U.S. Department of Health and Human Services

Principle 10: Provide Patient-Centered Diabetes Care

Providing patient-centered care is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” 1 Shared decision making—eliciting patient perspectives and presenting options and information so patients can participate more actively in care—is a key component of patient-centered care. 2, 3 Patient-centered care is also furthered by applying the medical home model that provides accessible, continuous, comprehensive, and coordinated care that is delivered by a health care team in the context of family and community. 4

Elements of patient-centered care for prevention and management of diabetes and its comorbidities include:

  • A proactive approach to health promotion, disease prevention, and chronic disease management
  • Respecting the patient’s values, preferences, and expressed needs
  • Development of individualized care plans incorporating access to community resources 5
  • Assessing the intersecting social, financial, clinical, and emotional needs of the patient
  • Care coordination among providers, including effective use of health information systems 6, 7
  • Communicating effectively and providing care in a culturally and linguistically appropriate manner

Collaborative multidisciplinary team care can enhance patient-centered care by providing continuous, supportive, and effective care for people with diabetes throughout the course of their disease. Well-implemented diabetes team care can be cost-effective or cost-neutral 8 and the preferred method of care delivery, particularly when services include health promotion and disease prevention in addition to intensive clinical management. The person with diabetes (or family) plays a central role as self-care manager and decision maker. Team care integrates the skills of primary care providers, physician specialists, and other health care professionals, such as diabetes educators, registered dietitians/registered dietitian nutritionists, and pharmacists, with those of the patient and family into a comprehensive diabetes management program. 9

Patient-centered care is challenging but rewarding. The expansion of options for treatment and prevention of diabetes and its complications provides greater opportunities for choice. However, information for tailoring care based on individual patient characteristics is often lacking. Patient preferences may conflict with evidence-based guidelines. Although discussion of treatment options, pros and cons of these alternatives, and patients’ goals and preferences requires time and effort, the process is key to patient satisfaction and good outcomes. People who report having a better experience with their health care providers are more likely to take their medicines regularly and follow other components of treatment plans.

Consideration of health literacy and numeracy

Attention to health literacy is essential if people are to successfully contribute to their diabetes management. A range of skills and knowledge about health and health care are required, including literacy and numeracy; the ability to find, understand, interpret, and communicate health information; and the ability to seek appropriate care and make critical health decisions. Older people, non-whites, immigrants, and those with low incomes are disproportionately more likely to have trouble reading and understanding health-related information. 10 Limited health literacy is associated with poorer health outcomes and higher health care costs. 11

Resources that address health literacy and numeracy

Comorbid conditions that involve team care coordination

In addition to increased risk of macrovascular and microvascular complications of diabetes, people with diabetes are at increased risk for many comorbid conditions, including depression, cancer, infectious disease, periodontal disease, liver disease, osteoarthritis, osteoporosis, sleep disorders, cognitive impairment, hearing loss, erectile dysfunction and hypogonadism in men, and urinary incontinence in older adults. Comorbid conditions can worsen diabetes control and outcomes through a variety of mechanisms, including limiting the time and resources available for diabetes care and prevention.

Nearly half of adults with diabetes have diagnosed arthritis, 12 which may limit physical activity. Inflammation associated with periodontal disease can worsen diabetes control, and both diabetes and periodontal disease are associated with increased cardiovascular disease (CVD) risk. Depression, which affects about one-quarter of those with diabetes, also increases the risk for CVD and can impede diabetes self-management. People with diabetes are at increased risk for pneumonia and influenza and have worse outcomes, heightening the importance of preventive vaccination. Hip fracture risk is increased in both type 1 and type 2 diabetes, despite higher bone mineral density in people with type 2 diabetes.

Hearing loss is doubled in adults with diabetes and can impair communication with health care providers. Cognitive impairment is also doubled and may precipitate medication errors and hypoglycemia risk. Severe vision loss is 29 times more common in patients with diabetes and may impose significant obstacles to good self-care. Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder. 13 Shared risk factors between type 2 diabetes and cancer (obesity and physical inactivity) may contribute to the association, and addressing these risk factors can lower risk for both type 2 diabetes and cancer. 14

Patient-centered care of common comorbidities

Patient-centered care of common comorbidities associated with diabetes requires the health care team to regularly conduct a number of clinical assessments and related interventions, as outlined below.

Medications

  • Provide a comprehensive assessment of symptoms and medications at every visit. This is particularly important as people age and comorbidities and medication use increase.
  • Assess for ability to afford medications. Offer generic medications, if possible.

Self-care

  • Involve family or friends or access community resources to assist people with self-management tasks if appropriate. 15
  • Consider cognitive impairment as a factor limiting diabetes self-management.
  • Refer to self-management education programs for joint disease and physical activity programs to help teach people the skills they need to engage in effective, joint-friendly physical activity. 16

Screening

  • Screen for and attend to depression, diabetes-related distress, or anxiety; integrate the services of behavioral health professionals. 7
  • Ask about urinary incontinence and erectile dysfunction and refer as necessary.
  • Ask about symptoms of sleep apnea and refer those with symptoms for testing.
  • Encourage people with diabetes to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, smoking, physical inactivity). 14
  • Evaluate people with elevated alanine aminotransferase or aspartate aminotransferase for nonalcoholic steatohepatitis in the absence of excessive use of alcohol, viral hepatitis, or medications that cause liver disease.

Falls

  • Assess gait and balance, fracture history, and risk factors; refer for bone mineral density testing if appropriate; ensure adequate calcium and vitamin D intake; and recommend strategies to reduce falls.

Dental and eye care

  • Ensure that people with diabetes receive regular professional dental care and brush and floss teeth daily to help prevent the oral complications of diabetes. Well-controlled diabetes can reduce the risk for periodontal disease.
  • Ensure that people with diabetes receive regular eye care from an optometrist or ophthalmologist experienced with diabetes and that they understand good vision does not preclude the presence of sight-threatening diabetic eye disease like proliferative retinopathy, macular edema, or glaucoma, three substantial causes of vision loss and blindness. Referring people with vision loss to a low-vision specialist for rehabilitative eye care can greatly improve capacity for independent living and good diabetes self-care. 17, 18

Vaccinations

  • Provide annual influenza vaccine to all people with diabetes older than 6 months, pneumococcal polysaccharide vaccine to all people with diabetes older than 2, and a one-time revaccination for individuals older than 64 if the pneumococcal vaccine was administered more than 5 years previously. CDC recommends hepatitis B vaccination for unvaccinated adults with diabetes ages 19 to 59.

References

1. Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

2. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651–61.

3. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35(6):1364–79.

4. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Patient Centered Primary Care Collaborative . 2007. Accessed on July 17, 2014.

5. Margolius D, Bodenheimer T. Transforming primary care: from past practice to the practice of the future. Health Aff. 2010;29(5):779–84.

6. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320(7234):569–72.

7. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care. 2011;34(4):1047–53.

8. Scanlon DP, Hollenbeak CS, Beich J, Dyer AM, Gabbay RA, Milstein A. Financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes in a federally qualified health center. Diabetes Care. 2008;31(11):2160–5.

9. Roman SH, Harris MI. Management of diabetes mellitus from a public health perspective. Endocrinol Metab Clin North Am. 1997;26(3):443–74.

10. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy NCES (2006–483). Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.

11. Berkman N, DeWalt D, Pignone M, et al. Literacy and Health Outcomes (AHRQ Publication No. 04-E007–2). Rockville, MD: Agency for Healthcare Research and Quality; 2004.

12. Cheng YJ, Imperatore G, Caspersen CJ, Gregg EW, Albright AL, Helmick CG. Prevalence of diagnosed arthritis and arthritis-attributable activity limitation among adults with and without diagnosed diabetes: United States, 2008–2010. Diabetes Care. 2012;35(8):1686–91.

13. Suh S, Kim KW. Diabetes and cancer: is diabetes causally related to cancer? Diabetes Metab J. 2011;35:193–8.

14. Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. Diabetes Care. 2010;33(7): 674–85.

15. Boucher JL, Evert A, Daly A, et al. American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care. J Am Diet Assoc. 2011;111(1):156–66.e1–27.

16. Bolen J, Hootman J, Helmick CG, Murphy L, Langmaid G, Caspersen CJ. Arthritis as a potential barrier to physical activity among adults with diabetes — United States, 2005 and 2007. MMWR. 2008;57(18):486–9.

17. Stelmack JA, Tang XC, Wei Y, Massof RW. The effectiveness of low-vision rehabilitation in 2 cohorts derived from the veterans affairs Low-Vision Intervention Trial. Arch Ophthalmol. 2012;130(9):1162–8.

18. Stelmack JA, Tang XC, Reda DJ, Rinne S, Mancil RM, Massof RW. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol. 2008;126(5):608–­17.