2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S20
Organization of Diabetes Care
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee
The initial draft of this chapter was prepared by Sora Ludwig MD FRCPC,
Maureen Clement MD CCFP, Peggy Dunbar MEd PDt CDE and Jeffrey A. Johnson PhD
KEY MESSAGES
• Diabetes care depends upon the daily commitment of
the person with diabetes to self-management practices
with the support of an integrated diabetes healthcare
(DHC) team.
• The DHC team should be multi- and interdisciplinary,
and should establish and sustain a communication network
among the health and community systems needed
in the long-term care of the person with diabetes.
• Diabetes care should be systematic and, when possible,
should incorporate organizational interventions such as
electronic databases, automatic reminders for the patient
and DHC team, to enable timely feedback.
INTRODUCTION
Diabetes care depends upon the daily commitment of the
person with diabetes to self-management practices with the
support of an integrated diabetes healthcare (DHC) team
(1-3). Multifaceted interventions by a wide array of healthcare
providers within the DHC team are needed to improve
management, and should be supported by organizational
interventions that promote regular diabetes monitoring
and recall (4). Diabetes care should be founded on evidence-based
clinical practice guidelines and be continuous,
planned and equitable in terms of access. Diabetes programs
and services should be community-based, culturally and
socially appropriate, and respectful of age, gender and
socioeconomic conditions.
DHC TEAM
The DHC team should be multi- and interdisciplinary. It
should establish and sustain a communication network
among the health and community systems needed in the
long-term care of the person with diabetes (1-3,5-7). The
person with diabetes and his or her family are central members
of the DHC team. Family support has been shown to
benefit the person with diabetes (8).
The core DHC team includes the family physician and/or
specialist, and the diabetes educators (nurse and dietitian)
(3,5-7). The membership of the team is extensive and
includes numerous disciplines. A variety of individual and
community healthcare supports, in particular psychological
support, can improve glycemic control when part of usual
diabetes care (9). Flexibility in the operation of the DHC
team is important. Changes in the core team, such as adding
a team member, active participation by >1 discipline, and
role expansion, have been shown to be associated with
improved clinical outcomes (10,11).
The DHC team provides comprehensive, shared care that
is collaborative in nature. This approach has been shown to
increase the commitment and participation of the person
with diabetes, and recognizes and enhances the role and
practices of all members of the team (12-15).
The family physician’s role is unique as the first, and at
times, the principal medical contact for the person with diabetes.
Family physicians can provide continuity of care for
the person with diabetes, and provide care in the context of
the family unit (16). This unique provider relationship can
also provide opportunities to assist other family members
who may be at risk for developing type 2 diabetes.
In some circumstances, this role may be shared with or
assumed by a diabetes specialist (4,17,18). Studies suggest
that diabetes-related outcomes are improved if medical care
provided by the family physician is influenced by a diabetes
specialist (18).This influence can vary from indirect input by
the specialist as an opinion leader to direct involvement as
part of a collaborative care model (4,19). Other effective
interventions include the opportunity for input into qualityimprovement
working groups and direct feedback on
processes and outcomes (20).
SELF-MANAGEMENT
Diabetes self-management is most effective when ongoing
diabetes education and comprehensive care occur together
(21-23). Effective diabetes self-management programs have
been demonstrated to improve glycated hemoglobin (A1C)
values (23-25).
Diabetes education must support self-management
through approaches that promote informed, independent
decisions relating to the individual’s diabetes management.
These approaches have been shown to improve patient
adherence to treatment recommendations (26). Self-management
education should include problem-solving,
goal-setting and active participation in decision-making.
This includes supporting the learner in interpreting and
acting on the results of self-monitoring of blood glucose;
making informed management decisions about insulin,