Organization of Diabetes Care

Abstract

Diabetes care should be organized around the person living with diabetes who is practising self-management and is supported by a proactive, interprofessional team with specific training in diabetes. Diabetes care should be delivered using as many elements as possible of the chronic care model. The following strategies have the best evidence for improved outcomes and should be used: promotion of self-management, including selfmanagement support and education; interprofessional team-based care with expansion of professional roles, in cooperation with the collaborating physician, to include monitoring or medication adjustment and disease (case) management, including patient education, coaching, treatment adjustment, monitoring and care coordination. Diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. HELPFUL HINTS BOX: ORGANIZATION OF CARERecognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.Register: Develop a registry for all of your patients with diabetes.Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, dietitian, nurse, pharmacist and other specialists.Relay: Facilitate information sharing between the person with diabetes and the team for coordinated care and timely management changes.Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.

Effectiveness of community-based peer-led diabetes self-management programmes (COMP-DSMP) for improving clinical outcomes and quality of life of adults with diabetes in primary care settings in low and middle-income countries (LMIC): a systematic review and meta-analysis

“…5 While community resources have not traditionally been integrated into care, community partnerships should be considered as a means of gaining better care for people with diabetes. 6 In LMIC, as health resources become more and more strained, healthcare providers and researchers have developed various approaches by which diabetes can be more efficiently and economically managed. 7 Peer support empowers patients to connect with others who have had similar experiences and can have positive benefits for patient satisfaction and motivation.…”

Exercise as medicine—the use of group medical visits to promote physical activity and treat chronic moderate depression: a preliminary 14-week pre–post study

“…20 21 The evidence for GMVs in various medical settings is detailed elsewhere. [21][22][23][24][25][26] Briefly, the theoretical rationale for this approach is a multifactorial 'interdisciplinary model', 27 including medication/treatment monitoring, patient education, coaching, social support, goal setting and motivation for improving person's selfperception to uptake PA. [28][29][30] We have completed a preliminary study of a 14-week intervention that linked GMVs with exercise classes to motivate patients diagnosed with a chronic mood disorder to engage in regular PA as measured by pre-post 'step counts'. Our objective was to investigate the impact of PA-focused GMVs on PA and symptoms of depressive and anxiety.…”

“…The study aligned with the interdisciplinary approach recommended by Tulloch et al 27 and it incorporated key aspects of the Chronic Care Model, including "selfmanagement, support and education, inter-professional team-based care…medication adjustment…and coaching". 30 Gentle hatha yoga classes led by a certified yoga therapist reinforced the interdisciplinary aspect of care delivery. 30 This interdisciplinary approach is not standard in Canada, but may be one way to address some 'gaps in care' identified in the current mental healthcare model.…”

“…30 Gentle hatha yoga classes led by a certified yoga therapist reinforced the interdisciplinary aspect of care delivery. 30 This interdisciplinary approach is not standard in Canada, but may be one way to address some 'gaps in care' identified in the current mental healthcare model. 30 Study participants experienced significant increases in levels of PA (as measured by steps), confidence and enjoyment.…”

“…30 This interdisciplinary approach is not standard in Canada, but may be one way to address some 'gaps in care' identified in the current mental healthcare model. 30 Study participants experienced significant increases in levels of PA (as measured by steps), confidence and enjoyment. By 3 months postintervention, participants had moved beyond a 'sedentary lifestyle' (≤5000 steps/ day) to a daily step count average (5746) comparable to those for US adults (5100-6500 steps/day).…”