New Centre for Complex Diabetes Care offers a team approach to patients

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Following two strokes caused by diabetes and high blood pressure, Guillermo Rodas learned about the new Centre for Complex Diabetes Care (CCDC) at The Scarborough Hospital (TSH) – a specialized ‘one-stop shop’ for patients living with the disease.

Since his first appointment, Guillermo has been delighted with the interprofessional care provided by the team.

“When you have a chronic disease, having support to deal with not only medical, but emotional, social and economic issues is vital to minimize the tension and uncertainty that exists,” he explains. “For the first time, I felt I was being heard by a team of experts in the field of diabetes, and I believe they spent the necessary time with me for a proper medical examination to get an accurate diagnosis for future treatment.”

There are currently 1.2 million Ontarians living with diabetes, and with Scarborough’s diverse population, it is home to many residents who are at a greater risk for the disease, including those of Asian, South Asian and African descent.

The CCDC is a regional care delivery program established to assess and support patients with diabetes who have complex needs, such as stabilization and management of blood sugar, eye monitoring, counselling and mental health supports, insulin administration and monitoring, nutritional counselling and diet planning, monitoring and management of related cardiovascular health needs, and foot and wound care, and require intensive short-term case management.

It also provides a single point of access to a specialized interprofessional team that includes nurse practitioners, registered nurses, social workers, pharmacists and registered dietitians.

The Central East CCDC was established at the Central East Community Care Access Centre with three care delivery sites located at Lakeridge Health, Whitby; Peterborough Regional Health Centre; and The Scarborough Hospital, General campus.

Guillermo was so impressed with the CCDC that he recommended the program to his wife, and after her first interview, Mrs. Rodas was pleasantly surprised to see how well the team approach worked.

“We’re really so happy,” says Guillermo. “It’s the best unit we’ve found for people living with a chronic disease.”

Dr. Paul Tam, Medical Director of Nephrology and Chronic Disease Management Lead at TSH, has been working with diabetes patients for more than 30 years.

“If this kind of team approach had existed back when I started, it would have been heaven,” he said. “A centre like this is a place where all of a patient’s care, including treatment, education and rehabilitation, will be coordinated.”

Services provided by the CCDC, include:

  • Support for patients including assessment, education, treatment, and transition/discharge, which utilize an intensive case management process and frequent follow-ups.
  • Collaboration among the patient, care team and primary care provider to develop an individualized plan that addresses the patient’s unique needs.
  • Support in navigating the health system as identified in the individualized care plan.
  • Support for providers who are involved in patient care such as specialties, primary care providers and the CCAC.
  • Regular communication with all providers regarding patient care plans.
  • Transition/discharge support as the patient moves back to his or her primary care provider or Diabetes Education Program.

Garth Clarke has been receiving care for his diabetes at TSH since 2010. He was referred to the CCDC in September, and because of its team approach has gone from managing his disease on “autopilot” to taking charge of his health.

“It’s great because they fashion everything to your unique needs,” he says. “I’m feeling much better and things are looking better.”

The addition of the CCDC at the General campus allows TSH to better treat its diverse community that historically has presented with a high incidence of diabetes.

“As a leader in chronic disease management, The Scarborough Hospital is so pleased to add the Centre for Complex Diabetes Care to our range of specialized services,” says Ethel Doyle, Director, Chronic Disease Management at TSH. “We are confident that this centre will result in fewer complications associated with diabetes, including reducing or delaying the need for dialysis, which will help us achieve our mission of providing an