Unit 6 Assignment: Chronic Illness Self-Care Management Program
Chronic Illness Self-Care Management Program
Self-care management in Type 2 Diabetes Mellitus (T2DM) aims to enhance the ability of individual patients and their families to promote and maintain their health, particularly by preventing complications associated with the illness and generally coping with the illness. It involves practices, habits, and lifestyle choices that are incorporated into the patient’s life to promote their health. Self-care interventions for T2DM patients may also include medication adherence, treatment adherence, the use of self-management devices, diagnostic tests, patient monitoring digital tools, and regular follow-ups and screenings. This self-care management program details the goals, key resources and activities, self-management action plan, and evaluation presented to T2DM patients in a primary care setting.
Point of Management and Its Need/Literature Support
Diabetes, and more so T2DM, is one of the chronic illnesses that require continuous self-management to improve control and prevent complications. According to Ahmad and Joshi (2023), poor control of T2DM can potentially lead to severe complications, which include cardiovascular disease, neuropathy, retinopathy, and kidney failure. Patients with T2DM have a low quality of life and incur more healthcare costs, especially with associated complications.
A study by Wang et al. (2023) found that diabetes knowledge acquisition from self-care management programs plays a crucial role in improving diabetes self-management behaviors, consequently preventing complications, hospitalizations, and associated costs. Diabetes self-management education has also been associated with a positive impact on lifestyle changes and self-care in patients with T2DM (Ernawati et al., 2021). Therefore, there is a need to implement self-care management programs that empower patients to control their condition and prevent complications effectively.
Primary Goal and Program Goals
The primary goal of this program is to empower patients with T2DM to effectively manage their condition through education, self-monitoring, and adjustment to lifestyle modifications. The first program goal is to increase patient self-efficacy in managing blood glucose levels, improve adherence to medication, and promote lifestyle changes. The second goal is to reduce preventable hospitalizations and emergency visits by enhancing patient engagement in proactive care.
Key Resources and Activities
The key resources and activities that will be included in the program include the following:
Staffing
The staff responsible for educating and coaching patients are Certified Diabetes Educators (CDEs). The CDEs will be supported by primary care providers, who will offer medical oversight, registered dietitians for nutritional counseling, and community health workers who will provide additional support to patients and assist with follow-ups.
Content of the Support
Various valuable content resources will be used in this program. These include guidelines from the American Diabetes Association (ADA) and other online educational resources. Mobile apps will be used for tracking glucose levels, and peer group sessions will provide patients with shared experiences and motivation.
Patient Population Served
The patient population that will be served by this program includes adults diagnosed with T2DM and patients at risk for poor adherence to treatment plans. Additionally, the program will serve patients identified as having barriers to self-management, including those with low health literacy.
Information Support
The information support in this program will include materials such as digital and printed educational handouts, telehealth follow-ups for remote support, and a 24/7 free nurse helpline to address urgent patient queries.
Protocols
Staff members will provide support through structured coaching sessions that focus on glucose monitoring, medication adherence, and dietary choices. Additionally, routine follow-ups via videoconferencing will be used for patients who are unable to visit the clinic, while in-person visits will also be employed.
Staff Training
The staff providing education and coaching to patients will participate in ongoing professional development sessions on diabetes management to enhance their knowledge and competence. They will also be trained in communication skills to enhance patient engagement.
Communication with Patients
The staff will communicate with patients enrolled in the program through weekly check-ins via phone calls and text reminders. Secure patient portals will also be used to raise questions and provide program updates to the patients.
Team Communication
To enhance effective program delivery, the staff team will communicate using regular interprofessional case reviews. They will also use shared electronic Health Records (EHR) to ensure coordinated care.
Self-Management Action Plan
Among the self-management actions that the patient will be taught in this program are blood glucose monitoring, dietary adjustments, and physical activity. The patients will be taught to self-monitor blood glucose levels, recognize abnormal levels, and what to do in such cases. Additionally, they will receive coaching on portion control, carbohydrate counting, and meal planning to facilitate dietary adjustments. Furthermore, educators will work with patients to set realistic physical exercise goals aimed at improving insulin sensitivity and overall health.
According to Camargo-Plazas et al. (2023), shared decision-making in DSME program development enhanced patient participation and outcomes. Similarly, this program will ensure clinical decisions are made through shared decision-making. The staff will ensure that they take feedback from patients and incorporate it into program improvements. There will also be open and clear communication channels to enhance shared clinical decision-making among staff.
Furthermore, the program has been developed with health literacy considerations for all patients involved. For instance, the educational materials will be at an appropriate reading level based on the patient’s health literacy. Additionally, visual aids and hands-on demonstrations will be used to enhance learning and comprehension, hence assisting patients with low literacy levels.
Program Evaluation
Program evaluation is crucial in determining program effectiveness and ensuring that outcomes are achieved. Nutbeam and Muscat (2021) also note that program evaluation promotes learning and improvement of similar future programs. This program will be evaluated using patient engagement and clinical outcome measures. The patient engagement criteria will entail the percentage of patients attending scheduled education and coaching sessions, as well as self-reported adherence to medication and lifestyle adjustments. Additionally, clinical outcome measures will include a reduction in HbA1C levels within six months of program implementation and a decrease in preventable emergency visits and hospitalizations associated with T2DM among program participants.
Conclusion
Managing T2DM can feel overwhelming, but no one has to navigate it alone. This program is built around patients, recognizing that self-care is not only about numbers but also about feeling empowered, supported, and confident in managing your health. Whether it is learning to manage blood sugar levels, making healthier food choices, or finding a routine that works for you, our team is here to support you every step of the way. Overall, the program recognizes that every patient brings unique challenges, strengths, and experiences to their care journey. Therefore, it combines evidence-based education, personalized coaching, and ongoing support from a dedicated care team, aiming to reduce complications, hospitalizations, associated costs, and the emotional burden that often accompanies living with a chronic illness. More importantly, it seeks to empower patients to become active participants in their care, fostering lasting habits and self-efficacy.
References
Ahmad, F., & Joshi, S. H. (2023). Self-care practices and their role in the control of diabetes: A narrative review. Cureus, 15(7), e41409. https://doi.org/10.7759/cureus.41409
Camargo-Plazas, P., Robertson, M., Alvarado, B., Paré, G. C., Costa, I. G., & Duhn, L. (2023). Diabetes self-management education (DSME) for older persons in Western countries: A scoping review. PloS One, 18(8), e0288797. https://doi.org/10.1371/journal.pone.0288797
Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus (T2DM) patients: Systematic literature review. Journal of Public Health Research, 10(2), 2240. https://doi.org/10.4081/jphr.2021.2240
Nutbeam, D., & Muscat, D. M. (2021). Health Promotion Glossary 2021. Health Promotion International, 36(6), 1578–1598. https://doi.org/10.1093/heapro/daaa157
Wang, X., Tian, B., Zhang, S., Li, J., Yang, W., Gu, L., & Zhang, W. (2023). Underlying mechanisms of diabetes knowledge influencing diabetes self-management behaviors among patients with type 2 diabetes in rural China: Based on the Health Belief Model. Patient Education and Counseling, 117, 107986. https://doi.org/10.1016/j.pec.2023.107986
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Chronic Illness Self-Care Management Program
Background: Self-care management support programs assume a complex sequence of effects. Developers expect these programs to change patients’ behavior by increasing the patients’ self-efficacy and knowledge. Improved behavior is expected to lead to better disease control which should, in turn, lead to better patient outcomes and reduced utilization of health care services, particularly preventable emergency room visits and hospitalizations, and to reduced costs. This sequence of assumptions gives self-management support programs multiple objectives and multiple endpoints for evaluation. The pivotal objective, however, is to change people’s behavior.
In Word, you will create an introductory design of a self-management program with strategies to support improved outcomes in a particular chronic illness. Use the bold topics as level one headings in your paper. You are not to explain what a self-care management program is. You are to create base introductory content for one. Use the required reading as resources.
Self-Care Management Program: The first step in designing a self-management support process is identifying the point of management and its need. Examples could include primary care, inpatient hospital, telemedicine, sleep clinic, community home care, etc. Identify and describe the chronic illness. Include lifespan influences. Address the primary goal and two program goals with an ideal outcome. Include literature support for the benefit of self-management programs related to chronic illness. Self-care management programs provide both coaching and patient education. The provider is involved but not the main focus. The patient is the main focus, and other staff members have specific roles.
Key Resources and Activities: Include the following as level two headings.
- Staffing: Identify who will be doing the coaching and education as well as other support needed.
- Content of the Support: Include outside resources.
- Patient Population Served
- Information Support
- Protocols: How staff members are to provide the support.
- Staff Training
- Communication With Patients: How this will occur.
- Team Communication: Between providers and self-management support teams.
Self-Management Action Plan: Address three self-management actions of the patient that they will be taught and the associated goals. Include how clinical decisions will be discussed to facilitate shared decision-making. How does health literacy impact the plan’s development?
Evaluation: Address how the program will be evaluated. Identify at least two specific measures and criteria.
Appendix A: Structure model. Using SmartArt, create a simplistic visual representation of the self-management program with key points and an overview. Research for ideas and examples.
Include 3–5 pages of content in the paper, including an introduction and conclusion. Ensure the title page, reference page, and Appendix A are also included. These do not count toward the base page count. Be concise vs elaborative.