Guiding principles and key elements of initial and ongoing DSME/S (45,58,81)
| Engagement. Provide DSME/S and care that reflects person’s life, preferences, priorities, culture, experiences, and capacity. |
| • Solicit and respond to questions |
| • Focus on decisions, reasons for the decisions, and results |
| • Ask about strengths and challenges |
| • Use shared decision making and principles of patient-centered care to guide each visit |
| • Engage the patient in a dialogue about current self-management successes, concerns, and struggles |
| • Engage the patient in a dialogue about therapy and changes in treatment |
| • Remain “solution neutral” and support patient identifying solution(s) |
| • Provide support and education to patient’s family and caregiver |
| Information sharing. Determine what the patient needs to make decisions about daily self-management. |
| • Discuss that DSME/S is an important and essential part of diabetes management |
| • Describe that DSME/S is needed throughout the life cycle and is on a continuum from prediabetes, newly diagnosed diabetes, health maintenance/follow-up, early to late diabetes complications, and transitions in care related to changes in health status and developmental or life changes |
| • Avoid being didactic |
| • Provide “need-to-know” information and avoid providing the encyclopedia on diabetes |
| • Review that diabetes treatment will change over time |
| • Provide information to the patient using the above engagement key elements |
| • Take advantage of “teachable moments” to provide information specific to the patient’s care and treatment |
| • Assess DSME/S patient/family needs for the behavioral and psychosocial aspects of informed decision making |
| Psychosocial and behavioral support. Address the psychosocial and behavioral aspects of diabetes. |
| • Assess and address emotional and psychosocial concerns, such as diabetes-related distress and depression |
| • Present that diabetes-related distress and a range of emotions are common and that stress can raise blood glucose and blood pressure levels |
| • Discuss that diabetes self-management is challenging but worth the effort |
| • Support self-efficacy and self-confidence in self-management decisions and abilities |
| • Support action by the patient to identify self-management problems and develop strategies to solve those problems, including self-selected behavioral goal setting |
| • Note that it takes about 2–8 months to change a habit/learn/apply behavior |
| • Address the whole person |
| • Include family members and/or support system in the educational and ongoing support process |
| • Refer to community, online, and other resources |
| Integration with other therapies. Ensure integration and referrals with and for other therapies. |
| • Ensure access to ongoing MNT |
| • Recommend additional referrals as needed for behavioral therapy, medication management, physical therapy, etc. |
| • Address factors that limit the application of diabetes self-management activities |
| • Advocate for easy access to social services programs that address basic life needs and financial resources |
| • Identify resources and services that support the implementation of therapies in health care and community settings |
| Coordination of care across specialty care, facility-based care, and community organizations. Ensure collaborative care and coordination with treatment goals. |
| • Understand primary care provider and specialist’s treatment targets |
| • Provide overview of DSME/S to referring providers |
| • Follow medication adjustment protocols or make necessary recommendation to primary care provider |
| • Correspond with referring provider about education plan, progress toward treatment goals, and needs to coordinate education and support from entire clinical team; ensure documentation in the health record |
| • Ensure provision of culturally appropriate care |
| • Use evidence-based decision support |
| • Use performance data to identify opportunities for improvement |
| Engagement. Provide DSME/S and care that reflects person’s life, preferences, priorities, culture, experiences, and capacity. |
| • Solicit and respond to questions |
| • Focus on decisions, reasons for the decisions, and results |
| • Ask about strengths and challenges |
| • Use shared decision making and principles of patient-centered care to guide each visit |
| • Engage the patient in a dialogue about current self-management successes, concerns, and struggles |
| • Engage the patient in a dialogue about therapy and changes in treatment |
| • Remain “solution neutral” and support patient identifying solution(s) |
| • Provide support and education to patient’s family and caregiver |
| Information sharing. Determine what the patient needs to make decisions about daily self-management. |
| • Discuss that DSME/S is an important and essential part of diabetes management |
| • Describe that DSME/S is needed throughout the life cycle and is on a continuum from prediabetes, newly diagnosed diabetes, health maintenance/follow-up, early to late diabetes complications, and transitions in care related to changes in health status and developmental or life changes |
| • Avoid being didactic |
| • Provide “need-to-know” information and avoid providing the encyclopedia on diabetes |
| • Review that diabetes treatment will change over time |
| • Provide information to the patient using the above engagement key elements |
| • Take advantage of “teachable moments” to provide information specific to the patient’s care and treatment |
| • Assess DSME/S patient/family needs for the behavioral and psychosocial aspects of informed decision making |
| Psychosocial and behavioral support. Address the psychosocial and behavioral aspects of diabetes. |
| • Assess and address emotional and psychosocial concerns, such as diabetes-related distress and depression |
| • Present that diabetes-related distress and a range of emotions are common and that stress can raise blood glucose and blood pressure levels |
| • Discuss that diabetes self-management is challenging but worth the effort |
| • Support self-efficacy and self-confidence in self-management decisions and abilities |
| • Support action by the patient to identify self-management problems and develop strategies to solve those problems, including self-selected behavioral goal setting |
| • Note that it takes about 2–8 months to change a habit/learn/apply behavior |
| • Address the whole person |
| • Include family members and/or support system in the educational and ongoing support process |
| • Refer to community, online, and other resources |
| Integration with other therapies. Ensure integration and referrals with and for other therapies. |
| • Ensure access to ongoing MNT |
| • Recommend additional referrals as needed for behavioral therapy, medication management, physical therapy, etc. |
| • Address factors that limit the application of diabetes self-management activities |
| • Advocate for easy access to social services programs that address basic life needs and financial resources |
| • Identify resources and services that support the implementation of therapies in health care and community settings |
| Coordination of care across specialty care, facility-based care, and community organizations. Ensure collaborative care and coordination with treatment goals. |
| • Understand primary care provider and specialist’s treatment targets |
| • Provide overview of DSME/S to referring providers |
| • Follow medication adjustment protocols or make necessary recommendation to primary care provider |
| • Correspond with referring provider about education plan, progress toward treatment goals, and needs to coordinate education and support from entire clinical team; ensure documentation in the health record |
| • Ensure provision of culturally appropriate care |
| • Use evidence-based decision support |
| • Use performance data to identify opportunities for improvement |