Problems or Concerns about Personal
Relationships
Feeling dissatisfied with personal relationships
Possible Actions
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Feeling family / friends don’t appreciate how hard
it is living with diabetes
Feeling family / friends are not supportive of selfcare
Feeling tension in relationships with family /
friends
Probe for the source of the dissatisfaction
Invite patient to include family member(s) in next patient clinic visit
Schedule public health nurse home visit
Provide family members with pamphlets, books, and/or educational materials
about diabetes care:
http://ndep.nih.gov/diabetes/pubs/TipsHelping_Eng.pdf
Refer to social work
Refer to family counseling
Provide patient and family with information about area support groups
Gauge patient and family interest in hospital pastoral services.
Mental health services provider locator: http://store.samhsa.gov/mhlocator
 Invite patient to include family member(s) in next patient clinic visit
 Schedule public health nurse home visit
 Provide family members with pamphlets, books, and/or educational materials
about diabetes care:
http://ndep.nih.gov/diabetes/pubs/TipsHelping_Eng.pdf
 Refer to social work
 Refer to family counseling
 Provide patient and family with information about area support groups
 Invite patient to include family member(s) in next patient clinic visit
 Schedule public health nurse home visit
 Provide family members with pamphlets, books, and/or educational materials
about diabetes care:
http://ndep.nih.gov/diabetes/pubs/TipsHelping_Eng.pdf
 Refer to social work
 Refer to family counseling
 Provide patient and family with information about area support groups
 Probe for the source of the relationship tension
 Invite patient to include family member(s) in next patient clinic visit
 Schedule public health nurse home visit
 Provide family members with pamphlets, books, and/or educational materials
about diabetes care:
http://ndep.nih.gov/diabetes/pubs/TipsHelping_Eng.pdf
 Refer to social work
 Refer to family counseling
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Feeling dissatisfied with ability to do things for
family
Feeling that diabetes interferes too much with
family / social life
Provide patient and family with information about area support groups
Gauge patient and family interest in hospital pastoral services.
Mental health services provider locator: http://store.samhsa.gov/mhlocator
 Dialog with patient regarding self-care workload; discuss with patient ways to
reduce self-care workload
 Refer to diabetes care coordinator or diabetes educator
 Refer patient to area support group (one that teaches coping skills)
 Provide patient with educational resources to help with diabetes self-management
 Dialog with patient regarding self-care workload; discuss with patient ways to
reduce self-care workload
 Refer to diabetes care coordinator or diabetes educator
 Refer patient to area support group (one that teaches coping skills)
 Provide patient with educational resources to help with diabetes self-management
Problems or Concerns about Monitoring
Health
Difficulty testing your blood sugar (glucose) levels
Possible Actions
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Feeling bothered by the time and energy required
to test your blood sugar levels
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Difficulty keeping a record of your blood sugar
levels
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Difficulty finding a place to check blood sugar or
take insulin when you are away from home
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Feeling bothered taking medical instruments (such
as a glucose monitor, insulin syringes) wherever
you go
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Difficulty checking your feet
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Discuss daily BG testing routine with patient, try to identify specific source of
difficulty. Discuss Alternative testing sites, easier meter if applicable
Consider reviewing with patients tips for successful blood glucose monitoring.
Focus on tips that align with specific barriers.
If available, refer patient to diabetes educator for more instruction, or use
resource below to find an educator in your area. Consider printing and reviewing
with the patient an Insulin Adjustment Workbook
 http://www.diabeteseducator.org/DiabetesEducation/Find.html
 Certified diabetes educator: look at ways to simplify medication program with
motivational interviewing to see what the patient is willing to work at, set
behavioral goals with follow-up phone calls. (Decrease blood glucose testing
to minimum requirements so patient is able to cope with the task)
Review patient’s daily routine looking for inefficiencies.
Contract with patient behavioral goal changes to work with patient to commit to
meet a behavioral goal 80% of the time.
Suggest that the patient research web-based diabetes tracking software or smart
phone applications
Download meters at clinic
 http://www.vitalmhealth.com/top-diabetes-iphone-apps
 http://www.diabetesnet.com/diabetes-technology/diabetes-software
Review patient’s daily routine, try to identify specific source of difficulty.
If available, refer patient to diabetes educator for more instruction, or use
resource below to find an educator in your area.
Discuss smaller glucose monitors, insulin pens
Direct patient to websites or supply stores that have insulated travel wallets and
carriers for their supplies.
 http://www.insulincase.com/
Discuss foot checking regimen, try to identify specific source of difficulty (vision,
flexibility, remembering).
 If vision/flexibility is the issue, suggest (1) enlisting a family member, neighbor,
or visiting nurse to help (2) long-handled mirror and magnifiers
 If remembering is the issue, suggest a watch alarm or daily checklist
Reinforce good foot care habits, provide footcare video (if available)
http://diabetes.niddk.nih.gov/dm/pubs/type1and2/care.aspx#foot
Difficulty checking blood pressure
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Difficulty monitoring body weight, calories or
carbohydrates
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Discuss daily BP testing routine with patient, try to identify specific source of
difficulty.
Consider printing/reviewing with the patients tips for successful blood pressure
monitoring focusing on tips aligned with specific barriers.
Meet with a dietitian to educate about plate method, food record books
Refer patient to online web sites for meal plans
 http://www.diabetes.org/food-and-fitness/food/planning-meals/
Problems or Concerns about
Emotional Health
If any “emotional health” item is selected
Possible Actions
Step 1:
- Dialog with patient about the source of the distress
- Judge whether problem is a consequence of:
(a) transient mood (with continued interest in activities and ability to
experience joy) OR
(b) a more significant psychological problem
- If discussion with patient fails to distinguish (a) or (b), then administer PHQ-9
(screen for depression) and GAD-7 (screen for anxiety)
Step 2:
- IF (a), then possible actions include:
• Referral to diabetes care coordinator or diabetes educator
• Referral to patient support group
• Gauge patient and family interest in hospital pastoral services.
• Provide patient with educational resources about diabetes care
• Provide patient with resources to improve stress management skills
(e.g., relaxation training)
- IF (b), OR PHQ-9 ≥ 10 OR GAD-7 ≥ 10, then possible actions include:
• Referral to social work or mental health care coordinator
• Referral to psychology / psychiatry
Electronic resources for emotional health:
Depression: http://www.nimh.nih.gov/health/publications/depression/completeindex.shtml#pub8
Anxiety: http://www.nimh.nih.gov/health/publications/generalized-anxiety-disordergad/generalized-anxiety-disorder-gad-when-worry-gets-out-of-control.shtm
Relaxation techniques:
http://www.helpguide.org/mental/stress_relief_meditation_yoga_relaxation.htm
General information about diabetes:
http://diabetes.niddk.nih.gov/dm/pubs/type1and2
Mental health services provider locator: http://store.samhsa.gov/mhlocator
Problems or Concerns about Money
Possible Actions
Problems paying your medical bills
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Problems paying for all the care you
needed
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Problems paying for all the medicines
or supplied that you needed
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Not maintaining health insurance
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Skipped a recommended test or
medical treatment
Not filled a prescription for a medicine
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Cut pills in half or skipped doses of
medicine
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Direct patient to your clinic’s patient account services for information on payment options.
Connect patient with financial aid services
 http://www.dlife.com/diabetes_resources/saving_money/financial_help/index.page1
Direct patient to your clinic’s patient account services for information on payment options.
Connect patient with financial aid services
 http://www.dlife.com/diabetes_resources/saving_money/financial_help/index.page1
Review medication list for opportunities to substitute generic or less expensive options.
Consider printing and reviewing with the patient the “Financial Help for Diabetes Care”
information from the NIDDK website.
 http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf
Direct patient to programs for free or discounted prescription medicine.
 http://www.state.mn.us/portal/mn/jsp/home.do?agency=Rx
 http://www.health.state.mn.us/clearinghouse/prescription.pdf
 http://www.minnesotahelp.info/QA/default.aspx?se=senior
If available - refer to social services for financial/job counseling and insurance assessment
Consider generics/educate about the use of generics Medication reconciliation with attention to
cost
Use decision aid cards about medication choices that include costs
Consider printing and reviewing with the patient the “Financial Help for Diabetes Care”
information from the NIDDK website.
http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf\
Recommendations for pharmaceutical support programs
Referral to free clinics (e.g. Salvation Army)
Review order and determine if test/treatment is necessary or could be substituted with a less
expensive test/treatment.
Review medication list for opportunities to substitute generic or less expensive options.
Consider printing and reviewing with the patient the “Financial Help for Diabetes Care”
information from the NIDDK website.
 http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf
Direct patient to programs for free or discounted prescription medicine.
 http://www.state.mn.us/portal/mn/jsp/home.do?agency=Rx
 http://www.health.state.mn.us/clearinghouse/prescription.pdf
 http://www.minnesotahelp.info/QA/default.aspx?se=senior
Review medication list for opportunities to substitute generic or less expensive options.
Consider printing and reviewing with the patient the “Financial Help for Diabetes Care”
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Skipped dental, vision or mental health
care visit because of cost
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Put off or postponed getting health
care you needed

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information from the NIDDK website.
 http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf
Direct patient to programs for free or discounted prescription medicine.
 http://www.state.mn.us/portal/mn/jsp/home.do?agency=Rx
 http://www.health.state.mn.us/clearinghouse/prescription.pdf
 http://www.minnesotahelp.info/QA/default.aspx?se=senior
Direct patient to resources for free or discounted eye exams (if eligible).
 http://www.aoa.org/visionusa.xml
 http://www.eyecareamerica.org/
Provide NIDDK brochure on dental self-care
 http://diabetes.niddk.nih.gov/dm/pubs/complications_teeth/teeth.pdf
Direct patient to state and local resources for lower cost dental care.
 http://www.health.state.mn.us/clearinghouse/resources.htm
Direct patient to state and local resources for free or discounted mental health services.
 http://www.usc.salvationarmy.org/usc/www_usc_rochester1.nsf/
 http://www.co.olmsted.mn.us/cs/AFS/abh/Pages/default.aspx
Direct patient to local diabetes support group
 http://www.defeatdiabetes.org/support_groups_minnesota.htm
Direct patient to your clinic’s patient account services for information on payment options.
Connect patient with financial aid services
 http://www.dlife.com/diabetes_resources/saving_money/financial_help/index.page1
Problems or Concerns about Health Behaviors
Eating too much or too little
Not sticking to your meal plan
Not exercising the right amount
Difficulty doing everyday physical activities such
as walking, climbing stairs, carrying groceries
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Not sleeping enough to feel well-rested
Feeling you should cut down the amount of
alcohol you drink
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Possible Actions
Discuss daily eating habits with patient, try to identify specific problem behaviors
Discuss creating a meal plan
Consider printing and reviewing with the patient publicly available brochures with
tips for eating the right amount. Focus on tips that align with specific problem
behaviors.
 http://diabetes.niddk.nih.gov/dm/pubs/eating_ez/Eating_Diabetes.pdf
If available, refer patient to diabetes dietician.
Discuss current meal plan with patient, identifying specific barriers
Consider printing and reviewing with the patient publicly available brochures with
tips for eating the right amount. Focus on tips that align with specific problem
behaviors.
 http://diabetes.niddk.nih.gov/dm/pubs/eating_ez/Eating_Diabetes.pdf
 http://www.mayoclinic.com/health/diabetes-diet/DA00077
If available, refer patient to diabetes dietician
Discuss current exercise regime with patient
 Educate about amount of exercise needed
 Consider printing and reviewing with the patient publicly available brochures
with tips for eating the right amount. Focus on tips that align with specific
barriers.
 http://diabetes.niddk.nih.gov/dm/pubs/physical_ez/physactivity.pdf
 If available, refer to community classes or gyms
 If available, refer patient to diabetes educator for more instruction.
Discuss which specific activities are problematic
Consider referral to physical therapy
Discuss getting more exercise
Discuss if patient needs help with/has assistance getting everyday tasks done
Consider referral to community resources
 Discuss sleeping patterns
 Identify barriers to getting enough sleep and strategies for overcoming barriers
 Consider referral to sleep therapist
 Consider prescription for a sleeping aid
Evaluate drinking behavior
Educate about the harmful impact of excess alcohol intake
Consider printing and reviewing with the patient publicly available brochures
available at: http://rethinkingdrinking.niaaa.nih.gov/
Consider referral to a specialist
Feeling you should quit smoking or using tobacco.
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Give resources to community-based programs such as AA
Congratulate patient for thinking about quitting
Consider printing and reviewing with the patient publicly available brochures
with tips for quitting, see: http://www.mayoclinic.com/health/quitsmoking/MY00433
Problems or Concerns about Medicine
Difficulty taking your medicine the way you should
(at the right time and in the right amount)
Possible Actions
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Feeling bothered by the time and energy needed
to take your medicine
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Difficulty paying for your medicine
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Experiencing side effects from your medicine
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Discuss daily medication routine with patient, try to identify specific barriers.
Consider printing and reviewing with the patient publicly available brochures with
tips for managing medications. Focus on tips that align with specific barriers.
http://www.health.state.ny.us/diseases/aids/docs/9388.pdf
Refer to pharmacist to review medications/ pill boxes/calendar
Refer to social services for Home health care if available
Review medication schedule for opportunities for consolidation. Are there
medications that would be easier to manage (e.g. less frequent administration,
administration at times that fit patient’s daily schedule) that could be substituted
for current medications?
If available, refer patient to diabetes educator for more instruction.
Review medication list for opportunities for consolidation. Are there medications
that would be easier to manage (e.g. less frequent administration) that could be
substituted for current medications?
Suggest diabetes support group, if available
Refer to certified diabetes educator, if available. CDE to look at ways to simplify
medication program with motivational interviewing to see what the patient is
willing to work at and set behavioral goals with follow-up phone calls.
Review medication list for opportunities to substitute generic or less expensive
options.
If available - refer to social services for financial counseling.
Consider printing and reviewing with the patient the “Financial Help for Diabetes
Care” information from the NIDDK website.
 http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf
Determine whether the pharmaceutical company that manufactures the patients’
medications has a drug/medication assistance programs for low income
individuals with diabetes
Confirm that medicine is being taken correctly.
Review medication list looking for opportunities to substitute current medication
with one associated with fewer side effects.
Discuss options for managing side effects.
Difficulty adjusting amount and timing of medicine
based on sugar levels, meals or changing body
weight
Difficulty administering insulin
Difficulty understanding what medicines you
should be taking

Consider printing and reviewing with the patient an Insulin Adjustment Workbook
 http://www.bd.com/us/diabetes/download/insulin_adjustment_workbook_compl
ete.pdf
 Meet with certified diabetes educator, if available. CDE to look for ways to simplify
medication program with motivational interviewing to see what the patient is
willing to work at and set behavioral goals with follow-up phone calls. (Decrease
blood glucose testing to minimum requirements so patient is able to cope with the
task)
 Suggest that the patient research web-based diabetes tracking software or smart
phone applications
 http://www.vitalmhealth.com/top-diabetes-iphone-apps
 http://www.diabetesnet.com/diabetes-technology/diabetes-software

Discuss daily BG testing routine with patient, try to identify specific source of
difficulty. Discuss Alternative testing sites, easier meter if applicable

If available, refer patient to diabetes educator for more instruction, or use
resource below to find an educator in your area.
 Discuss daily medication routine with patient, try to identify specific barriers.
 Consider printing and reviewing with the patient publicly available brochures with
tips for managing medications. Focus on tips that align with specific barriers.
http://www.health.state.ny.us/diseases/aids/docs/9388.pdf
 Refer to pharmacist to review medications/ pill boxes/calendar
 Refer to social services for Home health care if available
 Review medication schedule for opportunities for consolidation. Are there
medications that would be easier to manage (e.g. less frequent administration,
administration at times that fit patient’s daily schedule) that could be substituted
for current medications?
 If available, refer patient to diabetes educator for more instruction.
Problems or Concerns about
Getting Health Care
Not knowing who to talk to about a health concern
Not getting through to your doctor or nurse on the
telephone
Possible Actions
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Discuss with patient which specific health concerns that they need help with
Refer to specialist, educator, or community resource as appropriate
Discuss types of issues that they are calling in with
Give patient email address, phone numbers, contact names if appropriate

Difficulty getting an appointment soon enough

Not finding a clinic or doctor that was open when
you could get there
Difficulty finding transportation to your doctor or
nurse’s visit
Problems getting mental health care
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Problems getting dental or vision care
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Problems paying your medical bills
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Ask what type of appointments patient is having difficulty obtaining –
consider other referrals
Set up multiple appointments for the patient ahead of time
 Refer to clinics with weekend/evening hours
 Arrange triage call schedule for off hours
Refer to social services – programs for free cab rides, etc.
Secure social worker (if appropriate)
Determine peer or ambassador support
Consider telemedicine if available
Direct patient to state and local resources for free or discounted mental health
services.
 http://www.usc.salvationarmy.org/usc/www_usc_rochester1.nsf/
 http://www.co.olmsted.mn.us/cs/AFS/abh/Pages/default.aspx
Direct patient to resources for free or discounted eye exams (if eligible).
 http://www.aoa.org/visionusa.xml
 http://www.eyecareamerica.org/
Provide NIDDK brochure on dental self-care
 http://diabetes.niddk.nih.gov/dm/pubs/complications_teeth/teeth.pdf
Direct patient to state and local resources for lower cost dental care.
 http://www.health.state.mn.us/clearinghouse/resources.htm
Direct patient to local diabetes support group
 http://www.defeatdiabetes.org/support_groups_minnesota.htm
If available - refer to social services for financial counseling and insurance
assessment
Consider printing and reviewing with the patient the “Financial Help for
Diabetes Care” information from the NIDDK website.
http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf
Recommendations for pharmaceutical support programs
Referral to free clinics (e.g. Salvation Army)


Not maintaining health insurance coverage
Medication reconciliation with attention to cost
Consider generics/educate about the use of generics Medication reconciliation
with attention to cost
 Use decision aid cards about medication choices that include costs
 If available - refer to social services for financial/job counseling and
insurance assessment
 Consider generics/educate about the use of generics Medication reconciliation
with attention to cost
 Use decision aid cards about medication choices that include costs
 Consider printing and reviewing with the patient the “Financial Help for
Diabetes Care” information from the NIDDK website.
http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/financialhelp.pdf\
Recommendations for Pharmaceutical support programs
Referral to free clinics (e.g. Salvation Army)
Problems or Concerns about Work
Your health impacts your ability to work outside
the home or do housework
Possible Actions
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You accomplished less at work because of your
health
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You were limited in the kinds of work you could
do because of your health
It is difficult to manage your diabetes at work (take
breaks for food or medicine, test blood sugar)

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Your work makes it hard to be healthy (eat right,
exercise, sleep enough)

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You can’t afford to take time off work for medical

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Identify barrier to working (i.e., pain, fatigue, disability, cognitive impairment).
Refer to community resources for employment opportunities or job counseling to
help patient find a job that matches his/her ability to work.
 http://www.rochesterpubliclibrary.org/reference/employmenthelp.html
If indicated, refer patient to physical therapy or rehabilitation medicine
Refer to Employee Assistance Programs, often available through health plan or
human resources department.
Identify barriers responsible for accomplishing less (i.e., fatigue, pain, ability to
concentrate, having to take breaks for monitoring/eating)
If indicated, refer patient to physical therapy or rehabilitation medicine
Suggest patient work with his/her supervisor or human resource department to
discuss work responsibilities.
Refer to community resources for employment opportunities or job counseling to
help patient find a job that matches his/her ability to work.
 http://www.rochesterpubliclibrary.org/reference/employmenthelp.html
 http://www.positivelyminnesota.com/JobSeekers/WorkForce_Centers/See_All_
WorkForce_Center_Locations/WFC_-_Rochester/index.aspx
If indicated, refer patient to physical therapy or rehabilitation medicine.
Discuss tips for managing diabetes at work.
 http://www.mayoclinic.com/health/managing-diabetes-at-work/MY00818
Inform patient s/he has the right to request “reasonable accommodations” to
manage their diabetes at work under Americans with Disabilities Act.
 http://www.eeoc.gov/facts/diabetes.html
Does the patient do shift work? If yes, discuss tips on managing diabetes with
shift work.
 http://www.mayoclinic.com/health/diabetes-and-shift-work/MY00817
 http://www.allaboutdiabetes.net/managing-diabetes-during-night-shift/ (page
down to the "Night shift diabetes management" section)
Discuss tips for good sleep hygiene
 http://awakeinamerica.info/2010/health/sleep-hygiene/sleep-hygiene-tip-foradults/
Discuss tips on eating right at work.
 http://www.mayoclinic.com/health/managing-diabetes-at-work/MY00818
Provide nutritional counseling
Discuss tips for managing diabetes at work.
appointments


 http://www.mayoclinic.com/health/managing-diabetes-at-work/MY00818
Inform patient s/he has the right to request “reasonable accommodations” to
manage their diabetes at work under Americans with Disabilities Act.
http://www.eeoc.gov/facts/diabetes.html
Problems or Concerns with physical health
Pain
Fatigue

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Vision problems
Sleep problems
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Difficulty walking

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Shortness of breath

Possible Actions
Assess where, when, severity, duration, associated with
New onset vs recurrent
Therapy and effect
Patients assessment of why they have pain
Impact of pain on daily life
Administer brief pain inventory for more details
Consider pain clinic referral
Assess intensity of fatigue
New onset vs chronic issue
Patient assessment of why they are fatigued
Discuss sleeping patterns and habits
Consider administering brief fatigue inventory for more details
Look for common causes of fatigue: depression, blood sugar
elevated or low, medications causing fatigue, stress
Consider an evaluation for anemia with appropriate interventions
such as exercise program counseling or iron supplements
Assess pattern and new or sudden onset
Associated symptoms such as pain or watering
Consider referral for eye exam---if pain may need to be emergent
Assess risk of elevated blood sugar
Discuss sleeping patterns
Identify barriers to getting enough sleep and strategies for
overcoming barriers
Consider depression screen
Consider referral to sleep therapist
Consider prescription for a sleeping aid
Assess why: dyspnea, pain, weakness, gait issues, etc
Consider referral to physical therapy
Discuss getting more exercise
Discuss if patient needs help with/has assistance getting everyday
tasks done
Assess when: walking, laying flat, activities
Skin changes or infections
Sexual problems
Numbness/tingling in your hands and feet
Something else

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Assess related symptoms: cough, wheeze, chest pain, leg pain
New or recurrent, changing
Probe for details, why, when, where, associated with
Consider referral for foot exam
Probe for details, why, when, where, associated with
Consider resource material http://mayoweb.mayo.edu/spforms/mc0400-mc0499/mc0449-38.pdf
Assess when: constant, intermittent, with activity, with anxiety
Referral?
Probe for details, why, when, where, associated with
administer MDASI, SF/PROMIS physical domain