Q: What approach can I use in working with my diabetes patients to ensure their goals and outcomes are being met?

We have learned over the last decade that there are two components that contribute to improvements in patient outcomes: Standardized evidence and improvement in systems of care to approach the population (American Diabetes Association [ADA], 2017). The six core elements that optimize care are based on the Chronic Care Model and include: 1) Moving to a proactive rather than reactive system where planned visits are coordinated through a team-based approach, 2) self-management support, 3) basing clinical decisions on evidence-based guidelines, 4) using registries to identify patient and population information, 5) developing resources to support healthy lifestyle, and 6) creating a quality-oriented culture.

In order to provide this level of expertise, home care clinicians should be well educated in techniques of motivational interviewing, developing mutual goals, providing education, and monitoring progress. Home care clinicians should work closely with the primary care provider. They should use evidence-based guidelines to make sound decisions, be proactive, and provide resources to support the patient. Adding the home care perspective to the overall health system model and using data and quality outcomes to drive improvements complete the system approach that has been so successful to date.

Even with the system developments that have led to improved patient outcome measures such as A1c, blood pressure, and cholesterol management, there is still a consistent lack of continued improvement in measures, which may be due to social disparities. The patient focus and individualized plan is another area where the home care professional can excel. Applying the evidence to each individual is critical to developing a patient-centered plan. For example, home care professionals can assess the social context of the individual in relation to food insecurity, housing stability, and financial barriers and apply this information to the plan development. Social and environmental factors play a large role in development of Type 2 diabetes and obesity. "Social determinates of health can be defined as the economic, environmental, political and social conditions in which people live" (ADA, 2017, p. 58). Understanding the impact of the social determinants of health help the care provider identify areas that should be included in the plan of care.

Food insecurity is the unreliable availability of nutritious food. More than 14% of Americans are food insecure. The percentage is higher in some minority groups such as African Americans and Latino populations, low-income areas, and homes headed by a single mother. Food insecurity increases risk for Type 2 diabetes two times because the household may trade quality/nutrition for less expensive, high-carbohydrate processed foods, which can contribute to obesity. In addition, special attention to medications that lower glucose levels, like oral sulfonylureas and insulin, is important because an unreliable food source may increase the risk of hypoglycemia. Assistance with local resources can help patients get more nutritious food (ADA, 2017).

The use of lay health coaches and community healthcare workers can help those without access to education programs. Strong social support can lead to improved outcomes, decreased psychosocial issues, and better lifestyles. Community support can assist with language and cultural barriers, as well as help bridge financial difficulties. The key is to individualize patient care based on the needs of the patient, and then match community resources to meet those needs.

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