Patient is a 65-year-old African American male coming in the clinic today for his routine check-up and lab draws. He presents with a history of hypertension for which he is compliant with his medications. On presentation to his appointment, his blood pressure is well controlled. He is not followed by a cardiologist at this time. He does admit to some non-compliance with a low-sodium diet. He also has a history of hyperlipidemia and admits to non-compliance with a low cholesterol diet. He denies any unwanted side effects of his cholesterol medications. Lastly, he presents with a history of type 2 diabetes. He reports that he may occasionally miss his diabetic medications anywhere from 2-4 times a month. He feels that for the most part he is usually compliant and does not understand why his blood sugar is high. His A1C has increased from his last appointment; currently is 9.1. He does report, due to pain and a “non- healing sore” on his foot, he was prescribed steroids for about 8-10 days.
His A1C has been continuously elevating because he is not following the correct diet. I have instructed him on the importance of the diet along with his medications to control his sugar. We also discussed that a high A1C means that for the last 3 months his blood sugars have not been controlled. Prior to this jump in his A1C, he was controlled on his current medications. We will make medication adjustments today as well as reiterate medication and diet compliance.
[bookmark: _Hlk40031502] In summary, this patient is a non-compliant diabetic. His A1C has continued to increase over his last visits. This patient is at risk for being admitted to the hospital for complications with his diabetes including but not limited to neuropathy, DKA, renal disease, and an infection. One approach that can be taken to improve his outcomes is the Plan, Do, Check, Act approach. Improving health outcomes is an ongoing process therefore, you will need to set goals that are agreed upon by not only the physician and patient but also the family as well. After the goals are set, they can be monitored throughout each visit. If at any point, the goals cannot be met, they will need to be reevaluated (Healthcare Improvement Transcript, 2020).
127 our experts are availableright now
One of the first interventions that any provider should do is to figure out why this patient is non-compliant. There are usually several reasons why people do not take care of themselves and it is usually not because they just want to be sick. It could be anything from the knowledge deficit, the way the other members in the household eat, or the lack of resources such as money. One way of improving non-compliance or as the American Diabetes Association likes to refer to it as “improving patient adherence” is developing a patient-centered collaborative model of care. In this model, the provider should encourage patient autonomy and not tell them what to do.
The clinic should provide continuity of care with frequent telephone conversations, talk with patients about treatment goal, brain-storm and problem-solve with their patients, implementing a regimen that the patient can agree to, provide written instructions, and use social supports. Finally if the disease is unable to be under control the patient should be referred to a specialist (American Diabetes Association, 2016). Included in this approach means looking at the bigger picture outside the office and in the community. Chronic diseases cannot be improved in the office alone, it will require the patient to take the education and tools received at the clinic home with them and practicing what they learn. He has been educated from his primary care provider, but the education needs to be reinforced at home and through community programs. We live in a southern small rural town and the community is not as educated as they should be on chronic diseases: how they affect their body, diet, and medication compliance. One thing that the hospital is doing is holding a class that is geared towards diabetes education.
The hospital and the clinic gather a list of patients with diabetes and these patients are contacted to attend this class. In the class, they are taught what they should and should not be eating (portion size), importance of medication, and lastly what is diabetes. This class meets once a month in a meeting room at the hospital and the educators are certified in diabetes education. One of the activities in the class is requiring the patient to make weekly goals, keep track of their daily blood sugars and a food diary. This holds the patient accountable to the class and gives him incentive to improve his health. This type of program is considered part of the population health management for diabetes which has been known to improve quality (Schmittdiel, J. A., Gopalan, A., Lin, M. W., Banerjee, S., Chau, C. V., & Adams, A. S. (2017). This class has had great success with notable improvements in the patient’s outcomes.
