HomeMedicine By SpecialtyDiseasesWhat makes a diabetes care program a success?

What makes a diabetes care program a success?

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A commitment to collaborating with patients and community partners to achieve the best outcomes possible

In the spring of 2014, Alanis*, a 60-year-old woman, arrived at an emergency room at Grey Bruce Health Services in Owen Sound, Ontario ,with extremely high blood glucose (sugar) levels. Living in extreme poverty in an isolated rural community, she had no car and no family doctor to care for her type 2 . In many places, Alanis’s health care prospects would have been poor at best and she might not have received the help she needed.

A year later, Alanis tests her blood glucose (sugar) regularly, is receiving treatment for her diabetes, high blood pressure and cholesterol, and has a family doctor.

This outcome is the result of the work of Diabetes Grey Bruce (DGB), a dedicated team of health care professionals offering diabetes education, support and treatment at seven hospital sites across a region that stretches from Mount Forest in the south, to Tobermory in the north, Kincardine in the west, and Collingwood in the east.


This is a great example of the 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (Guidelines) in action in the area of team care and the organization of diabetes care. Support from health care teams and systems has been shown to improve care for people with diabetes – Alanis is proof of that.

A recipe for success

A conversation with DGB manager Lynda Hoffmeyer reveals that DGB owes its success to the exceptional commitment of its team members, their collaboration with community partners and their belief that they are part of the community and that their clients are like neighbours. “We very much see our clients as part of our community,” says Hoffmeyer. “We’re all at risk of diabetes.”

Commitment The team will go to impressive lengths to see clients get the care they need. For example, in addition to providing Alanis with diabetes education and treatment, DGB’s nurse practitioner, Patti Byne, looked after her diabetes and other health issues (which included high blood pressure and high cholesterol). The team also helped her find a family doctor so that she could receive ongoing care and even helped her apply for government-assisted funding to cover the cost of her medications.

Collaboration The health care team recognizes that many factors, such as poverty or mental health issues, can influence whether diabetes treatment succeeds or fails. DGB works in close partnership with other agencies, including hospitals, community health centres and mental health services.

Community Rather than seeing themselves as serving the community, the health care providers at DGB consider themselves very much part of it. As diabetes educator Joanne Reid put it, “We can meet up with clients in the grocery store.” It is this outlook that inspires team members to go the extra mile for clients like Alanis.


Setting a new standard

Registered nurse and certified diabetes educator, Shelley Jones, is the Director of Quality for the Canadian Diabetes Association’s (CDA’s) Diabetes Educator Section – Standards Recognition Program Committee. In its recent annual awards, the committee singled out DGB for recognition. “It really resonated with us [the committee]…how Diabetes Grey Bruce partnered with community organizations outside the diabetes field and how they were using that to help their patients,” says Jones. She identified a number of factors that set DGB apart.

  • Self-referral Any resident in the Grey Bruce area can access services without needing a doctor’s referral.
  • Treating the whole patient By working with many different community agencies and organizing frequent education efforts on everything from blood sugar control to healthy cooking, DGB addresses many different aspects of life that affect the health of people with diabetes.
  • Virtual teamwork Team members connect easily across different sites, using the Grey Bruce Health Network Integrated Patient Records and communicating by secure e-mail.
  • Accessible hours In addition to daytime hours, all rural sites are open early one weekday morning to make diabetes services as accessible as possible. The site in Owen Sound, Ont., is open two evenings a week.
  • Ongoing self-assessment. DGB uses regular surveys and patient questionnaires to assess the effectiveness of their programs, and adapts programs to meet the changing needs of their clients.Jones adds, “Diabetes Grey Bruce is a program that offers superior diabetes care and education and is well supported by a dedicated manager and many community partnerships.” And the happy result is that people living with diabetes, like Alanis, are better able to manage their diabetes and enjoy a better quality of life*Alanis is not her real name.

Where can health-care providers and patients find helpful resources to get them started or improve diabetes team care? The Guidelines’ Team & Organizing Care chapter is a good place to start. It features a range of materials, such as communication logs, diabetes flow sheets, and the video, “Angie’s Story: Building a Diabetes Care Team” about the roles and responsibilities of the various members of the diabetes For more information, including printable and downloadable tools, visit http://guidelines.diabetes.ca/organizingcare


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