has been shown to improve patient self-management, satisfaction, and glucose control (25,26), as has delivery of ongoing diabetes self-management support (DSMS), so that gains achieved during DSME are sustained (27–29). National DSME standards call for an integrated approach that includes clinical content and skills, behavioral strategies (goal setting, problem solving), and engagement with emotional concerns in each needed curriculum content area.

An institutional priority in most successful care systems is providing a high quality of care (30). Changes that have been shown to increase quality of diabetes care include basing care on evidence-based guidelines (19); expanding the role of teams and staff and implementing more intensive disease management strategies (6,22,31); redesigning the care process (32); implementing electronic health record tools (33,34); activating and educating patients (35,36); removing financial barriers and reducing patient out-of-pocket costs for diabetes education, eye exams, self-monitoring of blood glucose, and necessary medications (6); and identifying/developing/engaging community resources and public policy that support healthy lifestyles (37). Recent initiatives such as the Patient-Centered Medical Home show promise for improving outcomes through coordinated primary care and offer new opportunities for team-based chronic disease care (38). Additional strategies to improve diabetes care include reimbursement structures that, in contrast to visit-based billing, reward the provision of appropriate and high-quality care (39), and incentives that accommodate personalized care goals (6,40).

It is clear that optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health care professionals working in an environment where patient-centered high-quality care is a priority (6).

Some patients and their health care providers may not achieve the desired treatment goals. Reassessing the treatment regimen may require evaluation of barriers such as income, health literacy, diabetes-related distress, depression, poverty, and competing demands, including those related to family responsibilities and dynamics. Other strategies may include culturally appropriate and enhanced DSME and DSMS, comanagement with a diabetes team, referral to a medical social worker for assistance with insurance coverage, medication-taking behavior assessment, or change in pharmacological therapy. Initiation of or increase in self-monitoring of blood glucose, continuous glucose monitoring, frequent patient contact, or referral to a mental health professional or physician with special expertise in diabetes may be useful.