Jamie LeeFollow

Document Type


Publication Date

Fall 12-8-2018


Type 2 Diabetes Mellitus (T2DM) is a serious concern, that requires close monitoring and facilitation of self-management skills and strategies, as well as development of a sense of self-efficacy, in patients with this chronic disease. The development of nurse-led Diabetes self-management education (DSME) programs, combined with a multidisciplinary approach to care and management, is a safe and effective means of helping patients with uncontrolled T2DM to cultivate positive health behaviors, prevent long-term disability and effectively control blood sugars.

A DSME program like this was developed and implemented at Mercy Midtown Family Practice, for patients with a glycosylated hemoglobin (HbA1c) of 9% or higher, whose diabetes and related complications are managed by Primary Care. It employed a multidisciplinary approach with Primary Care Providers (PCPs), Disease Management Registered Nurses (DMRNs) and Care/Case Management (CM) coordinators to provide collaborative, comprehensive care management. This program features a comprehensive Diabetes Education program, bi-weekly follow-ups by phone or in clinic between patients and DMRNs, point of care testing (POCT) of HbA1c every 6 weeks in clinic and facilitation of self-management skills and health behaviors throughout the program.

This nurse-led DSME program resulted in an overall decrease in HbA1c of one point or more for 55% of participating patients. This includes HbA1c decreases for 22% of the participating patient cohort to below 7%. Additionally, 100% of participating patients report an increase in positive health behaviors and an increase in their sense of self-efficacy, as demonstrated through a skills self-assessment survey administered upon graduation from the program.