Case management is a collaborative process that entails much more than the direct clinical care that patients receive from professional health workers. It aims at meeting an individual and the family’s comprehensive health needs. The paper discusses in detail case management in youths with diabetes mellitus type 1 through an article critique and supporting evidence for application in practice.
Article Critique
The article, “General quality of life in youth with type 1 diabetes: Relationship to patient management and diabetes-specific family conflict” sets out to evaluate the quality of life of youths with type 1 diabetes as self-reported and reported by a parent (Laffel et al., 2003) . The reports are to be compared with those from the general pediatric population and its relationship to diabetes family conflicts and their effect on the quality of life assessed.
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From the introduction of the article, it is evident that the intensive treatment needed in the management of type 1 diabetes in adolescents is likely to result in interference with the normal quality of life. The researchers dismiss the use of the Diabetes Quality of life for youth tool (DQLY) and opt for the Pediatric Quality of Life Inventory (PedsQL) tool. The authors justify the transition arguing that the latter is more comprehensive and able to pick out other issues outside the primary problem of diabetes. However, this can be confusing as any challenges the youth could be facing in their social-emotional life may be attributed to diabetes, while this may not be the case. Young people are likely, as a result of their stage of growth, to have many more issues affecting them. The tool may also not be able to report any positive adjustments made to ensure the child’s comfort despite the condition. To have a more comprehensive perspective, the involvement of more family members would help generate a full perspective on how diabetes affects the quality of lives, not only for the patient but other siblings and caretakers involved in the care continuum.
The choice of specific children to interview is well elaborated; however, the same is not done for the parent. The authors seem to automatically assume the parents bringing the children to the hospital are the guardians that have been taking care of them at home. There ought to be a clearly set inclusion and exclusion criteria on which parents are qualified in giving a comprehensive report of the child. The choice to use the child’s clinician to evaluate adherence could result in interference. It is the child clinician’s role through the counselling to enforce adherence, the same clinician is also the one assessing the adherence and reporting it, which is based on their impression that can easily slight to subjectivity. Since the primary data on the adherence exists, it would have been more prudent to have another more independent clinician or research assistant assess adherence from the patient logs and in places where they felt that the primary clinician needed to intervene, inform them of the same.
The results presented were comprehensive in terms of the objectives that the paper set to find out. The conclusion is true as per the results but seems to contradict the earlier statement in the introduction that posited that intensive care for diabetics interferes with quality of life. Such a statement would have been true if increased injection frequencies or multiple clinic visits would have been reported as affecting the quality of life. The comparison with a healthy population within a similar age gap helped eliminate any biases in the tools. From the article, the main driver of changes in the quality of life is glycemic control, and that ought to be the main focus in any interventions seeking to improve a patient’s quality of life.
Application into Practice
Case management is a continuum that involves multiple players in a bid to offer the best quality of care to the patient. Case managers are expected to not only understand how to handle a case but also possess the ability to bring on board all the necessary players in the continuum. For a diabetic child, the clinician, the family members, and the teachers are central in the care of the child. The continuum of case management focuses not only on the human resource component of care but on other resources as well. Patient and caretaker education, advocacy and training, social support, and finances are all needed if the patient’s quality of life is to be maintained at an all-time high. Case management practices avail the necessary emotional aid needed by patients in their healing journey (Joo & Liu, 2018) . Health is a holistic concept that needs a holistic approach.
For type 1 diabetes mellitus, case management has to begin with the identification of the client. The process entails screening and verifying that the given child requires the care. During the identification, the family is engaged and made to appreciate the nature of the journey that they will walk with the child stemming from the chronicity of the condition. Assessment is then carried out where the client tells of their experience with the condition. Multiple laboratory tests are also carried out, such as Hb1c, vision, kidney, and liver functions. All these help in defining the extent of damage that may result from diabetes-specific steps and the option to be adopted. An understanding of the patient social and family background is also assessed, helping identify who would be the critical players to bring on board in the management continuum.
A care plan is then developed. This captures specifics such as the number of injections of insulin, doses, and frequencies. The targeted outcomes, such as the level of glycemic control expected after a given duration is usually captured in the plan of care. All possible barriers to the plan and possible solutions are thought through at this stage. The plan proceeds to the implementation stage where the child receives the insulin shots, and continuous monitoring is done. Unlike most other cases that have a mutually agreed closure, diabetes mellitus is a lifelong condition, and thus, the care proceeds during the patient’s lifespan.
The monitoring for the managing of diabetes mellitus in youth ought to focus on the quality of life besides the metabolic goals. Melissa Cousino et al. in their paper, posit that youth with a poor quality of life are unlikely to attain the treatment goals. In their study among 72 youths, they set to find out how shared responsibility and diabetes family conflicts impacted on the quality of life and subsequently affecting treatment outcomes in the diabetic youth. From the study, youth that reported shared responsibility had an improved quality of life. Those with a poor quality of life and increased family conflicts reported poorer outcomes (Cousino et al., 2013) . To, therefore, improve outcomes, interventions should foster an improved youth and parent relationship that encourages the sharing of responsibilities.
In an effort to revise and update the diabetes family conflict scale, Hood et al. set out on a study. The study involved 202 youths with diabetes who filled questionnaires indicating their emotions around glycemic control, perceived parental burdens, and quality of life. From the study, there was an evident strong psychometric component in diabetes management. These further rubberstamps the centrality of managing the emotional component in the continuum of care. The study also differentiated direct and indirect conflicts. Conflicts directly associated with the management of diabetes are more devastating in effect than indirect conflicts. Young people, due to their developmental stage, are overly emotional and sensitive to anything that informs their self-worth (Anderson, 2004) . Caretakers and family members ought to be taught these to offer their help to the teenagers better.
Diabetes care and self-management, unlike in most cases of illness management, occur at home. The home environment should provide all the conducive elements that encourage and motivate young patients to manage their health proactively. Self-efficacy is critical in the management of oneself and the continuous monitoring of one’s sugar level. Various factors have been known to build on as well as weaken one’s perception of their efficacy. Patients with lower self-efficacy have poorer outcomes compared to those that are confident in their abilities to take care of themselves (Sander et al., 2010) . In a study to determine the relationship between diabetes-specific family conflicts and self-glucose monitoring, it was established that family conflicts lower self-efficacy and subsequently resulting in poor glycemic control (Sander et al., 2010) . Self-efficacy focused training in addition to the other mentioned strategies can be of help in improving patient confidence (Jiang et al., 2019) . These trainings are secondary to reduced family conflicts, frequent follow-ups, and even other physiological and emotional strategies would be integral.
In conclusion, it takes much more than clinic visits to achieve optimal outcomes for young persons with diabetes type 1. The developmental stage of the patients, as well as the chronicity of the condition, calls for an elaborate and more encompassing approach to have optimal outcomes. Case management strategies help bring on board the right team that ensures the patient is able to have the right environment for their healing journey. Reduced family conflicts and increased self-efficacy by the patient are some of the salient factors that result in excellent treatment outcomes in the context of the above-discussed case.
References
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Anderson, B. J. (2004). Family Conflict and Diabetes Management in Youth: Clinical Lessons From Child Development and Diabetes Research. Diabetes Spectrum , 17 (1), 22–26. https://doi.org/10.2337/diaspect.17.1.22
Cousino, M., Hazen, R., MacLeish, S., Gubitosi-Klug, R., & Cuttler, L. (2013). Quality of life among youth with poorly controlled Type 1 diabetes: role of family conflict and sharing of treatment responsibility. Diabetes Management , 3 (6), 449–457. https://doi.org/10.2217/dmt.13.47
Hood, K. K., Butler, D. A., Anderson, B. J., & Laffel, L. M. B. (2007). Updated and Revised Diabetes Family Conflict Scale. Diabetes Care , 30 (7), 1764–1769. https://doi.org/10.2337/dc06-2358
Jiang, X., Wang, J., Lu, Y., Jiang, H., & Li, M. (2019). Self-efficacy-focused education in persons with diabetes: a systematic review and meta-analysis</p>. Psychology Research and Behavior Management , Volume 12 , 67–79. https://doi.org/10.2147/prbm.s192571
Joo, J. Y., & Liu, M. F. (2018). Experiences of case management with chronic illnesses: a qualitative systematic review. International Nursing Review , 65 (1), 102–113. https://doi.org/10.1111/inr.12429
Laffel, L. M. B., Connell, A., Vangsness, L., Goebel-Fabbri, A., Mansfield, A., & Anderson, B. J. (2003). General Quality of Life in Youth With Type 1 Diabetes: Relationship to patient management and diabetes-specific family conflict. Diabetes Care , 26 (11), 3067–3073. https://doi.org/10.2337/diacare.26.11.3067
Sander, E. P., Odell, S., & Hood, K. K. (2010). Diabetes-Specific Family Conflict and Blood Glucose Monitoring in Adolescents With Type 1 Diabetes: Mediational Role of Diabetes Self-Efficacy. Diabetes Spectrum , 23 (2), 89–94. https://doi.org/10.2337/diaspect.23.2.89
