The stages of diabetes care

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By Selma Al-Samarrai

John was first diagnosed with type 1 diabetes at the age of 33.

“It was a bit of an ordeal getting me properly diagnosed,” says John, now 38. “It took about nine months before I was referred to a specialist at St. Michael’s Hospital, and she recognized the symptoms of Diabetic ketoacidosis and diagnosed me within one minute of walking into her office.”

Since his diagnosis just over four years ago, John’s care team at St. Michael’s Centre for Diabetes and Endocrinology, under the hospital’s Diabetes Comprehensive Care Program, now includes an endocrinologist, a team of diabetes educators including a registered nurse and registered dietitian, and an ophthalmologist. He also saw a social worker when he was first diagnosed.

The Centre follows individuals whose diabetes management requires insulin, multiple medications, or whose diabetes itself is complicated and requires more specialized, comprehensive and multidisciplinary care.

“In our clinic, our goal is to aid individuals to achieve the best blood glucose possible to prevent acute and long term complications of diabetes and to help them live a full life,” says Dana Whitham, Clinical Leader Manager of the Centre

Complications can be acute such as hypo (low) or hyper (high) glycemia, or chronic such as long term damage to the eyes, kidney or blood vessels. Diabetes requires daily management and monitoring.

“Living with diabetes means you can never stop thinking about it. Little things like having a cold, going for a jog or drinking a glass of wine can really affect you.  You have to be paying attention all the time,” says John.

“I can ask very difficult, in-depth questions, so having an exceptional team available to answer my questions when I call or visit is very helpful. The St. Michael’s folks saved my life. I’m pretty grateful for that.”

Living with diabetes for an extensive period of time can present several associated complications.

Bryan Rickey was diagnosed with type 2 diabetes in 1998. In the last year, he had both of his feet amputated due to the progression of his diabetes. He rehabilitated in Providence Healthcare’s Amputee Rehab unit in June of 2017 after the amputation of his right foot, and again in February of 2018 after the amputation of his left foot.

The Orthopedic and Amputee Rehab teams at Providence Healthcare see patients who are recovering from a recent amputation and require rehabilitation. The two multidisciplinary teams provide inpatient and outpatient consultation, assessment, and rehabilitation services to patients with musculoskeletal injuries and amputations.

“Soon after the patient is admitted, we start to establish a safe discharge plan. This means we have to get to know our patient’s capabilities, strengths and potential barriers in order to maximize their independence at the time of discharge,” says Sofia da Silva, patient care manager for the Orthopedic Unit.

Rickey received a prosthetic to replace his right foot following the first amputation, and is now waiting to return to Providence to rehabilitate with a prosthetic for his left foot through the outpatient Mobility Clinic.

“My experience at Providence was wonderful, the team was extremely great. They did everything they could to help get me rehabilitated. I’m waiting to go back to get the second artificial leg so that I can get rehab to learn to walk again,” says Rickey.

To maximize recovery, the teams collaborate closely with other clinics in Providence including the Orthopedic and Amputee Outpatient Clinic, Falls Prevention Clinic, and the Frailty Intervention Team.

“Our primary focus is to identify what is meaningful to the patient and to learn what life looks like once they get home so they can return to their community as a functioning member of society,” says Caroline Monteiro-Pagliei, the patient care manager for the Amputee Rehab Unit.

At St. Joseph’s Health Centre, the goal of the Diabetes Education Program (DEP) is to help patients manage their health and prevent further complications.

The DEP’s team of certified diabetes educators screen newly referred patients. They advise patients on numerous areas concerning self-management of the chronic disease, including medication management and adjusting insulin doses. The use of technology in diabetes management has also become an integral part of every patient visit as it helps both patients and health care providers monitor and manage blood sugar levels.

“My role comes in when we recognize that there’s something we need to address and correct in order to prevent the development and progression of long term complications,” explains Brenda Pozzebon, Nurse Counsellor on Diabetes Education, DEP.

Depending on the patient’s health care needs, they also work with various care providers on the DEP’s multi-disciplinary team which includes nurses, registered dietitians, endocrinologists, a physiotherapist, and social worker.

“Our clinicians work collaboratively with patients to form successful partnerships and develop individualized care plans to effectively manage their diabetes care needs” says Jennifer Spencer, Patient Care Manager, Ambulatory Care Centre.

With the DEP embedded in the hospital’s Ambulatory Care Centre, patients can be referred to multiple clinics should they need help managing concurrent diseases that are associated with diabetes such as nephrology, the wound clinic and cardiology.

“Building partnerships with our patients and care providers across the continuum is fundamental in chronic disease management,” says Spencer.

Selma Al-Samarrai is a Communications Associate for the Network of Providence Healthcare, St. Joseph Health Centre and St. Michael’s Hospital.