99.98% of the time patients are on their own

“The diabetes self-management regimen is one of the most challenging of any for chronic illness.”

0.02% of the time

patients are with their healthcare team

The person living with diabetes must live every day with the management of this disease

– there is no time off!

The Burden of Diabetes: Life-long Self-management

Schillinger D et al. JAMA 2002; 288:475–482.

Self-Management Education (SME)

A systematic intervention that involvesactive patient participation

in self-monitoring and/ordecision-making

Elements of the Chronic Care Model

1. Delivery Systems Design: The Team

2. Self-ManagementSupport 3. Decision

Support

4. Clinical Information

Systems

5. Community

6. Health Systems

The following quality improvement strategies

should be used, alone or in combination, to improve

glycemic control:

Organization of Care - CPG2013

• 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

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)

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

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

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

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.