2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S22
RECOMMENDATIONS
1. Diabetes care should be organized around the person
with diabetes using a multi- and interdisciplinary DHC
team approach centred on self-care management
[Grade B, Level 2 (3,11,23,24)].
2. Diabetes care should be systematic and incorporate
organizational interventions such as electronic databases
and clinical flow charts with automatic reminders for
the patient and DHC team, to enable timely feedback
for management changes [Grade B, Level 2 (3,11,35,36)].
3.The DHC team should facilitate the transfer of information
among all members of the team as appropriate to
ensure continuity of care and knowledge transfer
[Grade B, Level 2 (11,70,71)].
4. Members of the DHC team should receive support and
education, which can vary from indirect input to direct
involvement from a diabetes specialist as part of a collaborative
care model [Grade C, Level 3 (4,11,17-19)].
5.The role of DHC team members, including nurse educators
[Grade B, Level 2 (11,44,51)], pharmacists [Grade B,
Level 2 (11,44)] and dietitians [Grade B, Level 2 (51)],
should be enhanced in cooperation with the physician
to improve coordination of care.The DHC team should
facilitate and/or implement timely diabetes management
changes without unnecessary delay [Grade B, Level 2 (3)].
6. Case management or care coordination by health professionals
with specialized training in diabetes should be
considered for those individuals with difficult-to-manage
diabetes [Grade B, Level 2 (11,50)].
OTHER RELEVANT GUIDELINES
Self-management Education, p. S25
Type 1 Diabetes in Children and Adolescents, p. S150
Type 2 Diabetes in Children and Adolescents, p. S162
Diabetes and Pregnancy, p. S168
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