ORGANIZATION AND DELIVERY OF CARE

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ORGANIZATION ANDDELIVERY OF CARE

• 2003 Clinical Practice Guidelines
• for the Prevention and Management
• of Diabetes in Canada

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DIABETES HEALTHCARE TEAM

• Central to the Diabetes Healthcare (DHC) team is
  the person with diabetes and his/her family.
• The DHC team provides comprehensive, shared care
  with ongoing communication amongst and
  participation of all members of the team.
• Professional members of the DHC team should
  explore within their organization, interventions
  that have been shown to improve patient outcomes.
• Models of care, using diabetes as a prototype for
  chronic disease management, have been described
  and may be used to improve healthcare delivery.

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ORGANIZATION DELIVERY OF CARE- RECOMMENDATIONS

• Diabetes care should be organized around the
  person with diabetes using a multi- and
  interdisciplinary DHC team approach Grade B,
  Level 2.
• Diabetes care should be systematic and
  incorporate organizational interventions that
  have been shown to improve healthcare
  efficiencies, such as databases to provide
  patient and physician reminders and transfer of
  information, organized diabetes clinics, and
  tools, including clinical flow sheets Grade B,
  Level 2.

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ORGANIZATION DELIVERY OF CARE- RECOMMENDATIONS

• As an essential member of the DHC team, the
  family physician and/or specialist and the other
  members of the DHC team have the responsibility
  to
• - Ensure that systematic, structured and
  standardized diabetes care is available Grade A,
  Level 1A
• - Incorporate current standards of diabetes care
  into daily practice Grade D, Consensus
• - Facilitate transfer of information among all
  members of the team to ensure continuity of care
  Grade A, Level 1A and
• - Endeavour to identify and prevent diabetes in
  those identified to be at risk Grade D,
  Consensus.

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ORGANIZATION DELIVERY OF CARE- RECOMMENDATIONS

• People with diabetes should be offered initial
  and ongoing needs-based diabetes education in a
  timely manner to enhance self-care practices and
  behaviours Grade B, Level 2.
• The role of diabetes nurse educators Grade B,
  Level 2 and other DHC team members Grade D,
  Consensus should be enhanced in cooperation with
  the physician to improve coordination of care and
  to effect timely diabetes management changes.