1.0.0.0 Pa­tient-‍Cen­tered Col­lab­o­ra­tive Care

The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) “Stan­dards of Med­i­cal Care in Di­a­betes” in­cludes ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions and is in­tend­ed to pro­vide the com­po­nents of di­a­betes care, gen­er­al treat­ment goals and guide­lines, and tools to eval­u­ate qual­i­ty of care. Mem­bers of the ADA Pro­fes­sion­al Prac­tice Com­mit­tee, a mul­ti­dis­ci­plinary ex­pert com­mit­tee, are re­spon­si­ble for up­dat­ing the Stan­dards of Care an­nu­al­ly, or more fre­quent­ly as war­rant­ed. For a de­tailed de­scrip­tion of ADA stan­dards, state­ments, and re­ports, as well as the ev­i­dence-‍grad­ing sys­tem for ADA’s clin­i­cal prac­tice rec­om­men­da­tions, please refer to the Stan­dards of Care In­tro­duc­tion. Read­ers who wish to com­ment on the Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

PA­TIENT-‍CENTERED COL­LAB­O­RA­TIVE CARE

A suc­cess­ful med­i­cal eval­u­a­tion de­pends on beneficial in­ter­ac­tions be­tween the pa­tient and the care team. The Chron­ic Care Model (1–3) (see Sec­tion 1 “Im­prov­ing Care and Pro­mot­ing Health in Pop­u­la­tions”) is a pa­tient-‍cen­tered ap­proach to care that re­quires a close work­ing re­la­tion­ship be­tween the pa­tient and clin­i­cians in­volved in treat­ment plan­ning. Peo­ple with di­a­betes should re­ceive health care from an in­ter­dis­ci­plinary team that may in­clude physi­cians, nurse prac­ti­tion­ers, physi­cian as­sis­tants, nurs­es, di­eti­tians, ex­er­cise spe­cial­ists, phar­ma­cists, den­tists, po­di­a­trists, and men­tal health pro­fes­sion­als. In­di­vid­u­als with di­a­betes must as­sume an ac­tive role in their care. The pa­tient, fam­i­ly or sup­port peo­ple, physi­cians, and health care team should to­geth­er for­mu­late the man­age­ment plan, which in­cludes lifestyle man­age­ment (see Sec­tion 5 “Lifestyle Man­age­ment”).

The goals of treat­ment for di­a­betes are to pre­vent or delay com­pli­ca­tions and main­tain qual­i­ty of life (Fig. 4.1). Treat­ment goals and plans should be cre­at­ed with the pa­tients based on their in­di­vid­u­al pref­er­ences, val­ues, and goals. The man­age­ment plan should take into ac­count the pa­tient’s age, cog­ni­tive abil­i­ties, school/‍work sched­ule and con­di­tions, health be­liefs, sup­port sys­tems, eat­ing pat­terns, phys­i­cal ac­tiv­i­ty, so­cial sit­u­a­tion, finan­cial con­cerns, cul­tur­al fac­tors, lit­er­a­cy and nu­mer­a­cy (math­e­mat­i­cal lit­er­a­cy), di­a­betes com­pli­ca­tions and du­ra­tion of dis­ease, co­mor­bidi­ties, health pri­or­i­ties, other med­i­cal con­di­tions, pref­er­ences for care, and life ex­pectan­cy. Var­i­ous strate­gies and tech­niques should be used to sup­port pa­tients’ self-‍man­age­ment ef­forts, in­clud­ing pro­vid­ing ed­u­ca­tion on prob­lem-‍solv­ing skills for all as­pects of di­a­betes man­age­ment.

Pro­vider com­mu­ni­ca­tions with pa­tients and fam­i­lies should ac­knowl­edge that mul­ti­ple fac­tors im­pact glycemic man­age­ment but also em­pha­size that col­la­bo­ra­tively de­vel­oped treat­ment plans and a healthy lifestyle can significant­ly im­prove dis­ease out­comes and well­be­ing (4–7). Thus, the goal of pro­vider-pa­tient com­mu­ni­ca­tion is to es­tab­lish a col­lab­o­ra­tive re­la­tion­ship and to as­sess and ad­dress self-‍man­age­ment bar­ri­ers with­out blam­ing pa­tients for “non­com­pli­ance” or “non­ad­her­ence” when the out­comes of self-‍man­age­ment are not op­ti­mal (8). The fa­mil­iar terms “non­com­pli­ance” and “non­ad­her­ence” de­note a pas­sive, obe­di­ent role for a per­son with di­a­betes in “fol­low­ing doc­tor’s or­ders” that is at odds with the ac­tive role peo­ple with di­a­betes take in di­rect­ing the day-‍to-‍day de­ci­sion mak­ing, plan­ning, mon­i­tor­ing, eval­u­a­tion, and prob­lem-‍solv­ing in­volved in di­a­betes self-‍man­age­ment. Using a nonjudgmen­tal ap­proach that nor­mal­izes pe­ri­od­ic laps­es in self-‍man­age­ment may help min­i­mize pa­tients’ re­sis­tance to re­port­ing prob­lems with self-‍man­age­ment. Em­pathiz­ing and using ac­tive lis­ten­ing tech­niques, such as open-‍ended ques­tions, reflec­tive state­ments, and sum­ma­riz­ing what the pa­tient said, can help fa­cil­i­tate com­mu­ni­ca­tion. Pa­tients’ per­cep­tions about their own abil­i­ty, or self­-efficacy, to self-‍man­age di­a­betes are one im­por­tant psychoso­cial fac­tor re­lat­ed to im­proved di­a­betes self-‍man­age­ment and treat­ment out­comes in di­a­betes (9–13) and should be a tar­get of on­go­ing as­sessment, pa­tient ed­u­ca­tion, and treat­ment plan­ning.

Lan­guage has a strong im­pact on per­cep­tions and be­hav­ior. The use of em­pow­er­ing lan­guage in di­a­betes care and ed­u­ca­tion can help to in­form and mo­ti­vate peo­ple, yet lan­guage that shames and judges may un­der­mine this ef­fort. The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) and Amer­i­can As­so­ci­a­tion of Di­a­betes Ed­u­ca­tors con­sen­sus re­port, “The Use of Lan­guage in Di­a­betes Care and Ed­u­ca­tion,” pro­vides the au­thors’ ex­pert opin­ion re­gard­ing the use of lan­guage by health care pro­fes­sion­als when speak­ing or writ­ing about di­a­betes for peo­ple with di­a­betes or for pro­fes­sion­al au­di­ences (14). Al­though fur­ther re­search is need­ed to ad­dress the im­pact of lan­guage on di­a­betes out­comes, the re­port in­cludes five key con­sen­sus rec­om­men­da­tions for lan­guage use:

Use lan­guage that is neu­tral, nonjudgmen­tal, and based on facts, ac­tions, or phys­i­ol­o­gy/‍biology.

Use lan­guage that is free from stigma.

Use lan­guage that is strength based, re­spect­ful, and in­clu­sive and that im­parts hope.

Use lan­guage that fos­ters col­lab­o­ra­tion be­tween pa­tients and pro­viders.

Use lan­guage that is per­son cen­tered (e.g., “per­son with di­a­betes” is pre­ferred over “di­a­bet­ic”).

Fig­ure 4.1—De­ci­sion cycle for pa­tient-‍cen­tered glycemic man­age­ment in type 2 di­a­betes. Adapt­ed from Davies et al. (119).