1. 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

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 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

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 Real Life Ideal Practice Ideal Practice

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Chronic Care for a Chronic Disease Acute and reactive Proactive, planned, and population-based The Chronic Care Model

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Barr VJ, et al. Hospital Quarterly. 2003;7:73-80.

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

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Elements of the Chronic Care Model 1. Delivery Systems Design: The Team 2. Self-Management Support 3. Decision Support 4. Clinical Information Systems 5. Community 6. Health Systems

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

9. You Your doctor Your nurse Your dietitian Your pharmacist YOU Optometrist or ophthalmologist Local diabetes education centre Foot care specialist Mental 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 …….

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

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

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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 https://guidelines.diabetes. ca 2013

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Patient Education Tools Help patients prepare for, and know what to expect from, a diabetes visit

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

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 5. Community Tapping into community resources to improve care or lifestyles May involve peer-led self-management support groups

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 6. Health Systems Promoting preventative care and appropriately planning resource allocation May include provider incentives for achieving milestones

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

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

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

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

21. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2.The following quality improvement strategies should be used, alone or in combination, to improve glycemic control: Recommendation 2 2013 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

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

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

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

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

26. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients