A team for every patient with diabetes An interdisciplinary approach to a complex, chronic disease

Diabetes Mellitus is a chronic illness that requires a lifelong commitment to complex lifestyle modifications involving nutrition management, physical activity, regular self-blood glucose monitoring, and adherence to medications and/or insulin therapy.

Proper management of these lifestyle modifications has been shown to reduce the risk and progression of diabetes complications. However, achieving and sustaining effective management is a huge challenge and more than half of those living with diabetes in Canada are unable to meet the recommended targets for glycemic control.

The majority of Canadians are receiving diabetes care solely from their primary care physicians. However, family physicians themselves have expressed concern with having sole responsibility for patients with diabetes. Managing diabetes over a patient’s entire life requires a lot of time and frequent visits to deal with the complex individual needs of each patient.

To most effectively manage diabetes, and to prevent or delay its complications, patients require the ongoing support of an interdisciplinary team of specialists. However, barriers often exist in accessing interdisciplinary services, and these services are required – often repeatedly – over a long period of time.

Trillium Health Centre, a community-based specialty hospital serving Mississauga and west Toronto, uses a multidisciplinary model and provides on-site “one stop shopping” for patients. The Diabetes Management Centre (DMC), part of Trillium’s GlaxoSmithKline Chronic Disease Management & Prevention Centre, has a team of over 40 staff. DMC patients have access to four endocrinologists, registered nurses, registered dietitians, foot care nurses, a social worker, an exercise specialist, a sports nutrition specialist, and a full-time inpatient diabetes educator.

Patient programs offered include services to adults with type 1 or type 2 diabetes, pre-diabetes, gestational diabetes, those requiring an insulin pump program, patients transitioning from pediatric to adult care, and those with dyslipidemia (an abnormal amount of lipids (e.g. cholesterol and/or fat) in the blood).

People with diabetes face many challenges and barriers as they attempt to manage their condition and the DMC has tailored programs and services designed to address the specific needs of their patients. Long term lifestyle modifications are supported by dietitians, nurses and the exercise specialist.

For example, patients participate in tours of local grocery stores – learning label reading skills and how to choose healthy foods. They attend cooking demonstrations in our cooking demo kitchen, developing life skills and learning how to cook healthier meals. Workshops to address heart health, eye, foot and kidney care are provided throughout the year.

To break down barriers to increased physical activity, our kinesiologist works with patients to develop an individual exercise prescription. She also runs Nordic pole walking groups and exercise classes for special groups.

Trillium sought out a partnership with City of Mississauga Recreation and Parks to create the “Sweet Success” Exercise Program, which offers people with diabetes the opportunity to exercise together in a community setting, providing a safe and welcoming environment in which to turn the “150 minutes of physical activity a week” guideline into real activity.

Younger adults are increasingly being diagnosed with Type 2 diabetes but often have trouble attending appointments during working hours. In response, the DMC improved access to care by offering evening appointments – three nights per week until 9 p.m,

Trillium serves a highly diverse community and the DMC offers services in 18 languages, delivering care in a culturally appropriate manner. Mobile Diabetes Teams and the South Asian Program team travel throughout the community to provide services in primary care offices. The South Asian Program serves patients who speak Hindi, Punjabi, Tamil and Urdu.

In addition to face-to-face care, the DMC offers daily telephone nursing service for insulin and medication dose adjustment based on established endocrinology and medical directives. This allows patients with more complex regimens to access support more frequently and to manage their glucose levels in a timely, convenient manner.

Finally, there are initiatives available at Trillium for specific patient groups who find it difficult to access diabetes care and manage successfully. For example, the PATH program (Promoting Action Toward Health) is a partnership with Trillium’s Mental Health Program promoting physical activity and healthy eating to patients with both mental illness and diabetes. An exercise and nutrition program specifically geared to this group is provided weekly at the DMC, and patients are supported to attend through the Mental Health Program.

Managing complex, chronic diseases like diabetes successfully requires a specialized, multidisciplinary team dedicated to supporting the patients in several different ways. The team assists patients in identifying their own health goals and provides practical support as they work towards achieving them.