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In many parts of the world today, the diabetes care model is based on the acute care model. In the majority of cases, the prescribed treatment for blood sugar control is based on one lab result called A1c. If a patient’s blood sugar is higher than the recommended guidelines, the usual solution is to increase the intake of insulin or other oral medication. This may have serious negative side effects that impact a patient’s quality of life if the medication is wrong or administered incorrectly.

Although A1c can be a good indicator for preventing potential health complications due to diabetes, it does not address other factors such as quality of life and psychological impact. In addition, the current diabetes care model has not achieved positive results based on the current outcome. For example, in North America about 50 percent of patients’ A1c level is less or equal to seven percent. The percentage is lower in many other parts of the world.


Proactive Diabetes Care


Factors

The proactive approach starts with knowledgeable and motivated patients who are active partners in managing their diabetes, rather than being passive recipients of care. Diabetes is complex and there are many factors that could affect blood sugar control. Also, patients’ genetic makeup affects the effectiveness and potentially adverse impact of diabetes medications.

Diabetes self-management data: diet, physical activity, sleep, stress, allergies, social activities and environmental factors are essential to understanding what affects a patient’s blood sugar levels. Such data are also indicators of preventive actions. Regular monitoring, as well as access to multidisciplinary healthcare providers, is also key to early intervention.

To implement proactive diabetes care, the following gaps in the current diabetes care model must be addressed:

  • Providing sustained patient education and motivation
  • Engage patients in their diabetes management
  • Supporting patients to implement realistic lifestyle changes
  • Overcoming the imbalance between the number of patients with diabetes and the number of healthcare providers
  • Providing access to care by a multidisciplinary team including diabetes specialists when required
  • Collaboration among healthcare providers and regular monitoring of patients
  • Outcome analysis
  • Providing support to healthcare providers in terms of training and eHealth efficient tools.

Successful diabetes management is not only the responsibility of healthcare providers but the responsibility of patients, too.

The Model


Patient Education
1 Patient Education

Following a diagnosis by a family physician (or through community screening programs), patients are advised to start learning about diabetes. This can be done through an authenticated on-line program prior to attending educational classes at Diabetes Education Centres if available.

It is recommended that the healthcare provider have his or her own learning program. The Virtual Diabetes Center’s Patient Education Portal has a Learning Content Management System. It is currently used by the British Columbia Endocrine Research Foundation (BCERF) for its Live Well with Diabetes initiative. This program provides culturally sensitive education in nine languages.


Patient Education
2 Diabetes Self-management

Patients must be encouraged by their healthcare provider to monitor and record their blood sugar levels and lifestyle factors to understand how to manage their diabetes. Also, physicians must ask the patient for these data. This information is vital to train the patient on managing diabetes, and recommend lifestyle changes (with the support of other care team including registered dietitians, social workers, physical trainers, etc.), as well as for physicians to prescribe accurate treatment.

Patients can record self-management data manually or use wearable and eHealth tools. All new glucose meters have simple software applications. Unfortunately, a very small percentage of patients and physicians are utilizing them. Patients have to be aware of the large numbers of diabetes applications that collect data for the purpose of marketing. Some applications have not been tested for outcome analysis.

myVDC
The Virtual Diabetes Center’s Patient Self-management tool, “MyVDC,” is a user-friendly, on-line, health data-recording tool. This program organizes and tracks the patient’s home test results for the healthcare team to review. The patient is provided with access to educational materials on diabetes to learn how to manage their disease. The program is easy to use and is accessible by personal computers, tablets and smart phones.

Through a secured link to the Virtual Diabetes Center’s Diabetes Case Management program, healthcare teams have access to patient data for review during clinic visits and for continuous monitoring. As well, MyVDC has a notification system alerting the healthcare team if there are any major changes in the blood sugar levels between the clinic visits.


Diabetes Education Centre
3 Group Learning

Patients may also attend diabetes education classes at Diabetes Education Centres (if available) or through pharmacies and other not-for-profit organizations to reinforce their knowledge about diabetes management. The patients who begin attending these classes without prior diabetes knowledge are often in a state of fear and denial, as well as are often unable to understand and retain this information.


Lifestyle changes
4 Supporting Lifestyle Changes

Making lifestyle changes and dealing with diabetes are challenging tasks if support isn’t available from healthcare providers or community and online resources. Recreation centres are valuable resources to assist patient with physical activity through group classes and personal trainers. Some of these programs are subsidized by government or not-for-profit organizations.

Some supermarkets offer nutritional and health-shopping tours as well as healthy cooking classes. Pharmacies can also provide diabetes education and patient support. Local and virtual diabetes support groups facilitate organizing group activities and educational classes, sometimes with the support of diabetes associations.


Patient Education
5 Motivational Interviewing

Prior to the doctor’s visit and following a group education session, a one-on-one motivational interview with a diabetes nurse educator or a pharmacist with a diabetes education certificate will allow a patient to address specific concerns and review self-management records.

myVDC
The nurse or pharmacist will use a diabetes medical records system to record a patient’s current health conditions, family history and other health complications. The Virtual Diabetes Center’s Diabetes Case Management (DCM) is an electronic diabetes visit record based on diabetes care practice guidelines. User-friendly forms capture detailed, patient-specific clinical information acquired by health care staff that is produced in a format easily reviewed by clinicians. This information includes: patient demographics, diabetes history, medical history, family medical history, medication, monitoring and hypoglycemia, diet and physical activity, cardiovascular and other complications, life style, physical exam, lab results and eye exams.

There are a number of studies that have demonstrated that the active participation of diabetes nurse educators (in some countries they are called diabetes nurse specialists) improves outcomes and reduces costs.


Lifestyle changes
6 Clinic Visit

The Virtual Diabetes Center's Diabetes Case Management data visualization allows medical professionals to access and review information on a patient’s current medical status, historical medical data as well as patients’ self-management data.

Data visualization maximizes time utilization during clinic visits and ultimately allows for more precise diagnoses and successful treatment outcomes. Understanding the relation between the patient’s lifestyle and blood sugar control allows physicians to treat the cause rather than the symptoms. This could include circumstances where a patient is dealing with a temporary stressful situation. Therefore, increasing or changing diabetes medication may not be the appropriate treatment.

Lifestyle changes
DCM facilitates the coordination among the integrated medical care team and patient self-management to provide better patient care and improve workflow and productivity of the healthcare system. Members can use the program to automatically produce comprehensive recommendation letters and letters to patients while storing existing forms that can easily be viewed by the entire team. This sharing of information improves efficiency, prevents duplication and provides a more comprehensive view of a patient's condition.
Lifestyle changes
The analytics section of DCM includes a series of standardized reports and customizable queries for outcome analysis. From the database, the healthcare team quickly and easily generates statistics relating to patients’ clinic visits, medications and laboratory results. These statistics and reports can be converted to PDFs and exported into Excel for integration into medical papers or for other uses. The program can also be used to develop a recall list. Patients who have high indicators can receive automated notifications to see their healthcare team.

Lifestyle changes
Personalized Diabetes Management
The proactive diabetes care model presented above is the first phase for developing a Personalized Diabetes Management system that includes pharmacogenomics, gut microbiota and big data analytics as the basis for devising treatment plans based on evidence-based guidelines that are tailored to an individual’s genetics, prognoses and lifestyle.




Diabetes Task Force Solutions


Diabetes Task Force Solutions has worked with a number of organizations to develop unique; evidence based comprehensive diabetes prevention and management programs ranging from education to community-based prevention and management models, and to state-of-the-art virtual diabetes center.

Our philosophy is based on empowerment and motivation of patients to play a leading role in managing their chronic diseases through culturally sensitive and holistic self-education interactive education programs; providing healthcare professionals with innovative technology based tools for better treatment and monitoring of patients; and integrated solutions for healthcare services to cost effectively manage their resources while providing efficient services to the clients. Read more..
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