organization of diabetes care chapter 6 maureen clement, betty harvey, doreen m rabi, robert s...

Organization of Diabetes Care

Chapter 6

Maureen Clement, Betty Harvey, Doreen M Rabi, Robert S Roscoe, Diana Sherifali

Canadian Diabetes Association 2013 Clinical Practice Guidelines

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

Key Points

1. Diabetes is a chronic disease that requires

proactive, planned and population-based care

2. It takes a team. Diabetes care should involve a

interdisciplinary team working within the chronic care

model

3. Technology (telehealth, reminder systems, EMRs,

etc.) can be used to improve care


Reality: Guidelines are NOT Followed

Care gap between diabetes management guidelines and real-life practice

Organizational and evidence-based approach to treating chronic diseases

Real Life

IdealPractice


Chronic Care for a Chronic Disease

Acute and reactive

Proactive, planned, and population-based

The Chronic Care Model


Barr VJ, et al. Hospital Quarterly. 2003;7:73-80.


The Chronic Care Model (CCM) Saves Lives

The CCM improves:

1. A1C

2. LDL-C

3. Use of statins

4. Drug and hospital expenditures

5. Overall mortality


Elements of the Chronic Care Model

1. Delivery Systems Design: The Team

2. Self-ManagementSupport 3. Decision

Support

4. Clinical Information

Systems

5. Community

6. Health Systems


1. Delivery Systems Design: The Team

• Expertise of nurses, dietitians, pharmacists, and psychological support

• Team working with primary care physicians supported by specialists

• Disease management model that uses patient education, coaching, treatment adjustment, monitoring, care co-ordination

You

Your doctor

Your nurse

Your dietitian

Your pharmacist

YOU

Optometrist or ophthalmologist Local diabetes education centre

Foot care specialistMental Health Professional

Other people you know who have diabetes

Physical activity specialist

Dentist

Heart specialist

Kidney specialist

Family and friends

Your diabetes care team may include a …….


2. Self-Management Support

• Formerly known as Diabetes Education• Shift from didactic diabetes education to a patient-

empowering motivational approach• Problem-solving and goal-setting


3. Decision Support

• Tools and techniques to improve patient care decisions

• Flowsheets, electronic medical records (EMRs), care algorithms, accessible specialist support, education, etc.

• Most helpful if available at point of care


The Patient Care Flow Sheet

• Organizes information for care of patients with diabetes

• Shown to improve outcomes

• Available for download & printing at https://guidelines.diabetes.ca

2013

https://guidelines.diabetes.ca/

https://guidelines.diabetes.ca/


Patient Education Tools

• Help patients prepare for, and know what to expect from, a diabetes visit


4. Clinical Information Systems

• Include EMRs and databases to plan and assess care for the population

• Allow practice overviews to prevent inertia and provide timely care


5. Community

• Tapping into community resources to improve care or lifestyles

• May involve peer-led self-management support groups


6. Health Systems

• Promoting preventative care and appropriately planning resource allocation

• May include provider incentives for achieving milestones


Telehealth

Not a specific element of CCM, but may facilitate other aspects

• Conferencing or education of team members• Telemonitoring of health data, such as glucose

readings• Disease management via telephone or internet• Teleconsultation with specialists

The 5Rs of Organized Care

1. Recognize: Consider diabetes risk factors for all of

your patients and screen appropriately for diabetes

2. Register: Develop a registry or a method of tracking

all your patients with diabetes.

3. Resource: Support self-management through the

use of interprofessional teams which could include

the primary care provider, diabetes educator, nurse,

pharmacist, dietitian, and other specialists.


The 5Rs of Organized Care (continued)

4. Relay: Facilitate information sharing between the

person with diabetes and team members for

coordinated care and timely management change

5. Recall: Develop a system to remind your patients

and caregivers of timely review and reassessment of

targets and risk of complications.



Recommendation 1

1. Diabetes care should be proactive, incorporate

elements of the chronic care model (CCM), and be

organized around a person living with diabetes who

is supported in self-management by an

interdisciplinary team with specific training in

diabetes [Grade C, Level 3].


2. The following quality improvement strategies

should be used, alone or in combination, to improve

glycemic control:

Recommendation 22013

• Electronic patient registries• Patient reminders• Audit and feedback• Clinician education• Clinician reminders (with or

without decision support) [Grade A, Level 1A]

• Promotion of self-management

• Team changes• Disease (case)

management• Patient education• Facilitated relay of clinical

information


Recommendation 3

3. Diabetes care management by an

interprofessional team with specific training in

diabetes and supported by specialist input

should be integrated within diabetes care delivery

models in the primary care [Grade A, Level 1A] and

specialist care [Grade D, Consensus] settings.

2013


Recommendation 4

4. The role of the diabetes case manager should be

enhanced, in cooperation with the collaborating

physician, [Grade A, Level 1A], including interventions led

by a nurse [Grade A, Level 1A], pharmacist [Grade B, Level 2], or

dietitian to improve coordination of care and [Grade

B, Level 2] facilitate timely diabetes management

changes.

2013


Recommendation 5

5. As part of a collaborative, shared-care approach within the CCM, an interprofessional team with specialized training in diabetes, and including a physician diabetes expert, should be used in the following groups:

• Children with diabetes [Grade D, Level 4]

• Type 1 diabetes [Grade C, Level 3]

• Women with diabetes who require pre-conception counseling [Grade C, Level 3] and women with diabetes in pregnancy [Grade D, Consensus]

• Individuals with complex (multiple diabetes related complications) type 2 diabetes who are not reaching targets [Grade D, Consensus]

2013


Recommendation 6

6. Telehealth technologies may be used as part of a

disease management program to: • Improve self-management in underserviced communities

[Grade B, Level 2]

• Facilitate consultation with specialized teams as part of a

shared-care model [Grade A, Level 1A]

2013


CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

organization of diabetes care chapter 6 maureen clement, betty harvey, doreen m rabi, robert s...

Documents

diabetes care team

care slide

chronic care model slide

care coordination slide

diabetes management

care algorithms

care gap

didactic diabetes education