• Fresh Views

    Transforming Primary Care Encounters: The Prediabetes Conversation

    “The secret of living well and longer is: eat half, walk double, laugh triple, and love without measure.” ~ Tibetan Proverb

    As we revisit our series on transforming primary care encounters, we’d like to take a step back, if you will, to the diagnosis of prediabetes. In our clinical experience there is a vast difference in these early conversations in the health care setting – sometimes a stern warning to change habits “or else”, to almost no recognition of the elevated blood glucose at all, with no discussion about the potential risk of developing type 2 diabetes. Deb discovered that both of her parents had been living with prediabetes for years, but neither of them had even been told of their lab levels except, “things look good.” As with a new diagnosis of type 2 diabetes, we believe that incorporating a solution-focused approach with a prediabetes diagnosis is equally as important. 

    If you’ve read our previous blogs you know that  a solution-focused approach is the opposite of a more traditional “problem-focused” approach. The goal is to help the individual recognize exceptions (times when their problems did not happen) and help them to focus on health behavior changes by doing “more of what works.” How can we use this approach in the prediabetes conversation?

    Using a solution-focused approach at the prediabetes diagnosis conversation

    The ADA 2022 Standards of Medical Care indicate that screening for prediabetes should start at age 35, but earlier for those with risk factors. We are advocates that everyone who meets the criteria for a prediabetes diagnosis deserves the information as early as possible so they may decide what types of health behavior changes they are willing and able to make. Thus, using a solution-focused approach from the beginning is critical to set the stage for a lifetime of ongoing conversations. A clinician’s approach to this conversation can make the difference in early action to help prevent or delay type 2 diabetes – and thus potential prevention of long-term complications, reduction in medication, and living a healthier life.

    Current guidelines suggest enrolling individuals with prediabetes into a National Diabetes Prevention Program (DPP) given DPP study outcomes that showed a 58% reduction in risk of progression to type 2 diabetes with lifestyle intervention. Research shows that participants who lose 5-7% of their body weight and add 150 minutes of exercise per week cut their risk of developing type 2 diabetes by up to 58% (71% for people over 60 years old). 

    The guidelines also recommend metformin for those with a higher BMI, higher A1C, and history of gestational diabetes. Since many don’t want to take medication, there is a great need for open discussion from the beginning to use shared decision-making to lay out the facts, what is known, what the research indicates, and their overall level of risk.  

    We know that patients (clients) greatly value what their primary care provider (PCP) recommends to them, so having these open discussions can help the PCP identify what the individual is willing and able to do. If they might benefit from medication, and are likely to be challenged to engage in physical activity or choose more healthful foods, then medication might be a beneficial option. It’s important to balance goals from the PCP perspective against the capacity of the person with the new diagnosis. Asking questions and engaging in problem-free talk can be more impactful than giving a list of instructions. Maybe you simply state, “I know this is hard to hear, how can I help?” and “What information would you like to hear from me today as you start to learn about prediabetes?” 

    As we shared in our type 2 diabetes diagnosis blog, the American Diabetes Association encourages four critical conversations that promote “early positive conversations about the nature of diabetes.” We believe that applying this during the prediabetes diagnosis can be equally as valuable. These conversations address many tenets we value in a solution-focused approach, including person-centered, strength-based language, problem-free talk, listening, and building a partnership with clients.

    4 critical conversations

    There are four critical conversations that need to happen early in the diagnosis. We’ve modified these questions to fit prediabetes and encourage you to build upon these questions at each visit. Start small with a few comments and then build upon them as the person is learning to accept the diagnosis and is ready to learn more. At diagnosis, conversation #1 is the most significant. (adapted from ADA Overcoming Therapeutic Inertia)

    1. Prediabetes may progress to type 2 diabetes over time, as your body’s insulin production changes.

    I want you to know that prediabetes is an opportunity to make health behavior changes that may prevent or delay type 2 diabetes. However, it’s important to know that even if you follow every guideline you may still develop type 2 diabetes.

    1. Your treatment plan will change over time as your prediabetes changes.

    You may need to add a medication as your prediabetes changes. This is not a personal failure, just a part of how the progression to diabetes may happen.

    1. You can’t do this alone.

    I am here to help you.

    1. Share your difficulties with following diabetes prevention guidelines.

    Managing prediabetes day in and day out can be hard. Share anything that may be getting in the way of managing your diabetes and also share your successes.

    Close the conversation with a scaling question.

    On a scale of 0-10 where zero is no stress and 10 is the worst stress you’ve ever experienced, where are you right now?

    Use their answer to finish the visit and provide one action for them to focus on.

    If 0-4:  Encourage doing some research online at trusted sources like the ADA, CDC or ADCES.

    If 5-7:  Identify one strength they already have and build upon it

    What is one thing you do for yourself every day that makes you feel healthy? How can  you do more of that?

    If 8-10: just encourage them to breathe and take some time to let it sink in and to come back with questions in one week

    I know how hard this can be, take some time, write down questions you have, and let’s meet and talk more next week.

    Create a supporting environment

    Reinforce that small changes can help move them in the right direction, and that you don’t expect perfection. If they do the best that they can do, that’s the best they can do.  Remind them that you are partners on this journey. We believe that creating a supportive environment from day one, can empower people to learn to live with their diabetes.

    Stop back by in 2 weeks as we wrap up our series on incorporating a solution-focused approach when managing type 2 diabetes in the primary care setting. We’ll focus on interpreting diabetes data in primary care in a solution-focused way.

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown Diabetes Center, but her words and opinions in this blog are her own.

  • Fresh Views

    Transform Primary Care Encounters: 7 Practical Tips to Get Started

    If it ain’t broke, don’t fix it. Once you know what works, do more of it. If it’s not working, do something different. – Steve de Shazer and Insoo Kim Berg, pioneers of solution-focused brief therapy

    Our last blog spotlighted the power of words and using person-first, strengths-based language in diabetes related conversations in primary care. As we continue our series on transforming primary care encounters by incorporating solution-focused techniques, maybe your interest is piqued by this new approach, but you’re not quite sure how to begin to incorporate it into your practice?  Today we share 7 practical tips to get started. 

    1 – Ask “exception” questions. Exceptions are times when an expected problem does not occur. These are times we want to identify, focus on, and encourage the client to explore. These exceptions help the client move towards their desired future. Here are 2 examples of “exception” questions:

    • You mentioned that you typically struggle to be physically active in the evenings but you were able to go to the gym after work last week? How did you manage to do that?
    • Cooking meals at home has been a challenge for you, yet you cooked two times last week. What changed to allow you to make that happen? And what else?

    2 – Use person-first, strengths-based language. This may seem simple, but is hugely impactful. This means using language that is neutral, non-judgmental, and free from stigma. Language that is inclusive, respectful, and imparts hope. Word choice that fosters collaboration with your client and is person- centered. Focusing on language can remove the stigma associated with diabetes.

    3 – Practice problem-free talk. By incorporating this one impactful change you will already notice how the quality of visits and client engagements will improve – building the therapeutic relationship, hope, and motivation. The conversation at the beginning of an encounter is critical to build the therapeutic relationship. By starting the conversation with the goal of the client, you acknowledge that you are focused on their needs and desires and are committed to helping to meet their goals.  Two great ways you could begin a visit are to ask your client:

    • What would make this a successful appointment for you? 
    • At the end of this visit, what would you need to know/learn to say this was worth your time?

    4 – Ask the Miracle Question.

    The Miracle Question applied to diabetes is one tool or technique in a solution-focused tool-box to help clients envision a future that is more problem-free. 

    • Miracle Question: If you could fast-forward to a time where you feel satisfied with your diabetes management, what will be different in your life that will let you know things are better?

    You can learn more about the Miracle Question applied to diabetes in a previous blog post here. The Miracle Question helps people identify those “exceptions” mentioned in #1. The Miracle Question challenges a person to look past their obstacles and feelings of hopelessness to focus on possibilities, opportunities, and a vision for the future. The goal is to help one identify what they’ve actually known all along, and that they have the power to make choices and changes that can move them forward. By focusing on “exceptions”, goals become different. Focus turns to what is desired in our life instead of what “won’t happen” anymore.

    5 – Ask eliciting questions. When incorporating a solution-focused approach you need to ask eliciting questions to uncover solutions and guide the individual. It is key that these questions are open-ended and help the individual see how they can be successful. Instead of asking  questions that focus on the problems (since living with a chronic condition cannot benefit from a “quick fix”), instead, explore their strengths and resources they already possess and how those resources can apply to their diabetes management.

    • What has been going well since I last saw you?” 

    That one question can  start the visit on a positive note, acknowledge  the work that it took to accomplish that, and then leverage how the client can continue those positive behaviors and build on them for future health success. Questions can also focus on details when the person identifies a success:

    • How exactly did you do that? What exactly did you do differently?

    6- Ask future visioning questions. These questions can focus on the short-term or long-term views of the client’s preferred future. These questions help the individual realize that solutions are possible and help them see their desired future state. As you recall one of the key tenets is the client is the expert about their own life and their own diabetes. (Read more about experts here)

    • What would you like to see yourself doing in the next (day, week, month) to move you forward towards your goals? And what else? 

    Following up with “what else?” encourages people to dig deeper and think through in detail what they are capable of.

    7 – Use scaling questions. Scaling questions are a great tool to move away from all or nothing thinking. They focus on progress, motivation, and confidence.

    • On a scale of 0-10 where 0 is not confident at all and 10 is very confident, how much confidence do you have that you can meet your goal to (insert personal goal here)?  

    If less than a 7, follow up with one of these:

    • What could move you to a 7? 
    • What would need to happen to move you one number higher?
    • What would one number higher look like? 
    • How would others notice you’re more confident?
    • How come you’re not at a lower number? How did you do that?

    Keep reading our series on incorporating a solution-focused approach when managing T2D in the primary care setting. Our next blog will focus on therapeutic inertia. Curious what that means? Stop back by in 2 weeks as we share more tips to build your solution-focused tool-kit over time. 

    We welcome anyone interested in our approach to Subscribe to our blog and we’ll email you when a new post is published!

    If you are a health care professional and interested in learning more about our solution-focused practice and approach, when you subscribe to our blog, we’ll send you in return a FREE resource of 10 Solution-Focused Questions to start a solution-focused discussion with your clients. 

    Follow us on Twitter and Instagram @AFreshPOVforYou

    Deb is employed by Dexcom, but her words and opinions in this blog are her own.

    Tami is employed by the University of Kentucky HealthCare Barnstable Brown DIabetes Center, but her words and opinions in this blog are her own.