Links To Medical Management

One of the key advantages to office-based psychosocial interventions is that the potential exists for coordination with, and integration into, regular clinical practice. Behavioural and psychological issues can be treated by health care staff and seen by patients as a regular part of patient care. This is in contrast to the situation that currently exists in most settings, in which a 'psychological or diabetes education/self-management' referral is seen as stigmatizing, separate from usual patient care, and something that is often poorly connected with the medical management of diabetes.

Still, just because an intervention is conducted in the office setting is no guarantee that it will be integrated with, or consistent with, other aspects of a patient's care. It is essential that all health care team members be aware of what other team members are working on with a patient, that they reinforce each other's efforts, and that they do not overwhelm the patient with too many goals and priorities at once. Such coordination and mutual support is much more likely to happen if it is programmed into the office practice and prompted by the use of patient goal setting and strategy forms (see Figure 6.4) rather than left to chance.

As reviewed above, there are different models for determining which staff member implements the behavioural strategies, and advantages and limitations to each. In terms of consistent and quality implementation, it makes most sense to have behavioural interventions delivered either by behavioural specialists experienced in diabetes and working in health care settings, by diabetes educators trained in behavioural intervention, or by user-friendly, highly interactive multi-media computer-based applications. The present-day reality, however, is that few offices, and especially few primary care settings responsible for treating the patients most in need, will have the resources to adopt such strategies.

It is also clear that one does not need to be a highly trained psychologist to deliver most of the behavioural intervention strategies that have been reviewed above. The few studies that have evaluated counsellor characteristics have not found one type of health professional to be more effective than others at producing behaviour change. This of course assumes that staff members are well trained and receive adequate supervision and feedback. From a social influence perspective, it makes most sense to have a physician deliver the intervention. In practice, this is seldom possible due to the extreme time limitations and lack of training of physicians in behavioural intervention83. The doctor is probably best utilized as a motivator, who can briefly emphasize the importance of behavioural goals and of working with the interventionist. The most generalizable model, especially in managed care settings, is probably to have some form of automated assessment, followed by a motivational message from the physician, and then intervention and follow-up conducted by a nurse or case manager.

The greatest opportunity for linking to medical management and improving overall quality of diabetes care lies in the area of tracking guidelines for preventive care, such as those developed by the American Diabetes Association and various other organizations, for all patients in an office practice. This assumes an accurate diabetes registry and a list of guidelines or best practices that includes behavioural, psychosocial and patient-focused issues6 in addition to medical and laboratory screening activities. The second most important issue, and one that has impressive empirical support, is to conduct brief follow-up contacts with patients, as discussed above.

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