1. Burson, Rosanne DNP, ACNS-BC, CDE, FAADE
  2. Moran, Katherine J. DNP, RN, CDE, FAADE

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Q: I am frustrated with all of my diabetes patients who are noncompliant. Why do they not just follow what the doctor told them to do? What can I do to help my patients follow their management plan?


Over the past few decades, the view of the patient's role in diabetes has evolved from that of compliant or noncompliant to the current concepts of empowerment, engagement, and shared decision making. Compliance suggests that the patient just follows what he or she is told to do. Noncompliance is attributed to denial, lack of will power, or deciding not to follow doctor's orders (Marrero et al., 2013). For patients with chronic disease, such as diabetes, the issue is much more complex. Patients are in control of their self-management. The choices they make will affect their outcomes and it is their right and responsibility to be the primary decision makers (Funnell et al., 2014).


For home healthcare clinicians to be effective in supporting patients with diabetes, one must look beyond the "do as I say" role and move to one of guidance. Believing that the patient is an expert in his or her life is paramount to moving forward as a team. Being willing to listen and ask questions rather than just delivering the answers can initially feel uncomfortable. However, with practice, the clinician can assist the patient in a much more motivating encounter that may result in improved outcomes.


A first step can be clarifying roles with the patient. Help him or her understand that they are the experts in themselves and that you and their provider are experts in discussing health options and acting as a support and guide. Work on developing an understanding that your time together is about defining what is important to them, identifying challenges they are having that may be barriers to their success, and creatively coming up with a workable plan.


Asking the patients to identify what is important to them in their life can assist with the process of assessment. For instance, they may state that they want to be able to play with their grandchildren. In response, you might ask what keeps them from being able to play with their grandchildren. If they state that they are extremely fatigued and do not have the energy to play, you can ask permission to share information that may assist them in overcoming this obstacle. Asking permission to share information can keep you and the patient in a partnership mode. At this point, you can share the effects of hyperglycemia, lack of sleep, and inadequate nutrition on energy. The patient may be able then to identify which aspects are contributing to this symptom. Developing individual goals that move the patient toward where they want to be is crucial to engagement and motivation.


When the home healthcare clinician is able to assess in this manner, several features are noted. Relationship and trust between patient and clinician strengthen. The home healthcare provider needs to be a coach who helps the patients walk themselves down a road of problem solving their individual situations. The clinician uses specific education that is needed just at the right time to help the patients understand the issues that they are interested in.


This process is actually a time saver because the discussion is streamlined to the areas that the patient is willing to work on. Rather than espousing all the information that you know about diabetes, you pull out the specific information that the patient needs to address in his or her current situation. It is helpful to jot down an agenda and a few open-ended questions to help you move from assessment to plan. Here is a sample agenda:


1. Discuss roles and expertise of the patient and the clinician.


2. Discuss the purpose of the meeting-what would the patient like to get out of the meeting.


3. Identify what is important to the patient (life issues that are not being accomplished because of health issues).


4. Have the patient identify what is keeping him or her from doing what is important.


5. Ask permission to share educational information that may shed light on their current situation.


6. Ask if any of this shared information seems to relate to the patient's specific situation.


7. When possible causes are identified, ask the patient what he or she feels can be done to move forward.


8. Motivated by his or her expressed interest, the patient develops a goal for moving forward.



The goal is that our patients are actively participating in their care and making informed decisions (Funnell et al., 2014). With these concepts in mind, the home healthcare clinician can move forward as an effective partner in the patient's self-management.


HHS Awards More Than $106 Million to Support State Home Visiting Programs

Health and Human Services Secretary Sylvia M. Burwell announced $106.7 million in fiscal year 2014 grant awards to 46 states, the District of Columbia, and five jurisdictions as part of the Maternal, Infant, and Early Childhood Home Visiting Program (Home Visiting Program) established by the Patient Protection and Affordable Care Act. These funds will allow states to continue and expand voluntary, evidence-based home visiting services to women during pregnancy and to parents with young children up to age 5 years. "The Home Visiting Program helps to ensure that young families have the option to participate in a program that promotes their children's healthy growth and development," Secretary Burwell said. "This announcement provides continued funding to support local home visiting programs as they work to improve the lives of children and families." The Home Visiting Program builds on decades of scientific research, which shows that families that choose home visits by a nurse, social worker, or early childhood educator during pregnancy and in the first years of life benefit from important support services for healthy children and families. Home visit programs have been shown to prevent child abuse and neglect, and promote child health and development. "These awards allow states to reach more parents and families in an effort to improve children's health while at the same time building essential supports within their communities," said Mary Wakefield, PhD, RN, administrator of the Health Resources and Services Administration (HRSA). HRSA administers the Home Visiting Program in partnership with the Administration for Children and Families to provide states with the resources they need to expand home visiting programs and early childhood systems. The Home Visiting Program serves as one part of a prenatal to age 5 years continuum with the other parts of President Obama's Early Learning Initiative: both high-quality infant and toddler care through Early Head Start-Child Care Partnerships and universal Pre-K to optimize the essential foundations in early childhood for future healthy development and well-being.

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Funnell M. M., Anderson R. M., Piatt G. A. (2014). Empowerment, engagement, and shared decisions, in the real world of clinical practice. Consultant, 53(5), 358-362. [Context Link]


Marrero D. G., Ard J., Delamater A. M., Peragallo-Dittko V., Mayer-Davis E. J., Nwankwo R., Fisher E. B. (2013). Twenty-first century behavioral medicine: A context for empowering clinicians and patients with diabetes: A consensus report. Diabetes Care, 36(2), 463-470. doi:10.2337/dc12-2305 [Context Link]