PSYCHO-SOCIAL ASPECTS OF DIABETES MANAGEMENT Barbara Dale L.C.S.W. Clinical Director, Visiting Nurse Health System, Long Term Care at Home and Karen Watkins, PhD., L.M.S.W. Clinical Assistant Professor, School of Social Work Georgia State University

Overview  

Psychosocial Factors Review of Evidenced-Based Diabetes Self-Management Interventions/Programs (DSME)  Case

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Management  Community Motivational Interviewing Motivational Interviewing Techniques

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Community Resources

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Psychosocial Factors of Older Adults with Diabetes 

Depression Symptoms

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Cognitive Decline

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Low Social Support

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Major Stressful Life Experiences

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Living in Urban versus Rural Environments

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Cultural implications

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Economic Resources

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Stress and anxiety

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Educational/ literacy levels

Protoplasmix.wordpress.com

(Bertera, 2006; DeCoster, 2001, 2009; Funnell et.al. 2007; Hewitt et.al 2010; Ling & Boey 2000; Lustman, 2000; Lustman & Clouse, 2004; Lustman et. al., 2000; Trief et.al, 2006; Schillinger et.al 2002 etc.)

Evidenced Based Self-Management Interventions Community 

Social Support

Case Management 

Community Health Worker

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Home Health

Networks 

Adult Day Care

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Diabetes Club

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Mental Health

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Focus Groups

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Videophone

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Psychoeducational

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Telephonic

Groups

Community Interventions 

Social Support Networks

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Adult Day Care

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Diabetes Club

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Focus Groups

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Psychoeducational Health.com

(Bertera, 2003; Cheng & Boey, 2000; Dabelko & DeCoster, 2007; DeCoster & George 2005; Lisbeth et. al., 2011; Trozzolino, et.al., 2003)

Case Management Intervention 

Community Health Worker 

Chronic Disease

http://patienteducation.stanford.edu/programs/diabeteseng.html

Casemanagementstlouis.com

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Home Health

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Mental Health

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Videophone

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Telephonic

(Garrelts et.al. 2010; Hawkins, 2010; Lee, 2004; Leeman et.al. 2008; Skelly, 2010; Spencer et.al 2008)

MOTIVATIONAL INTERVIEWING Evidenced-Based Approach to Behavior Change

Motivational Interviewing “… a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”  Developed

by William Miller 1983  www.motivationalinterview.org   

Motivational Interviewing and Healthcare Motivational Interviewing and Older Adults Motivational Interviewing and Diabetics

(Chen et.al, 2012; Cummings et.al., 2009; El-Mallakah et.al, 2012; Hunt, 2011; Miller & Rollnick, 2002; Minet

et. al 2011; Ridge et. al. 2012; Rubak, 2009; Welch et. al. 2006; Welch et.al. 2010)

No Time for Listening 

Brief, Practical Medical Interventions

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Effective discussion on front end can reduce headache on back end

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Increase success with “non-compliant” patients

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Increase levels of “change talk” and decrease resistance to change

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Well-intended suggestions fall on deaf ears

The Visit http://www.youtube.com/watch?v=80XyNE89eCs

http://www.healthteamworks.org/guidelines/MotivationalInterviewing.html

Based on her conversation with the MD, is she likely to stop smoking ?  

1___2___3___4__5___6___7__8__9__10___ 1= not at all 10= absolutely

Stages of Behavior Change 

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Precontemplation  ”I don’t have a problem” Contemplation  “I know I should change”

Preparation  “I’m taking steps to do something soon” Action  I’m doing it!!” Maintenance  “I’ve been doing it for at least 6 months!”

Relapse  ”OOPS!”

Stages of Behavior Change

http://well-fitbodies.com/yahoo_site_admin/assets/images/Stages_of_Change.23130956_std.JPG

MI Techniques 

Ask permission to discuss issue “You’ve been having these worrisome lab results, can we discuss this ?”

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Reflective listening Say back what you hear them saying; focus on ambivalence

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Ask open-ended questions “What might your life look like without this change?”

wrmtraining.com 

Elicit a response “What do you know about..”

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Give affirmation “This is really hard” (use scale)

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Summary of conversation and interventions

Scale of Change 

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Assess “Readiness”, “Confidence” and, “Importance” of change by using scale

1___2___3___4__5___6___7__8__9__10___ 1= not at all 10= absolutely

MI Techniques in Action Motivational Interviewing-Evoking a Commitment to Change http://www.youtube.com/watch?v=dm-rJJPCuTE

http://www.healthteamworks.org/guidelines/MotivationalInterviewing.html

GUIDE/INSTRUCTOR/LISTENER 

The Guide- asking open ended questions to raise doubt and help patients make informed decisions(“What might your life look like if you don’t make these changes?”)

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The Instructor- being more directive when the time is right

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The Listener- gathering information about the patient’s situation; focusing on their ambivalence

socialmediagovernance.com

DARES Principles 

Develop Discrepancy-patient should present arguments for change

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Avoid Argumentation-back off if too much resistance

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Roll with resistance- try to understand where they are

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Express empathy- reflective listening

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Support self-efficacy- support ability to change and

coming from (“I hate these meds”; “It hurts giving myself shots”)

build confidence

Miller WR, Rollnick S. Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guilford Press; 2002.

Effective Physician Video http://www.youtube.com/watch?v=URiKA7CKtfc

http://www.healthteamworks.org/guidelines/MotivationalInterviewing.html

Community Resources National 

American Association of Diabetes Educators www.diabeteseducators.org

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American Diabetes Association- www.diabetes.org

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Area Agency on Aging – National Website www.aaaphx.org/

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National Center for Chronic Disease Prevention and Health Promotion – www.cdc.gov/nccdphp

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National Diabetes Educational Program- www.ndep.nih.gov

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National Institute on Diabetes and Digestive and Kidney Diseaseswww.niddk.nih.gov

State 

Area on Aginghttp://www.georgiaservicesforseniors.org/Default.aspx#OutputAnchor

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Atlanta Regional Commission Age Wise - www.agewiseconnection.com

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Community Care Services Program (CCSP) 404-463-3333

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GA Area Agencies on Aging- http://www.georgiaservicesforseniors.org/

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Service Options Using Resources and Community Environments (SOURCE) (404) 463-3248 www.payingforseniorcare.com/

http://www.georgiaservicesforseniors.org/

Community Resources cont. Local Atlanta Medical Hospital- (404)265-4000 www.atlantamedicalcenter.com/ 

DeKalb Medical Center- (404) 501-1000 www.dekalbmedical.org

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Diabetes Association of Atlanta (Multiple Support Programs) www.diabetesatlanta.org Emory Healthcare System- (404) 778-7777 www.emoryhealthcare.org/ Grady Diabetes Clinic- Main: (404)616-3731 Pharmacy: (404)616-5500 www.gradyhealth.org/

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Piedmont Hospital: Sixty Plus Older Adult Services- (404) 605-3857 www.piedmonthospital.org

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Project Open Hand - Meal Program (Numerous)- (404) 872-6947 www.projectopenhand.org United Way- (211) www.211online.unitedwayatlanta.org

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Mental Health for Older Adults (Local)  Anchor Hospital (Supportive Care Unit)- (770) 991-6044 www.anchorhospital.com 

Emory Wesley Woods Center-(404) 728-6200 www.emoryhealthcare.org/senior-health-center/index.html

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GA Crisis Line - 1-800-715-4225 www.mygcal.com

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National Alliance on Mental Illness (NAMI) – www. nami.org Peach ford Hospital- (770) 455-3200 www.peachfordhospital.com

Ridgeview Institute-(770) 434-4567 http://www.ridgeviewinstitute.com/pat_serv_senior.htm  Summit Ridge (Senior Adult Inpatient Program)- (678) 442-5800 www.summitridgehospital.net Other Resources 

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Stanford Chronic Disease Self-Management Program - Diabetes specific http://patienteducation.stanford.edu/programs/diabeteseng.html WIC Works Resources-Sample MI statements and questions. www.nal.usda.gov/wicworks/WIC_Learning.../questions_MI.pdf

Questions and Answers

Feel free to ask any questions or add comments!

References Alberti G. The DAWN (Diabetes Attitude, Wishes and Needs) study. Practical Diabectology International. 2002; 19(1): 22-24. Bertera E. (2003). Psychosocial factors and ethnic disparities in diabetes diagnosis and treatment among older adults. Health and Social Work; 28(1) 33-42. Chen, Shu Ming, Creedy D, Lin Huey, & Wollin J. (2012). Effects of motivational interviewing intervention on selfmanagement, psychological and glycemic outcomes and Type 2 Diabetes: randomized controlled trial. International Journal of Nursing Studies, 49(6):367-644. Cummings S, Cooper R, & Cassie K. (2009). Motivational interviewing to affect behavioral change in older adults. Research on Social Work Practice, 19(2):195-204. dio: 10.1007/s10461-011-0016-x Dabelko H &DeCoster V. (2007). Diabetes and Adult Day Health Services. Health & Social Work, 32(4)279-288. DeCoster , V. (2001). The psychosocial challenges of Type 2 Diabetes and the roles of health care social work: A neglected area of practice. Health & Social Work, 26, 26-37. DeCoster, V. & Cummings, S. (2005). Helping adults with Diabetes: A review of evidence based interventions. Health & Social Work, 30, 259-264. DeCoster V. (2009). Diabetes treatments. Cummings S and N Kropf (Eds.) Handbook of Psychosocial Interventions with Older Adults: Evidence- Based Approaches. New York, NY. Routledge/ Taylor & Francis Group.102-125. dio:10.1080/01634370802137843. DeCoster V. & George, L. (2005A). A community based self-help intervention of elders living with Diabetes. The Journal of Educational Gerontology, 31, 699-713.

DeCoster V. & George L. (2005)B. An empowerment approach for elders living with Diabetes: A pilot study of community-based self- help group: The Diabetes Club. Educational Gerontology, 31(9): 699-713.

References Dellasega, C., Anel- Tiangco, R., & Gabbay, R., (2012), How patients with Type 2 Diabetes Mellitus respond to motivational interviewing. Diabetes Research & Clinical Practice, 95(1): 37-41. dio: 10.3109/02813432.2011.554271. El-Mallakh P., Chlebowy D, Wall M, Myers J, & Cloud R. (2012). Promoting nurse interventionist fidelity to motivational interviewing a diabetes self-care intervention. Research in Nursing & Health, 35(3): 289-300. Funnell M, Anderson R, Austin A, & Gillespie S, (2007), AADE position statement: Individualization of diabetes selfmanagement education. The Diabetes Educator; 33; 45-49. dio:10.1177/0145721706298308. Hawkins S. (2010). Improving glycemic control in older adults using a videophone motivational diabetes selfmanagement intervention. Research and Theory for Nursing Practice: An International Journal; 24;217-231. dio: 10.1891/1541-6577.24.4.217. Hewitt J, Smeeth L, Chaturvedi N, Bulpitt C, & Fletcher A. (2010). Self management and patient understanding of diabetes in the older person. Diabetic Medicine, 28, 117-1222. dio: 10.1111/j.1464-5491.2010.03142.x. Hunt J. (2011). Motivational interviewing and people with diabetes. European Diabetes Nursing. 8(2): 68-73b. dio: 10.1002/edn. 180. Jack, Jr., L, Airhihenbuwa C, Namageyo-Funa A, Owens M, & Vinicor F. (2004). The psychosocial aspects of diabetes care using collaborative care to manage older adults with Diabetes. Geriatrics. 59(5): 26-31. Lee, J.(2004). A profile of diabetic African American elderly receiving home health care: Implications for social workers, Journal of Social Work in Long- Term Care; 3 (2): 13-30. Leeman J., Skelly A., Burns D., Carlson J., & Soward A.(2008). Tailoring a Diabetes self-care intervention for use with older, rural African American woman. The Diabetes Educator. 34:310-317. Ling Cheng, Boey K. (2000). Coping, social support, and depressive symptoms of older adults with Type II Diabetes Mellitus, Clinical Gerontologist; 22(1): 15-29.

References Lustman P, Anderson RJ, Freeland KE, de Groot M, Carney RM, & Clouse RE. (2000). Depression and poor glucose control: A review of the literature. Diabetes Care.23:934-942. Lustman PJ, Clouse RE. (2004). Depression: A potentially modifiable risk factor for diabetes and its complications. Diabetes Spectrum, 17: 147-166. MacLean L, White, Jr., J, Broughton S, Robinson J, Shuitz J, Weeks D, & Willson M, (2012), Telephone coaching to improve diabetes self-management for rural residents, Clinical Diabetes, 30(1):13-16. Miller WR & Rollnick S. (2002) Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guilford Press.. Norris S, Nichols P, Caspersen C, Glasgow R, Engelgau M, Jack Jr.,L, Isham G, Synder S, Carande-Kulis V, Sanford G, Briss P, McCulloh D, & the Task Force on Community Presentive Services (2002), The effectivesness of disease and case management for people with diabetes, American Journal of Medicine , 22(4S) 15-38. Pitchert J, Anderst J, & Miller (2001) Teaching Persons with Low Literacy Skills. In: M. Franz, K. Kulkarni, W. Polonsky, P. Yarborough , & V. Zamudio (Eds.), Diabetes Education and Program Management: A Core Curriculum for Diabetes Education and Program Management. 4th ed. (123- 141) Chicago, Ill: American Association of Diabetes Educators. Pratt, C., Wilson, W., Leklem, J., & Kingsley, L., (1987), Peer support and nutrition education for older adults with diabetes, Journal of Nutrition for the Elderly, 6(4): 31-43. Ridge, K. Treasure, J., Forbes, A., Thomas, S. & Ismail K., (2012), Themes elicited during motivational interviewing to improve glycemic control in adults with Type 1 Diabetes Mellitus, Diabetes Medicine, 29(1): 148-152. dio: 10.1111/j.1464-5491.2011.03384.x

References Rosenbek Minet L, Lønvig, Erik Henriksen J, & Wagner L, (2011), The experience of living with diabetes following a self- management program based on motivational interviewing, Qualitative Health Research, 21(8): 1115-1126. dio: 10.1177/1049732311405066 Rubak, S., Sandbaeaek, A., Lauritzen, T., Borch- Johnson, K., & Christensen, B., (2011), Effect of “motivational interviewing” on quality of care measures in screen detected Type 2 Diabetes and patient: one year follow up of an RCT, ADDITION Denmark, Scandinavian Journal of Primary Health Care, 29(2): 92-98. Rubak. S., Sandbaeaek, A., Lauritzen, T., Borch- Johnson, K., & Christensen B., (2009), General practitioners trained in motivational interviewing can positively affect the attitude to behavior diabetes, Scandinavian Journal of Primary Health Care, 27(3): 172-179. Schilllinger D, Grumbach K, Piette J, Wang F, Osmond D , Daher C , Palacios J, Sullivan G, & Bindman A,(2002), Association of Health Literacy with Diabetes Outcomes. JAMA. 288(4):475-482. Skelly, A. (2010). Randomised controlled trial: Culturally tailored intervention for African American with Type 2 Diabetes administered by a nurse case manager and community health worker reduces emergency room visits. Evidence Based Nurse. 13(2):51-52. Skovlund SE, Peyrot M. &DAWN International Advisory Panel (2005), The Diabetes Attitudes, Wishes and Needs (DAWN) program: A new approach to improving outcomes of diabetes care. Diabetes Spectrum. 18:136-142. Spencer M, Rosland A, Kieffer E, Sinco B, Valerio M, Palmisiano G, Anderson M, Guzman J, & Heisler M, (2011), Effectiveness of a community health worker intervention among African American and Latino adults with Type 2 Diabetes: A randomized controlled trial. American Journal of Public Health. 101(12):2253-2260.

References Strodl E & Kenardy J, (2006), Psychosocial and non-psychosocial risks factors for the diagnosis of diabetes in elderly women. Diabetes Research and Clinical Practice; 74: 57-65. dio: 10.1016/j.diabres.2006.02.011 Trief P, Morin P, Izquierdo R, Teresi J, Emicke J, Goland R, Starren J, Shea S, & Weinstock R, (2006). Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project. Diabetes Care, 29(4): 830-5. Welch G, Zagarins S, Feinberg R, & Garb J, (2011), Motivational interviewing delivered by diabetes educators: does it improve blood glucose control among poorly controlled Type 2 Diabetes patients? Diabetes Research and Clinical Practice; 91: 54-60. Welch G, Garb J, Zagarins S, Lendel I, & Gabbay R, (2010), Nurse Diabetes case management interventions and blood glucose control: results of a meta-analysis. Diabetes Research and Clinical Practice; 88(1): 1-6. WIC Works Resources, (N.d) Sample mi statements and questions. Retrieved from: www.nal.usda.gov/wicworks/WIC_Learning.../questions_MI.pdf

Williams , G. & Zeldman, A. (2002). Patient-centered Diabetes Self-Management education. Current Diabetes Reports, 2, 145-152. Williams, J., Katon W., Lin, E., & Noel, P. et al. (2004). The effectiveness of depression care management on Diabetes-Related Outcomes in older patients. Annals of Internal Medicine, 140, 1015-1024.