Motivate patients to take compliance personally
Focus on the benefits important to them
Do you know what will make your patients do a better job managing their disease? Let them tell you. The clues you pick up about people you treat often can be extremely helpful in getting them to follow your instructions on controlling diabetes.
The catch is, a doctor isn’t going to be able to sit down with a stenographer’s pad and get the patient’s autobiography.
In today’s world of managed care, caregivers get about seven minutes per patient, says Nancy Bohannon, MD, an endocrinologist in private practice in San Francisco. That’s not much time for doing anything at all.
That’s why nurse practitioners, educators, and dietitians are such an important part of the diabetic care team, she says. Their job is to take the time to get to know each person receiving care. Patients often make an appointment to see one of these clinicians for an hour or more, one-on-one. Information can then be shared with the entire team to create a record everyone can use.
"Know the individual, and know what he cares about," she says. "Then find something that is important to him, and you can make the care personal, not vague."
Following are some different ways Bohannon has keyed in on the patient particulars, in order to win better adherence to a treatment plan. You may choose to use the information you find in different ways. But the important thing is to connect a sense of urgency to the situation for each patient:
• Patients may mention they have young children or grandchildren. If those patients smoke, get them to think about the example they are setting for the young ones in their lives. It can help convince them that they need to quit.
• Your patients are all going to have favorite activities or hobbies. Let them know that controlling their diabetes helps them to stay healthy enough to keep doing them. For example, Bohannon urged an avid equestrian to follow her disease management plan so she could still ride and jump horses. By keeping sugars under control, she is keeping her legs and feet healthy, so she will be able to feel and use the stirrups.
• Find out if your teen-age patients are interested in sports. Bohannon noticed one boy in her practice wanted to be an athlete, but his sugars were out of control. He soon learned why diabetes care is an essential part of his training regimen. "I told him with blood sugars over 200, you can’t build muscle."
• Girls at this age may also have other concerns with their developing bodies. When a girl entering her teens had not yet begun to menstruate, Bohannon told her that she first needed to get her blood sugar under better control.
• Younger children often can’t wait to grow up to be bigger like older siblings. These patients are usually interested in learning that glycemic control helps their bodies grow properly.
Why it works
When you find that personal key to a patient’s psyche, Bohannon says, "They listen, and they decide to make the changes because it relates to something that’s important to them."
Bohannon, who has practiced for more than 20 years, says the term "adherence" has become the politically correct word for patients following their treatment plan. She says it’s an appropriate word because it describes a partnership between a health care team and a patient who has a positive attitude about staying healthy.
"The difference is with the concept of adherence, the patient is taking care of himself better because he wants to and he knows it’s good for him," she says.
There’s no skeleton key that will unlock every patient’s desire to make healthy choices. But giving patients coping skills can give them more power over their disease, and that goes a long way, says Elizabeth Walker, RN, DNSc, CDE, president of health care and education for the American Diabetes Association in Arlington, VA.
"They are the ones who have to live with themselves and their disease and deal with the consequences of their choices," says Walker, who is associate professor of epidemiology and social medicine at Albert Einstein College of Medicine in New York City. "As health care providers, we can’t tell them what to do or lay guilt on them. In the end, they have to see that healthy choices are absolutely their choice. It is our job to support them and offer positive reinforcement," she says.
She adds that health care professionals are sometimes asked to hear confessions, or worse yet, act like the patients’ parent. Be wary; such dynamics shift the focus away from the patients. Get the patient back in charge of the situation.
"When a patient tells me she cheated,’ I reject that," she says. Instead, Walker tells the patient she is an intelligent adult and she made a particular choice. "I would suggest she might want to re-think that choice."
Help with lifestyle choices
Walker also encourages health care team members to help their patients make lifestyle choices that they can live with for a lifetime: "Urge them to think about your recommendations in terms of quality of life or they won’t stick with it," she says. Patients then feel sorry for themselves, cheat, and feel miserable afterward.
Maybe the health care team needs to lighten up the load just a bit, too, and aim for more gradual changes, Walker suggests. "Who wants to have an HbA1c of 6 and be miserable?"
Walker offers a counseling approach that has worked for her:
• Give the patient the information he/she needs to make healthy choices.
• Find out what is important to the patient and set priorities — losing weight, lowering lipid levels, etc.
• Implement a small change that you can agree upon together.
• Set goals.
• See how the goals are met before setting new ones.
"Good diabetes management is about moving through life with your patients," Walker says. "And that requires an investment of time from the health care team." She says your patients need to see you as a "nonjudgmental support system."
Walker adds that close contact between patients and caregivers improves outcomes. Frequent visits at the office or clinic are a must. But so is getting on the phone to find out how patients are doing. Caregivers or patients can initiate the call. The important thing is that the patient stays in contact to report monitoring results or to ask questions.
"In the end, you can’t make anybody do anything," Walker says. "But if you can unlock for them the reason why they want to make some changes, they’ll make those decisions for themselves."
Don’t forget about exercise
As you prod your patients to keep good gly-cemic control, make sure you tell them there’s more to good management than blood tests and medication. Some parts of the regimen can actually be enjoyable, such as exercising.
Too often, patients hear the word exercise and think they have to become prisoners in a gym. But stress to your patients that they don’t have to make huge commitments; they can gradually become more active by taking small steps, says Bradley Cardinal, PhD, assistant professor of sports and exercise psychology at Oregon State University in Corvallis.
Cardinal is a proponent of a program that classifies people in a stages of readiness for change and "identifies strategies to help them move through those stages," he says. The program is a modified version of a Centers for Disease Control and Prevention-sponsored study called PACE (Physician Assisted Counseling for Exercise).
Stage 1. Pre-contemplation: The patient is not even thinking about the prospect of beginning an exercise program.
Stage 2. Contemplation: The patient begins to think about exercise, to consider the possibility of beginning an exercise program.
Stage 3. Preparation and transition: The patient is "doing it a little," and perhaps has become a weekend warrior, exercising a couple of times a week.
Stage 4. Action: The patient is actively engaging in a regular exercise plan.
Stage 5. Maintenance: The exercise lifestyle is firmly ingrained after six months of success.
After about five years at Stage 5, Cardinal adds a sixth stage he calls "Transformed" where the participants are 100% confident they will continue and actually become almost evangelistic about preaching the gospel of fitness.
Practitioners should identify the patient’s stage of readiness to engage in exercise by asking yes or no questions to determine level of physical activity. He cautions against trying to move patients to the next stage too fast.
"To somebody who is at Stage 1, I might just engage in a discussion of the pros of exercise," says Cardinal. "It’s very soft sell." It’s important for practitioners to be aware that many patients are "quite defensive" about their inactivity and to "keep the negatives out."
With one patient at Stage 2, Cardinal says the patient was unsure she could walk a quarter mile. He gave her a pedometer, and she was very pleased to find she was already walking far more than a quarter of a mile a day in the ordinary course of her daily life.
By the time patients reach Stage 3, Cardinal says he works with them to see their progress and incorporate more activity into their day by small increments. For example, he might encourage them to increase the number of steps they take in a day by 500 and tells them of the Chinese philosophy that anyone who takes 10,000 steps in a day will have no health worries.
"It might be as simple as finding someone who will encourage them if they have negative spouses, or keeping an exercise diary or even just laying out their exercise clothes before they go to bed so it will be easy to get going in the morning," Cardinal says.
Avoiding lapses, relapses, and collapses
He also encourages a lot of self-reflection to help patients see the barriers to exercising and helping them find a way around those barriers.
And Cardinal is the first to admit that at certain times in life, it may not be a good idea for people to make larger lifestyle changes. "Maybe a new mother with a tiny baby just can’t fit exercise into her schedule." So he suggests even the tiniest changes can help, such as a brief daily walk with the baby in the stroller or even a few minutes in the backyard with the baby.
More importantly, he cautions against invoking any kind of guilt, which leads to lapses, relapses, and collapses, after which beginning the exercise contemplation process again becomes exponentially more difficult.
"Set the goal low, help them to exceed it, and the move on to the next goal," Cardinal advises.
For Lisa Tonrey, MHA, PhC, a pharmacist for the Indian Health Service (IHS) in Albuquerque, NM, the job of helping patients get better outcomes requires her to motivate entire communities at one time. "I like to look at the overall public health perspective, and particularly to encourage a broader community involvement in managing diabetes," she says.
With the heavy burden of diabetes that the Native American community faces, Tonrey says, there is already a rather high level of awareness of the disease and what is needed to manage it.
The IHS provides classic medical care with a physician and diabetic team. "But the [Sandia Pueblo] tribe decided it needed more, so they built a wellness center that includes a gym and hired a chiropractor," Tonrey says.
Sometimes a community is self-motivated, but sometimes educators and other health care professionals need to provide a little nudge, Tonrey says. "Find the key to the community," she suggests. "Who are the leaders? What institutions are respected?"
She adds, "When diabetes becomes the priority of the leadership of the community, that’s when it hits home." Health care professionals can assist that process by making correct information available to community leaders.
Tonrey’s contacts with her patients are also face-to-face and one-on-one. Since she can see a patient’s entire medication record, she can sometimes get an overview of what is happening with a patient, including how well the patient is adhering to medication schedules.
All patients are counseled about their medication, she says, but she also sees the times when they come to pick up their prescriptions as an opportunity to ask them what a physician might have told them. She asks open-ended questions and sometimes has them to sit down and take off shoes and socks to check whether they need foot cream.
Tonrey also recommends a colleague who has computer graphics that can show a patient his progress in terms of blood sugars, HbA1c levels, or cholesterol. "A patient who can see a graph showing his HbA1c has gone from 10 to 7 gets that visual," Tonrey says. "It’s a really big motivator."
Finally, Tonrey offers these words of advice to health care team members: "When you can’t do it the same old way by diet and exercise, you need to look for a way to do it a little differently. And sometimes you need to back off a little bit."
[Contact Nancy Bohannon at (415) 648-7622, Elizabeth Walker at (718) 430-3242, Brad Cardinal at (541) 737-2506, and Lisa Tonrey at (505) 771-5111.]
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