Enhancing interprofessional care for Diabetes Clinic patients


St. Joseph’s Health Centre’s Diabetes Clinic team is using new strategies that are enhancing their interprofessional approach to care, which have improved wait times for clinic appointments, improved the patient care experience and increased staff satisfaction.

Over the past two years, the team has undergone an interprofessional journey which included a structured assessment and team development plan. By utilizing a collaborative approach the clinicians have expanded their roles to work within their full scope of practice, this has allowed the team to build an infrastructure to keep these improvements and successes in place to meet the needs of our patients.

The Diabetes Clinic Team consists of endocrinologists, nurses, dietitians, social worker, and physiotherapist and there are approximately 1,900 patient visits to the Diabetes Clinic each year.

“Patients with diabetes who come to the Clinic may often also exhibit some of the long-term complications (such as kidney disease and heart disease) as well as other co-morbidities,” explains Brenda Pozzebon, Nurse Clinician in the Clinic. While some patients are able to manage their diabetes through their family physician, many with complex needs benefit from the support of an interprofessional team that the Clinic offers, including an endocrinologist.

As part of a quality improvement strategy, the Team participated in interprofessional training to better understand each person’s role and develop tools to support clinicians in working to their full scope of practice. The team also implemented new documentation to support better patient flow through the Clinic and developed ways to evaluate patient and staff satisfaction and report on their accomplishments.

Enhancing the model of care the team provided was really about improving access to care for patients as described by Carla Curto-Correia, Patient Care Manager, Ambulatory Care Centre, GI/Endoscopy and Fracture Clinic. “We worked with various partners and stakeholders to better understand our wait times and enhance our outpatient’s experience of care while using the resources that were available to us,” says Carla.

Using an interprofessional practice (IPP) framework and engaging the Point of Care Team and physician leadership to help develop a strategy to improve access to care, it resulted in reduced duplication in clinical functions and supported overall improvement in patient care.

“For example, in the past, the nurse was the only professional able to do the finger pricks to test patients’ blood sugar levels,” says Elaine Clark, one of the team’s Dietitians. “Now both nurse and dietitian are trained to perform this skill, which has helped to improve clinic flow.”

The Team also created educational tools, screening processes and documentation to make work flow more efficient. Curto-Correia says that, “utilizing a tailored approach for patients ensures they get the care they need. For example, the dietitian and nurse might see the patient together – so we try to improve efficiencies and enhance the patient experience.”

Clark explains that the creation of education flow sheets is another way that helps the team track what educational information patients are receiving in their appointment about diabetes care. “Having those details at a glance helps the team to see what patient’s have received and what education they still might need to make the most of each appointment,” she says.

“As part of the evaluation process, we also conducted a survey for patients which helped us identify what our patients felt they were lacking in terms of their educational needs,” Pozzebon explains. “We thought that what we were covering was adequate so it was good to hear from their perspective on where they needed more information from us.” She adds that foot care education was a need identified by patients so the team adjusted their teaching opportunities to capture this aspect regularly.

Through this journey, the team was able to reduce the current wait time for a clinic appointment from a four month wait (the average 18 months ago) down to four to six weeks for our outpatients. Increased staff satisfaction was also a key improvement, explains Curto-Correia. “The team felt they understood each other’s role better and in doing so were able to work better together. This process helped to break down barriers in order to work more effectively and share information with one another,” she added.

“No one discipline can have all the answers. We tap into each others expertise to address complex needs (of our patients),” says Pozzebon. “Doctor’s can prescribe medicine, but if a patient doesn’t have money for that or for healthy foods, that’s where a Team like ours can really benefit patients because we can link them with a social worker that can help find them the resources they need, or connect them with a dietitian who can advise them about how to maintain a healthy diet on a lower income.”

Curto-Correia credits the Team’s success to their desire and commitment to being responsive to the community’s needs and to providing patient-centred care. “Having a variety of strategies in place so that the Diabetes Clinic team can respond to what each patient needs is very rewarding,” she adds.

Patients can access this outpatient clinic with a referral from St. Joseph’s inpatient units, family physicians in the community or through the Emergency Department. For more information, contact St. Joseph’s Ambulatory Care Centre at 416-530-6043.