Implementation of a Diabetes Self-Management Education and Collaborative Goal Setting Intervention in the Primary Care Setting for Patients with Poorly Controlled Diabetes

The purpose of this project was to evaluate the implementation of a diabetes self-management education (DMSE) and collaborative goal setting (CGS) intervention in the primary care setting for patients with poorly controlled diabetes. Patients with a hemoglobin A1c (A1C) > 7% met with a registered dietician for < 30 minutes and a provider for < 10 minutes and received DSME and CGS via use of The Living with Diabetes Guide, a validated instrument. This was repeated at one-month follow-up intervals. Patients' weight, A1C, diabetes self-efficacy and self-management were measured at baseline and follow-up. During an initial three-month observation period, 17 patients received the intervention. Among participants who followed up, the majority met their collaboratively set goals; mean A1C decreased from 9.5% to 7.8%; 8 out of 9 participants lost weight and had an average weight loss of 4.5 lbs.; and 4 out of 4 reported an increase in the number of days exercised. The statistical significance of the data was limited by the small sample size and the high rate of patients overdue for follow-up; however, participants who followed up displayed clear trends towards improvement in outcome measures in a short period of time with limited resources. Diabetes self-management education and CGS interventions can be successfully delivered via a sustainable, multidisciplinary process, integrated into existing clinical roles and frameworks, utilizing a model which allows for reimbursement while also requiring minimal time from providers by delegating the primary activities of the intervention to other members of the healthcare team.