Motivating lifestyle change for diabetics
Education, support motivate participants
When staff at Mid-Florida Medical Services in Winter Haven, FL, launched an educational program on diabetes, their goal was to teach diabetics to manage their disease. It sounds simple in concept but is more difficult than it seems.
Program designers quickly learned that the people who first enrolled in the voluntary program were highly motivated. They all strived to achieve the outcomes, which was to reduce their hemoglobin A1c by 10% at three months, six months, and one year and stay out of the hospital. As the program progressed, it was more difficult to get people to enroll and stay committed to making the necessary lifestyle changes.
Yet, motivation was a key component in the program design. At an orientation meeting, potential participants learned what was expected of them and how controlling the disease would benefit them. If they chose to enroll, success was motivated in several ways:
• Educational classes to build a foundation.
Each participant attended four classes that lasted two hours. The first session covered the basics of the disease such as its definition, the difference between Type 1 and Type 2 diabetes, and self blood glucose monitoring. The second session focused on lifestyle change and analyzed such aspects as barriers to control, creation of a personal control plan, and exercise. The third class discussed diabetic medications and meal planning. The fourth class covered the complications of diabetes.
"A major goal of the program was to educate them on what they needed to know to better take care of themselves," says Laurel Spooner, RN, BSN, education coordinator for Mid-Florida Medical Services in Winter Haven.
• Personal counseling sessions.
Participants met with a nurse educator every two weeks for the first month, every month for the first year, and as needed. A consultation with the dietitian also was scheduled to discuss meal planning.
To help with the counseling sessions, participants filled out a diabetes health education assessment and took an evaluation test. (See examples of materials used in the diabetes program in the educational packet, inserted in this issue.)
"During the counseling sessions, we tried to have patients uncover what would personally motivate them to make the necessary lifestyle changes," says Linda Stearns, RN, CDE, diabetes education coordinator at Mid-Florida Medical Services. For example, one 44-year-old newly diagnosed diabetic was the father of twin baby girls. He wanted to remain healthy to raise his children.
If the patient had several changes that needed to be made, then the counselor would suggest they pick one thing to work on at a time. For example, if the patient needed to stop smoking, stop drinking, and start an exercise program, counselors would suggest he or she focus on one area initially. The dangers for a diabetic of smoking, drinking, and leading an inactive lifestyle are covered in the classes program participants take.
"We try to get them to pick what they want to work on first. We talk about ways to accomplish the goal, but they pick the goal," explains Stearns.
People are more likely to meet their goal if they choose it themselves, she explains. Also, it is easier to make lifestyle changes one step at a time.
People were encouraged to call when they had questions, and an answering machine was set up to catch calls when staff could not answer the phone. A counselor would return the call. There were three counselors in the program: Spooner, Stearns, and Myrna Rowland, RN, MEd, director of education at Mid-Florida Medical Services.
• Organized group meetings.
Once the classes ended, participants could attend a monthly educational session taught by a physician under contract with the HMO arm of Mid-Florida Medical Services. Continuing education was not a part of the original program design, but people in the pilot group wanted more educational meetings. Program designers determined that participants liked the opportunity to discuss problems and ask questions with other participants present.
• The removal of barriers.
Removing barriers to success was an important aspect of the program. To help people start exercising, the women were given free use of the fitness center at the medical facility. Since center membership was restricted to women, the hospital worked with a local fitness center for reduced membership fees for the men.
Also, HMO members were allowed to see their ophthalmologists for an annual retinal exam without a referral.
"We tried to eliminate the barriers to good health," explains Jim Morgan, MD, medical director for Florida 1st, the HMO arm of Mid-Florida Medical Services.
• Rewards.
Anyone in the program who reduced his or her hemoglobin A1c by 10% the first three months received $25. After six months, those who reduced their hemoglobin A1c 10% or held the 10% reduction they achieved the previous month received $50. At the end of the year, participants who reduced their hemoglobin A1c by 10% or maintained the reduction from previous months, and had stayed out of the hospital the entire 12 months received $100. There were 20 people in the pilot group, which was launched in May 1996. Seven people in this group received $100. To date, 65 people have participated in the program.
"Our hope is to eventually move the program out into the community and address every diabetic regardless of insurance coverage. We would like to promote the health of the community," says Morgan.
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