Health Care Team Issues

The core issue here is consistency and reinforcement of patient goals across different health care team members. Rather than having the physician emphasize medication, the nurse stress glucose testing, and the nutritionist recommend major dietary changes, all team members need to reinforce a common self-management behaviour for that visit. The Litzelman et al?5 study previously discussed provides a good example of how to coordinate preventive foot care activities, including brief education while patients are waiting to see the physician, having the nurse ask the patient to remove his/her shoes and socks before the physician arrives, followed by a physician foot examination and reinforcement of the patient education message about foot care. The patient needs to leave a given visit with a clear idea (and if possible a written 'goal' or 'contract sheet') of the key goal(s) for the next visit, and an understanding of why the goal is important to the management of his/her diabetes (see example, Figure 6.4). When patients are given assignments, it is particularly important, at the next visit or contact, to review and comment on any records that the patient has kept. The 1994 issue of Diabetes Spectrum, edited by Anderson and Jenkins,6 on educational innovations provides discussion of other issues in system-wide interventions, as does the special supplement to Diabetes Care edited by Mazze and Etzwiler68 and the conceptual article by Jenkins57.

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