• Fresh Views

    Transform Primary Care Encounters: Tackling the Diabetes Diagnosis

    “Health is a state of body. Wellness is a state of being.” ~ J. Stanford

    Our prior post in our series on transforming primary care encounters focused on combating therapeutic inertia. Today, we’d like to start from the very beginning – the conversation when the client first learns they have type 2 diabetes (T2D).  When beginning diabetes conversions using a solution-focused approach, we believe you will find that your relationship with your clients can improve and it will create an opportunity for ongoing shared decision-making.

    As a reminder, a solution-focused approach is the opposite of a “problem-focused” approach. The goal is to help the person with T2D recognize exceptions (when their problems did not happen) and help them to focus on their health behavior changes by doing “more of what works.”

    Using a solution-focused approach at the T2D diagnosis conversation?

    When preparing for the diagnosis conversation, first put yourself in your clients shoes. How would you want the conversation to go? What would you want to hear? Also consider your body language, your tone and word choice. We know in a busy primary care office, so much time is spent documenting in the EHR, but for this very important discussion, take a moment and step away from the computer, lean in to your client, show empathy and compassion while you say some very important words. Many are overwhelmed when they hear the news that they have T2D, and often won’t hear much of the rest of the conversation. Ask questions and engage in problem free talk, instead of 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 T2D?” Consider making this appointment brief and bring them back for a follow up “diabetes only” visit once they have time to absorb and process the information. 

    To build upon our blog on therapeutic inertia, we’re including some impactful information from the American Diabetes Association that encourages four critical conversations that promote “early positive conversations about the nature of diabetes.” 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 very early in the diagnosis. We 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. The nature of T2D is to change over time, as your insulin production changes.

    “I want you to know that diabetes is not a personal failure and it doesn’t mean you’ve done something wrong.”

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

    “You may need to add new medications as your diabetes changes. This is not a personal failure, just a part of how diabetes treatment progresses.”

    1. You can’t do this alone.

    “I am here to help you.”

    1. Share your difficulties with managing your diabetes.

    “Managing diabetes 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 diagnosis visit 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 them to do some research online at trusted sources like the ADA, Diatribe, 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.”

    Reinforce that small changes can help move them in the right direction, and that you do not 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.

    Keep reading our series on incorporating a solution-focused approach when managing T2D in the primary care setting. Next time we will focus on the first follow up visit after diagnosis.  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.

  • Fresh Views

    Transform Primary Care Encounters: Stop Therapeutic Inertia

    Where you stand determines what you see and what you do not see; it determines also the angle you see it from; a change in where you stand changes everything. – Steve de Shazer, pioneer of solution-focused brief therapy   

    As we continue our series on transforming primary care encounters, today we’re tackling the topic of combatting therapeutic inertia.  

    What is therapeutic inertia?

    In a general sense, “therapeutic inertia” is a lack of timely adjustment to the treatment plan when a client’s treatment goals are not being met. In the diabetes management arena, therapeutic inertia means being slow to add or change the care plan if a client’s A1C is above target. Delays in implementing the most effective care for each person with diabetes can  happen at any phase of diabetes treatment and can range for instance from referring for diabetes and nutrition education, to starting the first medication, or intensifying medication management, including starting insulin.

    Why stop therapeutic inertia?

    The evidence is clear on two things:

    1. Managing glucose levels early in the course of diabetes leads to better long-term outcomes and reduces risk of complications.
    2. Those who reach their A1C targets soon after they’re diagnosed with diabetes are more likely to keep their glucose in target. 

    This is such a timely and impactful topic that ADA has launched an initiative called Overcoming Therapeutic Inertia. There are many resources for primary care clinicians to learn practical tips to focus on diabetes care in a proactive, timely way to improve outcomes. Learn more here.

    Does shared decision making play a role?

    One key tenet of shared-decision making is that all care decisions are discussed together with the client, and decisions are made together, which will ultimately mean more people with diabetes are following their treatment plan. Research shows us that when people are not involved in their diabetes medication decisions, they often no longer take the medicine.

    When we talk about therapeutic inertia we are addressing both the clinician reluctance to advance therapy and the client’s reluctance to follow through with prescribed therapy. When we add shared decision-making we remove some of the barriers to medication taking. We discuss the potential side effects of the medication, costs, schedule and impact to their lifestyle.  These are important decisions that need to be understood for individuals to embrace new therapy.

    So how does incorporating a solution-focused approach address therapeutic inertia?

    A solution-focused approach that encourages shared decision-making can be a tool to overcome inertia. As we’ve discussed previously, incorporating  a solution-focused approach removes the shame and blame often associated with diabetes. When you discuss the clients goals and outcomes and what is working well for them, together you can identify the best therapy. 

    A solution-focused approach is a questioning approach, asking questions allows you to delve down to identify what is most important. An example of a medication-related question might be: What is most important to you when choosing a medication, the potential of weight gain or the need to check glucose before meals? ”And what else?” questions can be incorporated to learn more. 

    Since asking eliciting questions is a primary tenet, we encourage you to start all visits by listening and learning from your client. Remember, the client is the expert (read more about experts here), and even though they may be new to diabetes, they know what works in their life in other aspects, they know what they are capable of doing now. 

    When incorporating a solution-focused approach, each person will map out their own successful plan based on their lives, needs, strengths and desires. The care plan becomes personalized and directly relevant to the client. If something works, do more of it, help them recognize their strengths by identifying exceptions ( written about exceptions here.)

    This solution-focused shared decision-making can build relationships and guide clients towards achieving goals, thus overcoming therapeutic inertia.

    Next up

    Join us next time as we continue our series on incorporating a solution-focused approach when managing T2D in the primary care setting. We’ll visit the moment of diagnosis with diabetes and share tips/tactics you can use to continue to help you  build your solution-focused tool-kit.

    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.

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