In 2014, the Centers for Disease Control and Prevention Diabetes Report Card reported an overall national score of 57.6% for persons with diabetes (PWD) who ever attended a diabetes self-management class. When considering the direct and indirect costs of diabetes (a staggering 240 billion dollars in 2012), the need for quality self-management education becomes evident. The need for Certified Diabetes Educators (CDE) in home healthcare has never been greater.

Since the early part of the 1990s, I have been working with the diabetes population in the home healthcare setting and became a CDE through meeting the clinical practice criteria, based on my home care clinical experience. Although not the norm, it is possible to attain practice requirements to sit for the credentialing exam based on home healthcare practice. For further information on the current requirement, check the National Certification Board for Diabetes Educators (NCBDE) Web site-http://www.ncbde.org/certification_info/.

A CDE practicing in the home care setting has the distinct advantage of being able to assess through observation and discussion, the PWD in their own environment, surrounded by their available support system, and within their own community. Keep in mind that, on a day-to-day basis, diabetes mellitus (DM) is primarily managed by the patient. For a PWD to be successful, they need more than the "survival skills" most professionals consider basic diabetes education-diet, medication, blood glucose testing, signs and symptoms to report, and actions to take. They need an "individualized care/teaching plan" starting where the PWD is the one to identify the greatest need in their management plan. The ability to identify and solve problems is an essential key to successful self-management of DM-this requires guided practice by the patient, coaching from the professional, and support from the patient's diabetes team.

DM, when left uncontrolled (unmanaged), affects and causes destruction in every major body organ system over time. Many patients who are referred to home care have a primary diagnosis considered a comorbidity of DM, such as heart failure, peripheral vascular disease with ulceration of the lower extremities, peripheral neuropathy leading to poor balance, increased falls, and diabetic ulcers (when combined with vascular compromise). Regardless of the primary diagnosis for home care, when a PWD is referred for service, a comprehensive assessment with a focused diabetes self-management assessment is indicated.

An evidence-based approach in assessment of diabetes self-management leads to consistency in service and care provided. The American Association of Diabetes Educators (AADE) has published the AADE7-Self-Care Behaviors(TM), which I use as a basis for a comprehensive approach to assessment, teaching, and coaching of patients. Most clinicians have a comfort zone with instructing "survival skills" such as medications, healthy eating, activities, and monitoring; however, also essential within this paradigm are the skills of reducing risky behaviors, healthy coping, and problem solving. In addition to assessing cognitive and functional ability to perform tasks associated with diabetes management, the PWD's readiness to learn, motivation, and confidence level (self-efficacy) will impact accomplishment of goals and ability to self-manage day-to-day.

Prior to meeting a patient for the initial admission visit, I gather as much historical data as possible from the referral source. Depending on where you practice, this information may either be plentiful or scarce. For basic preparation, I search out type of diabetes, date of onset/years since diagnosis, date of the last hospitalization, relationship to diabetes and/or diabetes-associated complications, most recent glycosylated hemoglobin level, number of diabetes-related hospitalization/emergency department visits in the past year, immunizations, and confirm the physician/nonphysician practitioner managing the patient's diabetes and diabetes-related complications.

After the initial introductions when meeting the patient, I set the tone for the diabetes self-management experience. I discuss my perspective-they are a "person first and foremost" who has a disease called diabetes, which they have the ability to control and manage. They are not the disease (not a "DIABETIC"), but if left unmanaged the disease will control them.

For each new patient admission for diabetes management, a comprehensive home care assessment is completed with emphasis on a "focused diabetes self-management assessment." Regardless of how long the patient has been diagnosed with DM, observing (not just talking about) their skill set is absolutely essential to gathering baseline information. Through observation, I have found patients who have been administering insulin for several years not preparing, storing, or discarding insulin properly, injecting into wrong sites, and/or having serious insulin leak-back issues-all leading to unstable blood sugar levels and elevated glycosylated hemoglobin levels. In other words-these patients did not understand how to manage their diabetes, even though they had education on insulin and injections at the onset of insulin use-a time often associated with high anxiety levels.

Starting from the patient's priority, discussion occurs to establish measurable goals with date points. Most goals have a behavior related to accomplishment-such as-blood glucose testing will be performed twice a day before breakfast and dinner and recorded. The goals established are integrated into the plan of care and serve as an anchor for interventions planned to establish independent and safe diabetes self-management. It is critical the PWD gain not only knowledge of diabetes self-management, but also self-confidence in their ability to manage DM.

During revisits, first and foremost is evaluating the patient's success in accomplishing their goal since the last visit. Together we review the "patterns" of their day-to-day management, what worked and what didn't work and most importantly why it worked or didn't work. Once the PWD starts to be able to correlate the "why" to the outcome, the platform for problem-solving begins. At this point, education is provided, correlating to the "why" and the PWD is coached to begin exploring alternatives for success if indicated by the outcome, or select the next goal to accomplish.

For PWD who are having difficulty with certain aspects of their management (such as hyperglycemia in the morning, hypoglycemia at night), I will call them in between visits to check on their status and provide education and coaching to aid them in meeting their goal. A 2- to 5-minute assessment phone call once or twice a week provides opportunity to tweak the management plan, provide coaching, and in some cases prevent a trip to emergency department and/or hospitalization.

There are patients who will not choose to manage their DM. They may administer meds perfectly, perform blood glucose monitoring precisely, and repeat back what they should do in certain situation; however, in day-to-day life, they do not use their skills to self-manage. They are not ready to learn, may be unmotivated, depressed, in denial, or angry. Consult the diabetes team and explore possible options in addressing the root cause. Just providing diabetes education is not the answer.

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