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App A Diabetes IDTD Tool Feb09 PDF
App A Diabetes IDTD Tool Feb09 PDF
January 2008
TABLE OF CONTENTS
Introduction ...........................................................................................................1
Roles and Responsibilities...................................................................................2
Chronic Disease Prevention and Management Diabetes Program Key
Tasks......................................................................................................................3
Chronic Disease/Diabetes Program Key Tasks & Actions .............................4
1. Identifying Patients....................................................................................................4
2. Understanding Patient Needs and Available Resources............................................6
3. Developing Chronic Disease Management Programs ...............................................7
4. Delivering Chronic Disease Management Programs .................................................8
5. Coordinating Chronic Disease Management Programs ...........................................10
6. Measuring Success Evaluating Chronic Disease Management Programs............11
Appendix A ..........................................................................................................12
Patient Education Specialist Urban Family Health Team...........................................13
Health Promoter, Family Health Team .........................................................................14
From Wikipedia, the free encyclopedia.........................................................................15
Appendix B ..........................................................................................................16
References...........................................................................................................19
Project Sponsor:
Academic Family Health Team Forum
Department of Family and Community Medicine, University of Toronto
Project Funder:
Primary Health Care and Family Health Teams
Health System Accountability and Performance Division
Ministry of Health and Long Term Care
Introduction
The objective of this Task Group is to provide a tool for use by Family Health Teams (FHTs) in
Ontario to aid in developing their own chronic care management programs for type 2 diabetes. The
principles for care provision and support to patients/clients with diabetes by primary care team
practices include being: proactive, consistent, comprehensive and flexible.
Due to the different stages of development of FHTs, as well as the varying resources available, this
tool focuses on enabling individual FHTs and family practice teams to make decisions within their
team based on their organizations goals, patient needs and staffing capacity.
This document provides FHTs with a resource from which key tasks can be designated to the
participating members of the diabetes team.
The first step is to outline the scope of practice of the various team members. This ensures that all
members are aware of the roles and responsibilities of the different disciplines when creating an
interdisciplinary team. The Ministry of Health and Long Term Care (MOHLTC) has prepared a
guide1 as part of its Family Health Team information series that outlines the roles and responsibilities
of most of the professions. It describes what each Practitioner can do in terms of: Assessment,
Treatment/Management, Education/Advocacy, and Referrals/Collaboration. In addition to the health
professionals listed, we have provided information on other potential team members such as Diabetes
Nurse Educator, Heath Promoter, and Patient Educator Specialist, not described in the MOHLTC
guide. Please see appendix A.
The second step is to develop a diabetes program within the Ministry approved Chronic Disease
Prevention and Management framework.
The MOHLTC has outlined steps for FHTs to develop Chronic Disease Management Programs2. The
Task Group has further refined these functions to describe the necessary components of a diabetes
program, and have outlined the Key Tasks that each team should consider and/or implement.
Each FHT can use this resource to assign the key tasks to members of their diabetes management
team. We have provided a Roles Matrix to assist in this process. Assignment of actions to specific
team members ensures accountability and improves service delivery. The designation of who
completes the Key Tasks can apply uniformly to all patients/clients identified for diabetes
management, or can be adjusted for an individual patient/client. This flexibility takes into account
patient/client preferences for certain care providers as well as complexities of care for certain
individuals.
Family Physicians
Nurse Practitioners
Nurses
Nurse Educators
Dietitians
Pharmacists
Social Workers
Some teams also have either full time, part time or preferred access to chiropodists, occupational
therapists, physiotherapists, health promotion specialists, psychiatrists and other consultants.
It is assumed that health professional trainees may perform the same roles as fully certified colleagues
under appropriate supervision.
FHTs creating programs around diabetes management should include one or more professionals who
have the Certified Diabetes Educator status (or have team members working toward this designation).
The MOHLTC document Family Health Teams Advancing Primary Health Care: Guide to
Interdisciplinary Team Roles and Responsibilities1 is an important resource. It outlines the regulated
scope of practice of most of the professionals currently working within FHTs. Having an
understanding of what the various members can do under their Regulatory body or Professional
Association allows the team to avoid duplication of services delivered by its members and also
enables insights into the possible extent of services a practitioner may be able to offer. Within teams,
individual members of the practice may have refined their own scope of care delivery based on
expertise, preference and skill set. It is the assumption of this Task Group that these important
discussions will occur within each team and within the context of the design and implementation of
specific programs.
Identifying patients
Educating patients
The Task Group has refined these steps for development of a diabetes program by identifying Key
Tasks under each section. The Key Tasks are the action statements that the diabetes team must
consider and/or implement when developing their diabetes program. They are based on the
MOHLTC requirements,2,3,4 Guidelines Advisory Committee recommended guidelines5, research on
quality improvement strategies6 and input from the Task Group.
Most of the Key Tasks can be performed by different members of the diabetes team, and it is up to
each FHT to distribute the tasks at their local site. Task assignment can be made for each individual
patient/client, or globally for all patients/clients. We have provided a Role Matrix chart which the
team can use to assign the Tasks to the various members. As some tasks can be performed by
multiple members of the team, there will be some differing approaches from the pilot sites.
Team changes include: adding a team member or shared care, use of multidisciplinary
teams, expansion or revision of professional roles.6
Identify members of the team (what disciplines should and can be involved?)
Identify resources available to the team (What local resources do you have available in
your community that you can call upon? DEC? CDE at local pharmacy? Administrative
resources?)
Review roles, responsibilities and capabilities of team members. (See above section
Roles and Responsibilities)
Choose a standardized flow sheet to be used by the team (see Tools section for examples)
Ensure the flow chart incorporates all of the MOH and CDA4,5 recommended elements
Ensure all clinicians are familiar with and comfortable using the flowsheet
Decide on where new flowsheets can be accessed (hard copies versus electronic copies)
Eligible patients may include those at risk for diabetes, persons with diabetes or persons at
high-risk for complications, depending on the capacity of the team. Examples of targeting
patients include patients consistently out of their metabolic range, newly diagnosed patients,
socially or medically complex patients.
Eligible persons may be flagged by the physician or NP, for particular case management
approaches and goal setting. Some practices may decide to offer a full range of information
and counselling to all patients diagnosed or at risk of diabetes. The decision around
intensified treatment resources will rest with each FHT.
Electronic tracking system as this becomes possible with the fuller implementation of the
Electronic Health Records
As interim step, where necessary, develop a manual roster by eliciting help from the practice.
Reception staff may also be able to contribute to the creation of this list.
Case management includes any system for coordinating diagnosis, treatment, or ongoing
patient management by a person or multidisciplinary team in collaboration with or
supplementary to the primary care clinician. The most significant changes occur when the
case manager (either a nurse or pharmacist) can make independent medication changes.6
Be the main point of contact and post diagnosis referral for patients, team members and
external resources (e.g., community services)
Ensure completion of the must-do tasks for the Designated Visits (monofilament
testing, random blood sugars, discussion on progress of goals, reinforcement and
discussion of external provider visits e.g. education session)
Identify patients in need of additional services based on information obtained from initial
and follow-up designated visits, from the flow sheet and/or patient discussions; make
referrals as necessary(with the exception of specialist consultations).
Initial assessment of patient-centered determinants of health and how these may impact
compliance with care plan and goals
Compile and keep updated a list of key community partners such as Diabetes Education
Centres, community fitness programs, etc.
Engagement with community partners for capacity building and seamless care
This will help facilitate the shared care model, improve care efficiency and relieve external
stressors/burden on the primary caregivers
Nutrition
Smoking cessation
SMBG
Medication usage
Foot care
(See CDA Screening for type 2 diabetes, IFG and IGT flow diagram)
Cardiovascular complications
Dyslipidemia
Hypertension
Obesity
Psychological problems
Retinopathy
Nephropathy
Neuropathy
Erectile dysfunction
Identify and discuss patient specific barriers; establish goals and care plan accordingly
Review symptoms and complications of peripheral neuropathy and need for foot
examinations
Provide the patient with a patient tracker to facilitate awareness of target values (see
Tools)
If no dietician within your practice, consider referral to community resources (see Identifying
Community Partners section)
Establish a patient reminder system (e.g., postcards or telephone calls) to remind patients
about upcoming appointments or important aspects of self-care.
Use of patient roster to identify need to recall patients for regular appointment
Decision on what elements of routine visits and flowsheet recording can be done by
different team members
Identify need for external resources (e.g., referral for specialist care)
Horizontal referral between team members (with the exception of referral to specialty care);
external referrals to be coordinated by case manager or physician (as OHIP number may be
required).
patient barriers that may interfere or impact specific targets (e.g. metastatic cancer,
depression, chronic pain other co-morbid conditions) that may take precedent and impact
care delivery.
dates of appointments and recommendations from referrals to other providers (e.g. DEC,
endocrinologist etc.). The case manager should follow up and reinforce what was done at
these visits for continuity of care.
Consider conducting periodic meetings with the team to discuss progress, gaps, shortcomings,
successes and areas for improvement.
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Appendix A
For descriptions of the roles of other professionals within FHTs, we have borrowed job
advertisements from Family Health Team recruitments. There will be differences observed
among FHTs in terms of focus for qualifications and job profile in these areas. These are
intended as examples only.
To provide information on a Certified Diabetes Educator, we have excerpted from a wiki
definition. A person with this certification will be a member of profession such as nursing, or
pharmacy who, after being engaged in diabetes education for a minimum time as required
by the certifying body, can proceed to the certification steps.
12
13
14
A Certified diabetes educator (CDE) is a health care professional who is specialized and
certified to teach people with diabetes how to manage their condition.
Typically the CDE is also a nurse or dietitian who has further specialized in diabetes
expertise. Formal education and years of practical experience are required, in addition to
formal examination, before a diabetes educator is certified. In the US, certification is
awarded by the National Certification Board for Diabetes Educators. In Canada, certification
is awarded by the Canadian Diabetes Association.
The CDE is an invaluable asset to those who need to learn the tools and skills necessary to
control their blood sugar and avoid long-term complications due to hyperglycemia. Unlike an
endocrinologist, the CDE can spend as much time with a newly diagnosed person as is
needed both for educational purposes and emotional support.
[edit] References
15
Appendix B
The tools provided in this section are included as examples only. The task group recognizes
that a broad range of tools exist and others are being developed/adapted by individual
organizations to best suit the needs of their patients.
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17
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References
1 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to interdisciplinary team roles and responsibilities. 2005
2 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to chronic disease management and prevention. 2005
3 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to collaborative team practice. 2005
4 Ministry of Health and Long Term Care. Diabetes management incentive fact sheet, 2006.
5 Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of
diabetes in Canada. Canadian Journal of Diabetes. 2003, 27(suppl 2).
6 Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK.
Effects of quality improvement strategies for type 2 diabetes on glycemic control: a metaregression analysis. JAMA 2006;296:427-439.
7 Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease
management programmes: Are they consistent with the literature? Managed Care Quarterly, 1999.
7(3):56-66.
8 Langley C, Nolan K, Norman C, Provost L. The improvement guide: A practical approach to
improving organizational performance. San Francisco. Josey-Bass Publishers, 1996.
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