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Self-care in patients with diabetes: the X-PERT approach

Paula Jefferies
RGN NursingDip BSc(Hons)
Specialist Practitioner General Practice Nursing
Stockport Primary Care Trust

This programme was developed as part of Paula Jefferies' role as chronic disease management facilitator while working for Stockport PCT.

Diabetes and its complications can cause severe problems for affected individuals and their families. But it is proven that with better control, patients with diabetes can enjoy a better
quality of life.
The number of people with diabetes continues to grow, with an estimated 1.8 million diagnosed cases and a further one million undiagnosed cases in the UK alone.(1) Data from the April 2006 Quality and Outcome Framework indicates that 10,101 people in Stockport Primary Care Trust (PCT), that is about 3% of the population, has diabetes. Of these patients, 80% are cared for in primary care practices.(2)
Self-care is a crucial aspect of the UK government's programme for the management of long-term conditions. The 2001 Diabetes National Service Framework Standard 3 states that the NHS needs to develop, review and audit structured patient education programmes in order to empower people with diabetes.(3)
Guidance published by the National Institute for Health and Clinical Excellence in 2003 recommended that people with diabetes should have access to group-based education programmes.(4) This was reinstated in 2005 when all PCTs were asked to decide by January 2006 how to make structured patient education programmes available to people with diabetes. Stockport's local diabetes experts felt the existing X-PERT programme would suit the needs of the local population and meets NICE criteria (see Box 1).

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Before delivering the programme to patients with type 2 diabetes, facilitators attended a "train the trainer" course supported by the X-PERT team. A two-day intense course covered the programme content, delivery of part of the programme to a peer group, and an examination to confirm their new knowledge and skills.
The X-PERT education programme aimed to:

  • Form part of a whole system approach to managing patient education.
  • Provide patients with a clinically appropriate and acceptable service within primary care.
  • Improve quality of care for patients with diabetes.
  • Remove inequalities that may exist across the local health economy.
  • Respond to local health needs.

Why use a different approach?
Structured diabetes education aims to revolutionise patient care delivery as clinicians often think they fail in their attempts to persuade patients to adopt therapeutic targets.(5)
Evidence states that, on average, a patient with diabetes will only access healthcare for three hours each year.(5) That means that a patient is left to manage his or her own condition for the other 8,757 hours of the year.(5) Structured patient education programmes allow people to understand their chronic disease and take responsibility for their condition which is important if patient outcomes are to be optimised.(6)
There are two types of empowering self-management programmes: the first is delivered by healthcare professionals and is condition specific, such as the X-PERT programme; the second is a programme that is nonclinician-led and addresses how illness impacts on daily life. This has been piloted within the NHS in England and the intention for this programme is for self-management to be generic and become mainstream in the NHS.
The self-management model is not a new concept - it was developed over 30 years ago in the USA - and aimed to develop five core self-management skills, problem solving, decision making, resource utilisation, development of effective partnerships with healthcare providers and taking action.
Self-management programmes are not just about educating or instructing patients about their condition and then measuring success on the basis of patient compliance. If they are designed to build skills and confidence they can empower patients, and allow them to take responsibility for the management of their condition and develop greater control over their lives.(7) By doing this we equip the "expert" patient with the tools to take effective control and make informed decisions regarding their condition.(8)
Structured patient education benefits offer:

  • Consistent messages.
  • The chance for patients to become experts in diabetes.
  • Effective use of resources.
  • Locally accessible services for patients.
  • Flexible services for patients.
  • An informal approach to healthcare.
  • A patient-centred approach.

A structured patient education programme reflects the Diabetes National Service Framework "Standard 3" and empowers patients to take control of their own disease. By explaining the importance of treatments and therapeutic interventions, healthcare professionals have the opportunity to work in partnership with their patients. This can ensure that patients take a proactive role in making treatment decisions and the prescriber, in turn, understands the patient's beliefs and treatment expectations.(8)
The six-week X-PERT structured programme offers patients with type 2 diabetes 18 hours of teaching from trained educators (see Box 2). The sessions cover all aspects of diabetes and give the patient the opportunity to learn while interacting with other people who have the same disease and problems.

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Within the six weeks, patients are encouraged to make small changes in their day-to-day routine by setting lifestyle goals using a five-step approach to goal setting (see Box 3).(9)

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Delivering the X-PERT programme
Each practice interested in participating in the programme is given an information pack telling practice nurses and GPs how to inform patients of the programme content. They also included a quick reference guide detailing what is required for a patient to be referred to the programme.
Patients who are newly diagnosed within the last year are invited to attend and a letter of confirmation is sent to the patient including details of times and the venue. The programme has a maximum of 15 patients and there is a waiting list.
After their registered patients have completed the programme, GPs are informed. A Read code of 90LB (attended structured education) and also 90LC (family member or carer attended) was identified which could be entered into the patient's record and used for potential future audits.

Practical tips for setting up a structured patient education programme

  • Plan well ahead.
  • Get the support of the GP.
  • Attend the trainers training course if using an established programme.
  • Work collaboratively with other practice nurses, community dietitians and diabetes specialist nurses.
  • Have a suitable venue to accommodate patients and carers.
  • Secure admin support.
  • Approach PCT commissioning board with a strategy to gain funding, or discuss possibility for a local enhanced service/directly enhanced service.

Conclusion
The programme has been a success and will be repeated across the borough. Evaluation of the programme at week six showed that overall it was rated very highly, with patients feeling their knowledge about diabetes was greatly enhanced and their confidence to make changes to their lifestyle increased. Patient comments noted from the evaluation of the first programme include:

  • "Helped to fill in gaps in my knowledge."
  • "It gave me a greater understanding of my condition."
  •  "It makes you more aware of the possible complications of diabetes."
  • "I hope to continue to make changes to my lifestyle to control my condition."
  • "Presentation team had a very pleasing manner. They were highly approachable, informative and empathetic."

From a healthcare professional's point of view, when delivering this programme, the content was appropriate to the patient group and enjoyable to present.
It soon became apparent that this group approach to education can enhance quality of care because the patient has exposure to interactive techniques and positive dynamics and they identify with other members of the group. It certainly allows for better use of time and resources.


References

  1. Department of Health. National Service Framework for Diabetes. Delivery strategy. London: DH; 2003.
  2. Stockport Primary Care Trust. Quality and outcome data. General practice. Stockport PCT; 2006.
  3. Department of Health. National Service Framework for Diabetes. Standards. London: DH; 2001.
  4. NICE. Guidance on the use of patient education models for diabetes. Technology Appraisal 60. London: NICE; 2003.
  5. Wolpert HA, Anderson BJ. Management of diabetes: are doctors framing the benefits from the wrong perspective? BMJ 2001;323:994-6.
  6. DH. Chronic disease management and self-care. London: DH; 2002.
  7. DH. Saving lives: our healthier nation. London: DH; 1999.
  8. DH. A new approach to chronic disease management for the 21st century. The expert patient programme. London: DH; 2001.
  9. Health Education Authority. Helping people change: the process of change. London: Health Education Authority; 1994.