Clinician Role

The clinical role of the diabetes educator is a critical first encounter. Clinical background, including knowledge of the Clinical Practice Standards (3), facilitates recommendations for patient education and implementation of the treatment plan; it also fosters independence and access to the healthcare team. Clinical services (Table 3) provided often include objective analysis of current healthcare practices, preferences, and knowledge base, and assisting the person with diabetes to achieve metabolic control, following the DCCT goal Metabolic Control Matters (18). The person's understanding of personal clinical status, acquisition of technical skills, communication with clinicians, and observation of physical and emotional challenges, etc. are crucial to the development of a plan for care, guidance in achievement, and educational planning. This clinician educator role may occur in the inpatient or outpatient setting, through referral from the same or a different clinical setting, and the service can be delivered in a variety of creative ways (person to person, electronically, via the mail service, etc.). The clinical delivery alternatives also imply a modified team, which may include a variety of providers and specialists. Addressing risk reduction is a primary focus and the average patient will need hugely complex medical regimes involving multiple antidiabetic, antihypertensive, dlp's and lipid-lowering agents to achieve target. Management strategies consider (19):

■ Minimizing cost

■ Minimizing weight gain

■ Minimal injections (using a combination of pills, plus)

■ Minimal circulating insulin (order of introduction of agents)

■ Minimal patient effort (improves adherance, increases motivation, minimizes effort)

Hypoglycemia avoidance

■ Postprandial targeting (better control achievement)

Family practice physicians appear to recognize and incorporate clinical and educational care into their diabetes-related visits. Chronic illness provides multiple opportunities for patient education over time and chronic illness visits can be used as 'teachable moments' to facilitate collaborative care (21). Diabetes care requires distinctly different visits than an acute care illness (probably also life style versus other chronic diseases). A direct observational study found that 2.5 patient visits redo content and readdress physical needs, versus 2.1 visits for other chronic diseases, and 1.8 visits for acute care. More problems result in more visits. The amount of time spent on chronic topics, such as diet (meal planning), advice, negotiation, assessment of compliance, (achievement) exercise (activity planning), etc., is more for advanced patients and less for patients undergoing procedures (21).

TABLE 3 Organizing Diabetes Care: Strategies

1. Accurately identifying patients with diabetes

2. Monitoring one or more important clinical parameters, such as A1C or cholesterol levels

3. Prioritizing patients based on their clinical status and readiness to change

4. Intensifying care through active outreach or visit planning

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