App_A_Diabetes_IDTD_Tool_Feb09.pdf

Interprofessional Team Development

for Diabetes Care Discussion Paper

January 2008

TABLE OF CONTENTS

Introduction ...........................................................................................................1

Roles and Responsibilities...................................................................................2

Chronic Disease Prevention and Management Diabetes Program Key Tasks......................................................................................................................3

Chronic Disease/Diabetes Program Key Tasks & Actions .............................4

1. Identifying Patients....................................................................................................4

2. Understanding Patient Needs and Available Resources............................................6

3. Developing Chronic Disease Management Programs ...............................................7

4. Delivering Chronic Disease Management Programs .................................................8

5. Coordinating Chronic Disease Management Programs ...........................................10

6. Measuring Success Evaluating Chronic Disease Management Programs............11

Appendix A ..........................................................................................................12

Patient Education Specialist Urban Family Health Team...........................................13

Health Promoter, Family Health Team .........................................................................14

From Wikipedia, the free encyclopedia.........................................................................15

Appendix B ..........................................................................................................16

References...........................................................................................................19

Document contributed by:

Michelle Murti, Family Medicine Resident

Womens College Family Health Team

Document created as part of the work of the Diabetes Tool Kit Task Group

The Diabetes Tool Kit Task Group is one of four task groups formed as part of the project Interprofessional Clinical Program Development for a Network of Family Health Teams.

Project Sponsor:

Academic Family Health Team Forum

Department of Family and Community Medicine, University of Toronto

Project Funder:

Primary Health Care and Family Health Teams

Health System Accountability and Performance Division

Ministry of Health and Long Term Care

1

Defining Roles For Interprofessional Diabetes Teams

Introduction

The objective of this Task Group is to provide a tool for use by Family Health Teams (FHTs) in Ontario to aid in developing their own chronic care management programs for type 2 diabetes. The principles for care provision and support to patients/clients with diabetes by primary care team practices include being: proactive, consistent, comprehensive and flexible.

Due to the different stages of development of FHTs, as well as the varying resources available, this tool focuses on enabling individual FHTs and family practice teams to make decisions within their team based on their organizations goals, patient needs and staffing capacity.

This document provides FHTs with a resource from which key tasks can be designated to the participating members of the diabetes team.

The first step is to outline the scope of practice of the various team members. This ensures that all members are aware of the roles and responsibilities of the different disciplines when creating an interdisciplinary team. The Ministry of Health and Long Term Care (MOHLTC) has prepared a guide1 as part of its Family Health Team information series that outlines the roles and responsibilities of most of the professions. It describes what each Practitioner can do in terms of: Assessment, Treatment/Management, Education/Advocacy, and Referrals/Collaboration. In addition to the health professionals listed, we have provided information on other potential team members such as Diabetes Nurse Educator, Heath Promoter, and Patient Educator Specialist, not described in the MOHLTC guide. Please see appendix A.

The second step is to develop a diabetes program within the Ministry approved Chronic Disease Prevention and Management framework.

The MOHLTC has outlined steps for FHTs to develop Chronic Disease Management Programs2. The Task Group has further refined these functions to describe the necessary components of a diabetes program, and have outlined the Key Tasks that each team should consider and/or implement.

Each FHT can use this resource to assign the key tasks to members of their diabetes management team. We have provided a Roles Matrix to assist in this process. Assignment of actions to specific team members ensures accountability and improves service delivery. The designation of who completes the Key Tasks can apply uniformly to all patients/clients identified for diabetes management, or can be adjusted for an individual patient/client. This flexibility takes into account patient/client preferences for certain care providers as well as complexities of care for certain individuals.


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Roles and Responsibilities

Family Health Teams being developed in Ontario include a range of health professionals. Currently most teams have some combination of the following professionals:

Family Physicians

Nurse Practitioners

Nurses

Nurse Educators

Patient Education Specialists

Dietitians

Pharmacists

Social Workers

Health professional trainees

Some teams also have either full time, part time or preferred access to chiropodists, occupational therapists, physiotherapists, health promotion specialists, psychiatrists and other consultants.

It is assumed that health professional trainees may perform the same roles as fully certified colleagues under appropriate supervision.

FHTs creating programs around diabetes management should include one or more professionals who have the Certified Diabetes Educator status (or have team members working toward this designation).

The MOHLTC document Family Health Teams Advancing Primary Health Care: Guide to Interdisciplinary Team Roles and Responsibilities1 is an important resource. It outlines the regulated scope of practice of most of the professionals currently working within FHTs. Having an understanding of what the various members can do under their Regulatory body or Professional Association allows the team to avoid duplication of services delivered by its members and also enables insights into the possible extent of services a practitioner may be able to offer. Within teams, individual members of the practice may have refined their own scope of care delivery based on expertise, preference and skill set. It is the assumption of this Task Group that these important discussions will occur within each team and within the context of the design and implementation of specific programs.


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Chronic Disease Prevention and Management Diabetes Program Key Tasks

The MOHLTC document Family Health Teams Advancing Primary Health Care: Guide to Chronic Disease Management and Prevention2 has outlined the necessary steps in developing and implementing a chronic disease program. The steps are:

Identifying patients

Understanding patient needs and available resources

Developing a chronic disease management program

Adopting evidence-based guidelines

Translating guidelines into action

Delivering a chronic disease management program

Educating patients

Coordinating a chronic disease management program

Measuring success evaluating chronic disease management programs

The Task Group has refined these steps for development of a diabetes program by identifying Key Tasks under each section. The Key Tasks are the action statements that the diabetes team must consider and/or implement when developing their diabetes program. They are based on the MOHLTC requirements,2,3,4 Guidelines Advisory Committee recommended guidelines5, research on quality improvement strategies6 and input from the Task Group.

Most of the Key Tasks can be performed by different members of the diabetes team, and it is up to each FHT to distribute the tasks at their local site. Task assignment can be made for each individual patient/client, or globally for all patients/clients. We have provided a Role Matrix chart which the team can use to assign the Tasks to the various members. As some tasks can be performed by multiple members of the team, there will be some differing approaches from the pilot sites.


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Chronic Disease/Diabetes Program Key Tasks & Actions

1. Identifying Patients

This first step recognizes that the FHT has a population of patients with diabetes that require a collaborative and proactive approach to care. In order to create a diabetes program that addresses this population, all team members must have an understanding of the natural history and co-morbidity of diabetes and the need for various services over time. The team must also have an understanding of the application of chronic disease management programs and the necessary organizational changes to provide this care (e.g., rostering and case management).

Tasks:

Establish need and buy-in for the creation of a diabetes team Team changes include: adding a team member or shared care, use of multidisciplinary

teams, expansion or revision of professional roles.6

Identify members of the team (what disciplines should and can be involved?)

Identify other key players (e.g., specialists, family members)

Identify resources available to the team (What local resources do you have available in your community that you can call upon? DEC? CDE at local pharmacy? Administrative resources?)

Review roles, responsibilities and capabilities of team members. (See above section Roles and Responsibilities)

Choose a standardized flow sheet to be used by the team (see Tools section for examples) Ensure the flow chart incorporates all of the MOH and CDA4,5 recommended elements

Ensure all clinicians are familiar with and comfortable using the flowsheet

Standardize how and when information will be recorded on the flowsheet

Decide where the flowsheet will be placed

Decide on who will maintain the flowsheet

Decide on where new flowsheets can be accessed (hard copies versus electronic copies)

Develop criteria for identifying patients eligible for team-based care Eligible patients may include those at risk for diabetes, persons with diabetes or persons at

high-risk for complications, depending on the capacity of the team. Examples of targeting patients include patients consistently out of their metabolic range, newly diagnosed patients, socially or medically complex patients.

Eligible persons may be flagged by the physician or NP, for particular case management approaches and goal setting. Some practices may decide to offer a full range of information and counselling to all patients diagnosed or at risk of diabetes. The decision around intensified treatment resources will rest with each FHT.


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Roster patients within a reminder system Electronic tracking system as this becomes possible with the fuller implementation of the

Electronic Health Records

As interim step, where necessary, develop a manual roster by eliciting help from the practice. Reception staff may also be able to contribute to the creation of this list.

Identify a case manager. Case management includes any system for coordinating diagnosis, treatment, or ongoing

patient management by a person or multidisciplinary team in collaboration with or supplementary to the primary care clinician. The most significant changes occur when the case manager (either a nurse or pharmacist) can make independent medication changes.6

The care manager within diabetes team would:

Be the main point of contact and post diagnosis referral for patients, team members and external resources (e.g., community services)

Monitor patient progress/review charts

Ensure completion and updating of the flowsheets of rostered patients

Ensure completion of the must-do tasks for the Designated Visits (monofilament testing, random blood sugars, discussion on progress of goals, reinforcement and discussion of external provider visits e.g. education session)

Communicate next-steps for care process to the patient

Identify patients in need of additional services based on information obtained from initial and follow-up designated visits, from the flow sheet and/or patient discussions; make referrals as necessary(with the exception of specialist consultations).


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2. Understanding Patient Needs and Available Resources

Once patients are identified as requiring a diabetes management program, it is vital that the team understands the needs of this population and how to serve them. The team needs to assess the patients overall determinants of health and the resources in place to address them. The team should use patient-centred goal setting and motivational counselling to educate and empower patients for self-management. Ongoing advocacy for individuals, communities and healthy public policy are important facets of family medicine and primary care within communities.

Tasks:

Initial assessment of patient-centered determinants of health and how these may impact compliance with care plan and goals

Initial and ongoing assessment of patients stage of change

Identification and use of community resources Compile and keep updated a list of key community partners such as Diabetes Education

Centres, community fitness programs, etc.

Engagement with community partners for capacity building and seamless care

This will help facilitate the shared care model, improve care efficiency and relieve external stressors/burden on the primary caregivers

Motivational interviewing for self-management

Recommended physical activity

Nutrition

Smoking cessation

Maintenance of healthy weight

SMBG

Medication usage

Foot care

Use of community resources

Advocate for patient, community, and public policy


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3. Developing Chronic Disease Management Programs

Adopting Evidence-Based Guidelines and Translating Guidelines Into Action

The Guidelines Advisory Committee has provided a summary of the recommended guidelines (see Evidence section) for diabetes care.

All team members should understand and apply the guidelines relevant to their patient care. Individual team members need to maintain competency in their designated professions and engage in self-directed learning. Team-based learning, trainee supervision and research all promote on-going evaluation and integration of best practices.

Tasks:

Identify the learning needs of the diabetes team

Consider developing education committee/sub group to facilitate meeting the learning objectives. Clinician education includes interventions designed to promote increased understanding of principles guiding clinical care or awareness of specific recommendations for a target condition or patient population. Subcategories of clinician education include conferences or workshops, distribution of educational materials, and educational outreach visits such as academic detailing initiatives.6

Organize regular education activities for the team Disseminate relevant educational materials to the team

Review team member learning objectives regularly

Promote educational opportunities for trainees

Liaise with on-going research activities


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4. Delivering Chronic Disease Management Programs

This step is implementing the previous steps into actual practice. These Key Tasks reflect the service delivery of diabetes care. Team members should be committed to providing productive interactions between prepared, proactive teams and informed, activated patients/clients.7 There should also be a commitment to providing accessible, equitable and culturally-relevant diabetes care. To do this, partnerships with community providers may be necessary.

Tasks:

Screening of eligible patients (See CDA Screening for type 2 diabetes, IFG and IGT flow diagram)

Organize diagnosis of diabetes first visit and triage (see Developing the Care Pathway)

Initial screen for complications of diabetes and co-morbidity Cardiovascular complications

Dyslipidemia

Hypertension

Obesity

Psychological problems

Retinopathy

Nephropathy

Neuropathy

Erectile dysfunction

Initial patient education and patient-directed goal setting Patient education includes interventions designed to promote increased understanding of a

target condition or to teach specific prevention or treatment strategies, or specific in-person education (e.g., individual or group sessions with diabetes nurse educator; distribution of printed or electronic educational materials).6 Initial and ongoing needs-based diabetes education in a timely manner

Identify and discuss patient specific barriers; establish goals and care plan accordingly

Use of glucometer and self-monitored blood glucose (SMBG)

Review symptoms of hyperglycemia (and hypoglycemia if applicable)

Review targets for glycemic control (A1C and SMBG)

Review targets for lipid control

Review targets for blood pressure control


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Review targets for physical activity

Review need for ongoing screening for retinopathy

Review potential effects of diabetes on kidney function

Review symptoms and complications of peripheral neuropathy and need for foot examinations

Provide the patient with a patient tracker to facilitate awareness of target values (see Tools)

Nutrition counselling by a registered dietitian or Certified Diabetes Educator If no dietician within your practice, consider referral to community resources (see Identifying

Community Partners section)

Initial treatment of diabetes Primary care versus specialty care

Lifestyle versus medication

Routine visits and regular monitoring Establish a mechanism within your practice to schedule Designated Diabetes Visits

Establish a patient reminder system (e.g., postcards or telephone calls) to remind patients about upcoming appointments or important aspects of self-care.

Use of patient roster to identify need to recall patients for regular appointment

Use of case manager to identify need to perform elements of regular monitoring

Decision on what elements of routine visits and flowsheet recording can be done by different team members

Identification and management of suboptimal diabetes control and complications Adjustment of initial treatment

Identify need for other team members

Identify need for external resources (e.g., referral for specialist care)

Review patient-centered goals Need for further education, self-management support

Need for individually-tailored service delivery (e.g., language resources)

Review stage of change

Influenza and pneumococcal immunization


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5. Coordinating Chronic Disease Management Programs

Collaboration enables the separate and shared knowledge of the different providers to synergistically enhance the care provided to each patient/client and to improve access to a comprehensive range of high-quality and effective health care services.3 The team members should develop working relationships with each other to develop mutual trust, respect, understanding and support. The case manager should ensure there is regular, timely and thorough communication amongst the team and the patient. Each team member is responsible for maintaining the patient record to reflect relevant and active issues to communicate to the team, while respecting patient confidentiality.

Tasks:

Horizontal referral between team members (with the exception of referral to specialty care); external referrals to be coordinated by case manager or physician (as OHIP number may be required).

Establish means of regular communication amongst the team

Via case-manager, EMR, notes on flow sheet, internal email etc.

Address issues of communication breakdown by implementing a common record for documentation rather than use of flow char, other notes/tandem documents to record visits,

Identify and share information around

the primary goals (associated date) and notes on progress/regression/change of focus as care is delivered.

patient barriers that may interfere or impact specific targets (e.g. metastatic cancer, depression, chronic pain other co-morbid conditions) that may take precedent and impact care delivery.

dates of appointments and recommendations from referrals to other providers (e.g. DEC, endocrinologist etc.). The case manager should follow up and reinforce what was done at these visits for continuity of care.

Regular team-building activities and case conferences Consider conducting periodic meetings with the team to discuss progress, gaps, shortcomings,

successes and areas for improvement.


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6. Measuring Success Evaluating Chronic Disease Management Programs

Healthy program management includes developing objectives and evaluating outcomes to continually strive for improved delivery of care8. The team must be committed to continuous quality improvement initiatives that evaluate patient, provider and healthcare system outcomes.

Tasks:

Identify regular intervals for program assessment

Identify process outcome indicators Patient (e.g., A1C levels, quality of life, satisfaction with care)

Provider (e.g., appropriate screening and treatment)

Healthcare system (e.g., access to care, use and completeness of flowsheet)

Review benchmarks for indicators, and revisit objectives

Solicit regular user (e.g., patient, provider) feedback on program developments

Foster team champions to continue iterative quality improvement despite changes in team membership for sustainability


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Appendix A

For descriptions of the roles of other professionals within FHTs, we have borrowed job advertisements from Family Health Team recruitments. There will be differences observed among FHTs in terms of focus for qualifications and job profile in these areas. These are intended as examples only.

To provide information on a Certified Diabetes Educator, we have excerpted from a wiki definition. A person with this certification will be a member of profession such as nursing, or pharmacy who, after being engaged in diabetes education for a minimum time as required by the certifying body, can proceed to the certification steps.


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Patient Education Specialist Urban Family Health Team

Position Profile:

The PES will play a key role in patient education, health promotion, disease prevention and chronic disease management. As a member of the inter-professional team, the key role is the development of high quality primary care patient education initiatives geared towards both individual and group activities. The PES is accountable for the development and implementation of short-term and long-term strategic education plans that support the goals of the FHT initiative.

The candidate will promote and enhance the delivery of evidence passed primary care services through promotion of excellence in primary care and the development, implementation and evaluation of primary care indicators and outcomes that are impacted by educational initiatives.

Qualifications: (shortened list)

1. Baccalaureate degree in a Regulated Health Profession or other related health sciences required.

2. Formal training in Adult Education required, or in progress (Baccalaureate or Masters preferred). Masters degree in Education preferred.

3. Member in good standing of their relevant professional organization and/or regulatory body.

4. Minimum 2 years experience in outpatient and/or primary care setting providing education to a broad range of clients that face many challenges to education illiteracy, low reading level and language barriers.

5. Demonstrated competence in the design, delivery and evaluation of educational programs for patients in a primary health care environment.

6. Demonstrated skills in patient education planning, consultation and facilitation.


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Health Promoter, Family Health Team

(excerpt from ad in media)

Full Time:

We are presently looking for a Health Promoter with a holistic focus on newcomer and immigrant health to join our Family Health Team. The Health Promoter will provide mental health and addictions outreach, education, community development and advocacy to newcomers and immigrants within our catchment area with an emphasis on residents of social housing and people who are homeless. This is an exciting opportunity to work as a member of an interdisciplinary care team to develop and provide a diverse and varied service in a community based setting.

The Health Promoter utilizes adult education, community development, research/evaluation and policy strategies to enhance the mental well being of communities with a broad range of mental health, emotional health and substance use issues. S/he makes the links between mental health and substance use problems and trauma, violence, settlement, family or relationship issues, loss, coming out, and transitioning.

Qualifications:

Education at the bachelor level in social science or health discipline OR equivalent combination of education and experience

At least 3 years experience working with people with mental health and/or substance use issues

Excellent community outreach and community development skills Up-to-date knowledge of the needs of the diverse communities of South East Toronto and

experience developing culture specific resources Experience working in interdisciplinary/multidisciplinary teams Experience working with people affected by poverty, violence, homelessness, stigma, racism

and/or homophobia/transphobia Experience working within an anti-oppressive and trauma informed framework Ability to work flexible hours, including some evenings and weekends Excellent interpersonal and communication skills Preference will be given to applicants able to work in one or more of the following languages

in addition to English:Tamil, Tagalog, Cantonese, Mandarin, Somali, or Vietnamese


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Certified Diabetes Educator From Wikipedia, the free encyclopedia

Jump to: navigation, search

This article or section is missing citations or needs footnotes. Using inline citations helps guard against copyright violations and factual inaccuracies. (July 2007)

A Certified diabetes educator (CDE) is a health care professional who is specialized and certified to teach people with diabetes how to manage their condition.

Typically the CDE is also a nurse or dietitian who has further specialized in diabetes expertise. Formal education and years of practical experience are required, in addition to formal examination, before a diabetes educator is certified. In the US, certification is awarded by the National Certification Board for Diabetes Educators. In Canada, certification is awarded by the Canadian Diabetes Association.

The CDE is an invaluable asset to those who need to learn the tools and skills necessary to control their blood sugar and avoid long-term complications due to hyperglycemia. Unlike an endocrinologist, the CDE can spend as much time with a newly diagnosed person as is needed both for educational purposes and emotional support.

[edit] References

American Association of Diabetes Educators

National Certification Board for Diabetes Educators

The American Diabetes Association

The Canadian Diabetes Association


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Appendix B

The tools provided in this section are included as examples only. The task group recognizes that a broad range of tools exist and others are being developed/adapted by individual organizations to best suit the needs of their patients.

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References

1 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care: Guide to interdisciplinary team roles and responsibilities. 2005

2 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:

Guide to chronic disease management and prevention. 2005 3 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:

Guide to collaborative team practice. 2005

4 Ministry of Health and Long Term Care. Diabetes management incentive fact sheet, 2006.

5 Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of diabetes in Canada. Canadian Journal of Diabetes. 2003, 27(suppl 2).

6 Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK.

Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006;296:427-439.

7 Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease

management programmes: Are they consistent with the literature? Managed Care Quarterly, 1999. 7(3):56-66.

8 Langley C, Nolan K, Norman C, Provost L. The improvement guide: A practical approach to improving organizational performance. San Francisco. Josey-Bass Publishers, 1996.

App_A_Diabetes_IDTD_Tool_Feb09.pdf

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