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More so than most other diseases, effective control of type 2 diabetes (DM) requires that patients are actively engaged in the self-management of their health. In this paper we define and characterize the elements of self-management and review the published literature for the evidence of the benefit of interventions that support patient self-management.

Objective: To assess differences between women and men in developing an action plan for the management of their type 2 diabetes mellitus (DM). Methods: We chose a convenience sample of the first 153 patients who participated in a four-part educational class focused on the management of type 2 DM. The classes are run by a certified diabetes educator and have a specific format. We use a decision wheel to assist in the development of a patient-generated action plan to address a specific health behavior change. For each patient we documented age, gender, and glycosylated hemoglobin (HbA1c) level. Results: There was a difference in choice of action plan based on gender (p = 0.014). For women the distribution of action plans was exercise 38%, nutrition 22%, medication 20%, no action plan 13%, and monitoring 7%. For men the distribution of action plans was exercise 26%, nutrition 26%, medication 6%, no action plan 26%, and monitoring 16%. Age did not affect the choice of an action plan (p = 0.964); however, patients with a lower HbA1c level chose exercise more frequently (p < 0.002). Conclusions: The results of this study suggest there may be gender-based differences affecting the selection of an action plan for patients with type 2 DM. Further research is needed to determine the relative weight of other important factors on the decision for a particular action plan; e.g. sociodemographic factors, stage of readiness to change, and comorbid conditions.

Bridget R LevichUniversity of California Davis Health System, Sacramento, CA, USAAbstract: Type 2 diabetes is a major public health concern. Screening and early diagnosis followed by prompt and aggressive treatment interventions can help control progression of diabetes and its complications. Nurses are often the first healthcare team members to interact with patients and are being called on to apply their specialized knowledge, training, and skills to educate and motivate patients with diabetes about insulin use and practical ways to achieve treatment goals. Clinical nurse specialists possess specific training and skills to provide this level of care, while staff or office-based nurses may be trained by physicians to fulfill a task-specific role. This manuscript reviews the benefits of intensive glycemic control in type 2 diabetes, therapeutic goals and guidelines, advances in insulin therapy, and contribution of nurses in overcoming barriers to insulin initiation and related aspects of diabetes care. Nurses are particularly well positioned to fill the gap and improve efficiency in diabetes-related healthcare by assisting patients with insulin initiation and other aspects of glycemic self-management.Keywords: insulin, diabetes, diabetes educator, hypoglycemia, diabetes counseling, insulin clinic, insulin pens

1. Self-management is a core component of all chronic disease. All patients self-manage, some more effectively than others. 2. The most effective strategy for chronic disease management comes from an activated team, a team whose “captain” is in fact the person with the chronic illness. 3. When caring for your patients, you should consider reframing your role to that of a health “coach.” A coach: a. Helps guide patients to specifi c, self-generated, achievable goals b. Assesses patients for their readiness to change and provides appropriate educational resources that match the patients’ needs c. Helps patients develop problem-solving skills d. Understands the relevance of “importance” and “confi dence” from the patients’ points of view, particularly when it comes to recommended lifestyle changes e. Understands the need to probe for barriers, including common comorbid conditions such as depression and social/fi nancial problems that can easily derail the most effective, evidence-based clinical guidelines 4. One of the goals when working with patients around self-management is to empower patients to manage their health by emphasizing their central role in their own health care. 5. Everything you can do in your practice to support/promote selfmanagement for your patients will likely have a substantial return on your investment. 6. Some of the tools that you can use to support/promote selfmanagement are the following: a. Team approach with the patient as “captain” b. Assistance with behavior change using the Transtheoretical Model

Improving the quality of care for patients with chronic illness has become a high priority. Implementing training programs in disease management (DM) so the next generation of physicians can manage chronic illness more effectively is challenging. Residency training programs have no specific mandate to implement DM training. Additional barriers at the training facility include: 1) lack of a population-based perspective for service delivery; 2) weak support for self-management of illness; 3) incomplete implementation due to physician resistance or inertia; and 4) few incentives to change practices and behaviors. In order to overcome these barriers, training programs must take the initiative to implement DM training that addresses each of these issues. We report the implementation of a chronic illness management curriculum based on the Improving Chronic Illness Care (ICIC) Model. Features of this process included both patient care and learner objectives. These were: development of a multidisciplinary diabetes DM team; development of a patient registry; development of diabetes teaching clinics in the family practice center (nutrition, general management classes, and one-on-one teaching); development of a group visit model; and training the residents in the elements of the ICIC Model, ie, the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Barriers to implementing these curricular changes were: the development of a patient registry; buy-in from faculty, residents, clinic leadership, staff, and patients for the chronic care model; the ability to bill for services and maintain clinical productivity; and support from the health system key stakeholders for sustainability. Unique features of each training site will dictate differences in emphasis and structure; however, the core principles of the ICIC Model in enhancing self-management may be generalized to all sites.