It is recommended that physicians evaluate patient adherence utilizing the principles of motivational interviewing in order to better understand barriers to adherence. These principles include using open-ended questions, reflecting patient answers, and summarizing your discussion to clarify any miscommunication. Specific examples of motivational interviewing questions can be found below.
Use open ended questions.
What insulin are you taking and when do you take it?
How often do you miss a shot?
How did the extra insulin shots work out?
What went well? What were the problems?
What is your plan for when you have hypoglycemia?
Have you had any problems with your diet and exercise plan?
What are your concerns about this plan?
Which shots are you having the most difficulty remembering to give?
Reflect what the patient is telling you when following up on their answers. Start sentences with phrases like:
It sounds like you..
You mean that..
You’re wondering if..
So you feel..
Summarize what you heard the patient tell you.
Allows patients to clarify their statements
Provides direction and saves time
Reiterate why the approach that you’re recommending would benefit the patient or adjust the plan based on what you’ve heard the patient tell you.
Evaluating Blood Glucose Logs
Review the blood glucose logs with the patient and assess if a dose adjustment is needed based on the following patterns:
Recommended Adjustments Based on Blood Glucose Patterns
If improved as expected
Continue current action plan
If fasting blood sugar is above range
Increase basal insulin dose
Consider getting a 3AM blood sugar
If fasting blood sugar is below range or nocturnal hypoglycemia
Decrease basal insulin dose
If both bedtime blood sugars and fasting blood sugars above range
Increase pre-dinner insulin dose
If fasting blood sugar varies or If erratic pattern
Indicates issue with diet/carb intake, injection technique/ timing, or missed insulin doses. Suggest referral to CDE or specialist.
While evaluating the logs, ask the patient what they see. A long-term goal should be for patients to be able to identify glucose patterns and what they mean.
If the patient sees a pattern, use it to reinforce suggested changes.
If the patient does not see a pattern, show them what you see and ask what they think they can do to improve things further.
Deciding When to Refer to a Certified Diabetes Educator or an Endocrinologist
Certified Diabetes Educator
If possible, it is recommended that all patients see a dietician or diabetes educator when first starting mealtime insulin.
If the patient continues to have difficulty adhering to their treatment plan, a subsequent visit is recommended.
A diabetes educator is also recommended if there are significant:
Learning barriers (e.g. matching food and insulin)
Skill barriers (e.g. injection technique)
Endocrinologist / Diabetologist
The patient is not at goal after 6 months (e.g. consistent A1c of 9% or greater)
Difficulty breaking hyperglycemia
Severe or recurrent hypoglycemia despite cautious insulin therapy
Complications arise (e.g. gastroparesis)
Confusing or erratic patterns
Suspect type 1 diabetes
Suggest first checking anti-GAD and anti-islet cell antibodies
Also ask patient about carb avoidance which often delays diagnosis of latent autoimmune diabetes or slowly progressive type 1 diabetes