Diab HA1 Assess the healthcare needs of individuals with diabetes and agree care plans

Overview

This standard covers assessing the healthcare needs of an individual with diabetes and agreeing a care plan with the individual.  This involves gathering and interpreting information through discussion with the individual, and through examination. The care plan may be the first one an individual has agreed, or the result of a regular health review. The activity of agreeing a care plan may be accompanied by specific interventions, set out in more detail in other standards. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. The NSF for diabetes
2. The NICE guidelines on diabetes monitoring, management and education
3. The causes of diabetes
4. The signs and symptoms of diabetes
5. Normal and abnormal blood glucose and HbA1c values
6. How to monitor glucose levels, HbA1c, blood pressure
7. Typical progressive patterns of diabetes
8. The importance and effects of patient education and self management
9. The psychological impact of diabetes, at diagnosis and in the long term
10. How to gather information from patients about their health
11. How to work in partnership with patients and carers
12. The social, cultural and economic background of the patient/carer group
13. The impact of nutrition and physical exercise
14. The effects of smoking, alcohol and illicit drugs
15. The effects of, and how to manage, intercurrent illness
16. How to manage hypoglycaemia
17. The medications used to manage diabetes
18. The long term complications of diabetes and when they are likely to occur
19. How to examine feet and assess risk status
20. How to monitor cardiovascular risk
21. How to monitor for renal disease
22. How to monitor for diabetic retinopathy
23. The law and good practice guidelines on consent
24. The staff member’s role in the healthcare team and the role of others
25. Local guidelines on diabetes healthcare
26. Local referral pathways
27. Local systems for recording patient information
28. Quality assurance systems
29. The process of notification for legal and insurance purposes
30. Sources of practitioner and patient information on diabetes
31. Contact details of local and national support groups
32. How individuals can access local facilities for exercise and physical activity, education and community activities

Performance Criteria

You must be able to do the following:

1. communicate with individuals and carers in a manner which encourages an open exchange of views and information
2. listen to the individual’s description of their health and gather information on:
   1. what they see as their health needs
   2. their patterns of eating, diet and physical activity
   3. any concerns with their medication and other aspects of managing their diabetes
   4. self management issues, for those who are not newly diagnosed
3. assess through discussion:
   1. the individual's understanding of their diabetes
   2. their ability to self manage
   3. their attitude to self managing
   4. their emotional/psychological needs in relation to living with diabetes
4. explain to the individual and carer the purpose and nature of any examinations which need to be carried out, and confirm that the individual understands and consents to this
5. conduct the examinations in a manner which encourages the participation of the individual, and ensure that any unnecessary discomfort is minimised
6. review all of the information gathered from the individual, including that from screening services, and evaluate their overall risk against agreed guidelines and any targets previously agreed with the individual
7. consult with colleagues, or seek advice from others who are able to assist, where the information you have gathered is difficult to interpret
8. identify evidence of the development of long-term complications of diabetes and assess the overall risks for the individual
9. communicate with the individual and carer throughout in a way that fully involves them in discussing how to manage their diabetes
10. explain the findings from the assessment of the individual’s healthcare needs,  allow the individual and carer time to identify their issues of concern
11. in discussion with the individual jointly identify priorities for managing their  diabetes in the immediate future, taking into account:
    1. the risks revealed by all assessments
    2. the individual's belief and values
    3. the choices facing the individual
12. offer to help the individual and carer develop a care plan that will address the issues and risks raised by the assessment
13. where the individual and carer accept your offer, help them to develop a realistic plan of care that is appropriate to the needs, circumstances and wishes of the individual
14. agree upon what responsibility the individual will take for managing their diabetes, and what responsibilities will be taken by healthcare professionals and by carers, and provide appropriate encouragement and support
15. explore with the individual their preferred methods of communication for maintaining contact
16. provide appropriate information about agencies and sources of support and advice, to help the individual to access relevant services
17. refer the individual for further tests or treatment, with their consent, where the information you have gathered from the examinations or discussions indicates a further health risk
18. make an accurate record of the discussion and any agreed plan that can be followed by other members of the care team, the individual and carer

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning