Objective. To describe a comprehensive strategy for implementing an effective diabetes self-management support intervention incorporating goal-setting and followup support in community health clinics (CHCs) serving vulnerable patients. Methods. The Replicating Effective Programs (REP) framework was applied to develop an intervention strategy. In order to create a strategy consistent with the REP framework, four CHCs engaged in an iterative process involving key-informant interviews with clinic staff, ongoing involvement of clinic staff facilitating translational efforts, feedback from national experts, and an instructional designer. Results. Moving through the REP process resulted in an implementation strategy that aims to facilitate commitment, communication, and change at the clinic level, as well as means of providing interactive, time-limited education about patient behavior change and support to health care providers. Conclusion. The REP offered a useful framework for providing guidance toward the development of a strategy to implement a diabetes self-management intervention in CHCs serving medically underserved and underrepresented patient populations. 1. Introduction Effective patient self-management has been demonstrated to prevent adverse clinical outcomes from diabetes [1, 2]. While research has examined factors that influence patient receptivity and use of self-management skills, there has been less attention to the delivery of diabetes education and support in primary care settings, where most patients receive this counseling [3–5]. In fact, the quality of diabetes self-management support delivered in primary care falls short of that demonstrated to improve outcomes. Delivering even basic diabetes education is challenging to busy primary health clinics, much less providing ongoing support which addresses the many factors influencing patients’ ability to make significant lifestyle changes and integrate complex tasks into their daily lives such as problem-solving, collaboration, psychosocial issues, and behavior change skills [3, 4, 6]. Collaborative goal-setting between health care providers and patients has been proposed as a strategy for providing diabetes-related self-management support in busy primary care settings [7, 8]. Because research suggests that goal-setting increases patients’ self-efficacy and motivation to continue developing and maintaining self-management behaviors [9–11], goal-setting is now a common strategy in the more comprehensive Diabetes Self-Management Education curricula reimbursed by the Centers for Medicare and
References
[1]
T. L. Gary, J. M. Genkinger, E. Guallar, M. Peyrot, and F. L. Brancati, “Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes,” Diabetes Educator, vol. 29, no. 3, pp. 488–501, 2003.
[2]
S. L. Norris, J. Lau, S. J. Smith, C. H. Schmid, and M. M. Engelgau, “Self-management education for adults with type 2 diabetes. A meta-analysis of the effect on glycemic control,” Diabetes Care, vol. 25, no. 7, pp. 1159–1171, 2002.
[3]
M. Peyrot, R. R. Rubin, M. M. Funnell, and L. M. Siminerio, “Access to diabetes self-management education: results of national surveys of patients, educators, and physicians,” Diabetes Educator, vol. 35, no. 2, pp. 246–263, 252–256, 258–263, 2009.
[4]
M. Peyrot and R. R. Rubin, “Access to diabetes self-management education,” The Diabetes Educator, vol. 34, no. 1, pp. 90–97, 2008.
[5]
S. M. Schappert and E. A. Rechtsteiner, “Ambulatory medical care utilization estimates for 2006,” National Center For Health Statistics, no. 8, pp. 1–29, 2008.
[6]
M. M. Funnell, T. L. Brown, B. P. Childs et al., “National standards for diabetes self-management education,” Diabetes Care, vol. 32, supplement 1, pp. S87–S94, 2009.
[7]
K. MacGregor, M. Handley, S. Wong et al., “Behavior-change action plans in primary care: a feasibility study of clinicians,” Journal of the American Board of Family Medicine, vol. 19, no. 3, pp. 215–223, 2006.
[8]
T. Bodenheimer and M. A. Handley, “Goal-setting for behavior change in primary care: an exploration and status report,” Patient Education and Counseling, vol. 76, no. 2, pp. 174–180, 2009.
[9]
R. Marks, J. P. Allegrante, and K. Lorig, “A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part II),” Health Promotion Practice, vol. 6, no. 2, pp. 148–156, 2005.
[10]
P. A. Estabrooks, C. C. Nelson, S. Xu et al., “The frequency and behavioral outcomes of goal choices in the self-management of diabetes,” Diabetes Educator, vol. 31, no. 3, pp. 391–400, 2005.
[11]
K. Lorig, “Action planning: a call to action,” Journal of the American Board of Family Medicine, vol. 19, no. 3, pp. 324–325, 2006.
[12]
M. M. Funnell, T. L. Brown, B. P. Childs et al., “National standards for diabetes self-management education,” Diabetes Care, vol. 31, supplement 1, pp. S97–S104, 2008.
[13]
M. M. Funnell, T. L. Brown, B. P. Childs et al., “National standards for diabetes self-management education,” Diabetes Care, vol. 30, no. 6, pp. 1630–1637, 2007.
[14]
Institute for Healthcare Improvement, “Self management support measures,” http://www.ihi.org/knowledge/Pages/Changes/SelfManagement.aspx.
[15]
R. E. Glasgow, H. Whitesides, C. C. Nelson, and D. K. King, “Use of the patient assessment of chronic illness care (PACIC) with diabetic patients: relationship to patient characteristics, receipt of care, and self-management,” Diabetes Care, vol. 28, no. 11, pp. 2655–2661, 2005.
[16]
E. G. Eakin, S. S. Bull, R. E. Glasgow, and M. Mason, “Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations,” Diabetes/Metabolism Research and Reviews, vol. 18, no. 1, pp. 26–35, 2002.
[17]
S. A. Duke, S. Colagiuri, and R. Colagiuri, “Individual patient education for people with type 2 diabetes mellitus,” Cochrane Database of Systematic Reviews, no. 1, Article ID CD005268, 2009.
[18]
D. Schillinger, F. Wang, M. Handley, and H. Hammer, “Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes,” Diabetes Care, vol. 32, no. 4, pp. 559–566, 2009.
[19]
D. Schillinger, H. Hammer, F. Wang et al., “Seeing in 3-D: examining the reach of diabetes self-management support strategies in a public health care system,” Health Education and Behavior, vol. 35, no. 5, pp. 664–682, 2008.
[20]
L. J. Damschroder, D. C. Aron, R. E. Keith, S. R. Kirsh, J. A. Alexander, and J. C. Lowery, “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science,” Implementation Science, vol. 4, no. 1, article 50, 2009.
[21]
A. M. Kilbourne, M. S. Neumann, H. A. Pincus, M. S. Bauer, and R. Stall, “Implementing evidence-based interventions in health care: application of the replicating effective programs framework,” Implementation Science, vol. 2, no. 1, article 42, 2007.
[22]
B. A. Rabin, R. C. Brownson, D. Haire-Joshu, M. W. Kreuter, and N. L. Weaver, “A glossary for dissemination and implementation research in health,” Journal of Public Health Management and Practice, vol. 14, no. 2, pp. 117–123, 2008.
[23]
H. A. Pincus, L. Hough, J. K. Houtsinger, B. L. Rollman, and R. G. Frank, “Emerging models of depression care: multi-level (“6 P”) strategies,” International Journal of Methods in Psychiatric Research, vol. 12, no. 1, pp. 54–63, 2003.
[24]
H. K. Seligman, A. S. Wallace, D. A. DeWalt et al., “Facilitating behavior change with low-literacy patient education materials,” American Journal of Health Behavior, vol. 31, supplement 1, pp. S69–S78, 2007.
[25]
D. A. DeWalt, T. C. Davis, A. S. Wallace et al., “Goal setting in diabetes self-management: taking the baby steps to success,” Patient Education and Counseling, vol. 77, no. 2, pp. 218–223, 2009.
[26]
A. S. Wallace, H. K. Seligman, T. C. Davis et al., “Literacy-appropriate educational materials and brief counseling improve diabetes self-management,” Patient Education and Counseling, vol. 75, no. 3, pp. 328–333, 2009.
[27]
A. L. Sussman, R. L. Williams, R. Leverence, P. W. Gloyd, and B. F. Crabtree, “The art and complexity of primary care clinicians' preventive counseling decisions: obesity as a case study,” Annals of Family Medicine, vol. 4, no. 4, pp. 327–333, 2006.
[28]
T. W. Malone and M. R. Lepper, “Making learning fun: a taxonomy of intrinsic motivations for learning,” in Aptitude, Learning, and Instruction: III. Conative and Affective Processes Analysis, R. E. Snow and M. J. Farr, Eds., Lawrence Erlbaum, Hillsdale, NJ, USA, 1987.
[29]
D. G. Goldberg, S. S. Mick, A. J. Kuzel, L. B. Feng, and L. E. Love, “Why do some primary care practices engage in practice improvement efforts whereas others do not?” in Health Services Research, 2012.
