The Burden of Diabetes: Life-long Self-management

1. The Burden of Diabetes: Life-long Self-management The person living with diabetes must live every day with the management of this disease– there is no time off! 99.98%of the time patients are on their own 0.02%of the time patients are with their healthcare team “The diabetes self-management regimen is one of the most challenging of any for chronic illness.” Schillinger D et al. JAMA 2002; 288:475–482.

2. Self-Management Education (SME) A systematic intervention that involves active patient participation in self-monitoring and/or decision-making

3. Elements of the Chronic Care Model 1. Delivery Systems Design: The Team 2. Self-Management Support 3. Decision Support 4. Clinical Information Systems 5. Community 6. Health Systems

5. Organization of Care - CPG 2013 The following quality improvement strategies should be used, alone or in combination, to improve glycemic control: • Electronic patient registries • Patient reminders • Audit and feedback • Clinician education • Clinician reminders (with or without decision support) [Grade A, Level 1A] • Promotion of self-management • Team changes • Disease (case) management • Patient education • Facilitated relay of clinical information

6. Case Management – a QI Strategy • Case Managers embedded in Primary Care can promote and facilitate: • Promotion and support of self-management • Team changes • Patient education • Facilitated relay • Entry point to more directed care; • dietary resources (DEP and community) • Social services (DEP, Mental Health, Social Development)

7. Program Objectives of Case Management Implementation in New Brunswick • Provide support to both the Primary Care Providers and their patients with timely access to a Certified Diabetes Educator in the community setting. • Enhancement of assessment, planning and implementation of best practice guidelines. • Identify the knowledge and practice gaps of the patient with diabetes and the Primary Health Team. • Recommendation of appropriate treatments, referrals, or changes to therapy and, utilizing the skills of motivational interviewing and patient empowerment, support patient self-management practices in a patient centred-chronic disease model of care

8. Evaluation:New Brunswick Health Council • 51% of patients seen by Case Managers are >65 years of age: • suggests a higher burden of chronic illness for this population • 44% of patients seen are between the ages of 45-64 years of age: • This is largely a working and busy population where early intervention for the assessment, intervention, and management of vascular co-morbidities related to diabetes will have a positive impact for future health considerations both for the patient and the health care system

9. Approximately 70% of patients followed by a Case Manager achieved an A1C between 6 & 8% and, that from 3 months prior to the first visit with a Case Manager to after one year, the mean difference in A1C was a decrease of 0.82

10. Evaluation • New Brunswick Health Council Report noted that better outcomes for people living with diabetes were influenced by the following elements: • Strong relationships between the patient and the team • A team focus on meeting individual needs through sensitivity to values, preference and expressed needs • Good accessibility and flexibility in offering services • Good coordination and integration of internal team members with external team members • Case Managers demonstrate high levels of patient-centred care and alignment with the Expanded Chronic Care Model that will enhance the “shared care” aspect of any Health Delivery System.