Organization of Diabetes Care

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Maureen Clement MD, CCFP Betty Harvey RNEC, BScN, MScN Doreen M. Rabi MD, MSc, FRCPC Robert S. Roscoe BScPharm, ACPR, CDE Diana Sherifali RN, PhD, CDE

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • 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 self-management 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.

Highlights of Revisions

  • In 2008, recommendations focused on patient self-management with the support of an interprofessional diabetes healthcare team. The newly revised recommendations now focus on the chronic care model (CCM) which includes elements beyond the patient and healthcare provider, including delivery system designs, self-management support, decision support, clinical information, the community and health systems.
  • Telehealth technologies are now also recognized.
  • A new Patient Care Flow Sheet (p. S350) has been developed.

Recommendations

  1. Diabetes care should be proactive, incorporate elements of the chronic care model (CCM), and be organized around the person living with diabetes who is supported in self-management by an interprofessional team with specific training in diabetes [Grade C, Level 3 (1,2)].
  2. The following quality improvement strategies should be used, alone or in combination, to improve glycemic control [Grade A, Level 1 (3)]:
    • a) Promotion of self-management
    • b) Team changes
    • c) Disease (case) management
    • d) Patient education
    • e) Facilitated relay of clinical information
    • f) Electronic patient registries
    • g) Patient reminders
    • h) Audit and feedback
    • i) Clinician education
    • j) Clinician reminders (with or without decision support)
  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 (3,4)] and specialist care [Grade D, Consensus] settings.
  4. The role of the diabetes case manager should be enhanced, in cooperation with the collaborating physician [Grade A, Level 1A (3,4)], including interventions led by a nurse [Grade A, Level 1A (5,6)], pharmacist [Grade B, Level 2 (7)] or dietitian [Grade B, Level 2 (8)], to improve coordination of care and facilitate timely diabetes management changes.
  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:
    • a)Children with diabetes [Grade D, Level 4 (9)]
    • b)Type 1 diabetes [Grade C, Level 3 (10)]
    • c)Women with diabetes who require preconception counselling [Grade C, Level 3 (11–13)] and women with diabetes in pregnancy [Grade D, Consensus]
    • d)Individuals with complex (multiple diabetes-related complications) type 2 diabetes who are not reaching targets [Grade D, Consensus]
  6. 6.Telehealth technologies may be used as part of a disease management program to:
    • a)Improve self-management in underserviced communities [Grade B, Level 2 (14)]
    • b)Facilitate consultation with specialized teams as part of a shared-care model [Grade A, Level 1A (15)]

Abbreviation:
CCM, chronic care model.

Helpful Hints Box: Organization of Care

Recognize: 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.

References

  1. 1 K. Coleman B. Austin C. Brach E.H. Wagner Evidence on the chronic care model in the new millennium Health Affairs 28 2009 75 85
  2. 2 S. Stock A. Drabik G. Buscher German diabetes management programs improve quality of care and curb costs Health Affairs 29 2010 2197 2205
  3. 3 A.C. Tricco N.M. Ivers J.M. Grimshaw Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis Lancet 2012 12 21
  4. 4 C. Pimouguet G.M. Le R. Thiebaut Effectiveness of disease-management programs for improving diabetes care: a meta-analysis CMAJ 183 2011 e115 e127
  5. 5 G. Welch J. Garb S. Zagarins Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis Diabetes Res Clin Pract 88 2010 1 6
  6. 6 C.E. Clark L.F.P. Smith R.S. Taylor Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis Diabet Med 28 2011 250 261
  7. 7 C. Collins B.L. Limone J.M. Scholle Effect of pharmacist interventions on glycemic control in diabetes Diabetes Res Clin Pract 92 2011 145 152
  8. 8 A.M. Wolf M.R. Conaway J.Q. Crowther Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study Diabetes Care 27 2004 1570 1576
  9. 9 A.M. Glasgow J. Weissberg-Benchall W.D. Tynan Readmissions of children with diabetes mellitus to a children’s hospital Pediatrics 88 1991 98 104
  10. 10 J.C. Zgibor T.J. Songer S.F. Kelsey Influence of health care providers on the development of diabetes complications: long term follow-up from the Pittsburgh Epidemiology of Diabetes Complications Study Diabetes Care 25 2002 1584 1590
  11. 11 J.G. Ray T.E. O’Brien W.S. Chan Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis QJM 94 2001 435 444
  12. 12 J.L. Kitzmiller L.A. Gavin G.D. Gin Preconception care of diabetes. Glycemic control prevents congenital anomalies JAMA 265 1991 731 736
  13. 13 S.S. McElvy M. Miodovnik B. Rosenn A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels J Matern Fetal Med 9 2000 14 20
  14. 14 R.M. Davis A.D. Hitch M.M. Salaam TeleHealth improves diabetes self-management in an underserved community: Diabetes TeleCare Diabetes Care 33 2010 1712 1717
  15.  15F. Verhoeven K. Tanja-Dijkstra N. Nijland Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review J Diabetes Sci Technol 4 2010 666 684

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on guidelines.diabetes.ca, CPG Apps and in our online store remains exactly the same. For questions, contact communication@diabetes.ca.