Canadian Diabetes Association. Patients First Submission. Ministry of Health and Long-Term Care. Government of Ontario.

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1 Canadian Diabetes Association Patients First Submission Ministry of Health and Long-Term Care Government of Ontario February 29,

2 The Canadian Diabetes Association (CDA) is a registered charitable organization that leads the fight against diabetes by helping those affected by diabetes to live healthy lives and by preventing the onset and consequences of diabetes while we work to find a cure. Our staff and more than 20,000 volunteers including health care professionals provide education and services to help people in their daily fight against the disease, advocate on behalf of people with diabetes for the opportunity to achieve their highest quality of life, and break ground towards a cure. 2

3 Introduction The Canadian Diabetes Association (CDA) appreciates the opportunity to respond to the Government of Ontario s Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario. Today, more than 1.6 million people in Ontario are living with diabetes, and another 2.3 million people have prediabetes. The increasing rate of diabetes and its complications pose a serious burden on the quality of life of Ontarians, the province s publicly funded health-care system and our economy. The CDA shares many of the same goals as the Government of Ontario: strengthening population and public health, improving access to quality services and primary care, and strengthening collaboration and continuity of care among health care services. This is why the CDA publishes the Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, which are comprehensive, evidence-based recommendations for health care professionals to consider in the prevention and management of diabetes in Canada. They serve as a helpful resource and aid for anyone caring for people with diabetes and are recognized, not only in Canada but also internationally, as high-quality, evidence-based clinical practice guidelines. Within the guidelines there is an entire chapter devoted to improving the organization of diabetes care within the framework of the Chronic Care Model (CCM). Among the several recommendations to address the care gap between the clinical goals outlined in evidence-based guidelines for diabetes management and real-life clinical practice is the recommendation that diabetes care should be structured, evidence based and supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. These elements facilitate planning and coordination among providers while helping patients play an informed role in managing their own care. Within this submission, we propose the integration of the CDA Clinical Practice Guidelines into electronic medical records within our health care system to improve the organization of care, inter-professional collaboration and decision support for health care practitioners. 3

4 Background: Canadian Diabetes Association s 2013 Clinical Practice Guidelines Diabetes Care The 2013 Clinical Practice Guidelines support the promotion of patient self-management and recommend that diabetes care should be organized around the person living with diabetes. This person should be supported by a proactive, inter-professional team with specific training in diabetes. To improve patient self-management and outcomes, diabetes care should be delivered using evidence-based strategies including: self-management support and education and interprofessional team-based care. Inter-professional collaboration incorporates care coordination and the expansion of professional roles to include monitoring or medication adjustment and disease (case) management, in cooperation with the collaborating physician. Moreover, diabetes care should be supported by a clinical information system that includes electronic patient registries, clinician and patient reminders, decision support, audits and feedback. The Gap between Evidence-Based Clinical Goals and Clinical Practice Recent and ongoing CDA pilot projects have been designed to address some of the gaps between evidence-based guidelines and actual clinical practice by incorporating the Clinical Practice Guidelines into the health care system. Accordingly, this submission focuses primarily on interprofessional team collaboration within the delivery system, as well as decision support for health care practitioners through electronic medical records. For more information on the CDA s full set of recommendations on strengthening patientcentred care, please see the attached chapter Organization of Diabetes Care from the 2013 Clinical Practice Guidelines. RECOMMENDATION: Ensure that government policies fully support the implementation of the Canadian Diabetes Association s Clinical Practice Guidelines into clinical practice and the health care system. 4

5 Strengthening Inter-Professional Teams within LHINs The Patients First paper discusses examples of successful integration through collaborative care models, and asks the following questions: How do we support care providers in a more integrated care environment? How can we effectively identify, engage and support primary care clinician leaders? How can we support primary care providers in navigating and linking with other parts of the system? The Clinical Practice Guidelines support the chronic care model, as current evidence demonstrates the importance of a multi- and inter-professional team with specific training in diabetes within the primary care setting In adults with type 2 diabetes, this care model has been associated with improvements in A1C (i.e. blood sugar levels), blood pressure, lipids and care processes compared to care that is delivered by a specialist or primary care physician alone A reduction in preventable, diabetes-related emergency room visits also has been noted when the team includes a specifically trained nurse who follows detailed treatment algorithms for diabetes care. 6 Team membership may be extensive and should include various disciplines. Those disciplines associated with improved diabetes outcomes include nurses, nurse practitioners, dietitians, pharmacists and providers of psychological support. To help support and implement this model of collaborative inter-professional team care for managing diabetes, the Canadian Diabetes Association ran Inter-professional Collaboration (IPC) workshops in two Local Health Integrated Networks (LHINs), the Toronto Central LHIN and the Central East LHIN, in the spring of 2014 and winter of 2015 respectively. Each series of workshops ran over the span of three months to allow teams opportunities to implement quality improvement initiatives in collaborative care between sessions. The sessions were facilitated by a multidisciplinary team of diabetes and collaborative care experts including an endocrinologist, a pharmacist, a nurse and a dietitian. The workshops targeted primary care providers, Diabetes Education Program teams, other relevant health care providers (such as chiropodists, pharmacists, social workers and others) and administrators. The objectives of the IPC workshops were to: Enable comprehensive diabetes care and develop efficiencies in diabetes care by building skills and engaging a team approach Optimize inter-professional collaboration and communication Enhance diabetes management knowledge and skills through case studies Address participant-specific diabetes learning needs 5

6 Implement practical diabetes management tools immediately into practice The workshops were tailored to each LHIN through a needs assessment that engaged LHIN leadership, including primary care leads; Diabetes Education Program leadership; health care providers and administration. The needs assessment identified the current level of understanding and integration of inter-professional collaboration as well as individual learning needs for evidence based diabetes care according to the Clinical Practice Guidelines. Teams identified gaps and opportunities for inter-professional collaboration. Facilitators worked with the teams to develop quality improvement plans using action plans and techniques. Teams were expected to implement changes between sessions and report back on progress. In many cases, health care providers that were seeing the same patients for diabetes care had never met or communicated prior to the IPC workshops. The workshops provided an opportunity for providers to meet and plan in a strategic way toward improved collaboration, delineation of roles, efficiencies and communication. The results showed improvements to both individual and team comfort level in a number of areas related to diabetes management, collaborative care development of a registry and mechanisms to follow up with patients in an organized and timely manner. The inclusion of LHIN leads, primary care leads, and Diabetes Education Program leads allowed for the ability to identify areas of improvement and opportunities for Inter-professional Collaboration at a systems level, whereas individual health care providers, teams, and administrative support identified very practical solutions for improved collaboration and care. RECOMMENDATION: The Canadian Diabetes Association recommends that the Government of Ontario implement Inter-professional Collaboration workshops across the province to better facilitate team care and improve the quality of care and quality of life for people with diabetes. CDA: Electronic Medical Records Strategy Pilot Project Decision Support Over , the CDA will be running pilot projects involving electronic medical records (EMR) in Ontario and British Columbia to provide health care practitioners with best practice information at the point of care. This information will be based on the CDA s 2013 Clinical Practice Guidelines, and is intended help support decision making, leading to better access to patient-centred care and chronic disease management. 6

7 This type of decision-making support has been shown to improve outcomes for patients. In a systematic review, evidence-based guideline interventions, particularly those that used interactive computer technology to provide recommendations and immediate feedback of personally tailored information, were the most effective in improving patient outcomes. 9 For example, a randomized trial using EMR decision support in primary care found improvement in A1C (i.e. blood sugar levels). 10 A cluster randomized trial of a Quality Improvement program found that the provision of a clear treatment protocol supported by tailored postgraduate education of the primary care physician and case coaching by an endocrinologist substantially improved the overall quality of diabetes care provided, as well as major diabetes-related outcomes. 11 Incorporation of evidence-based treatment algorithms has been shown in several studies to be an integral part of diabetes case management. 1,7,12,13 Even the use of simple decision support tools, such as clinical flow sheets, has been associated with improved adherence to clinical practice guidelines for diabetes. 14 In Ontario, the CDA is identifying four Family Health Teams to run the pilot projects as well as clinical champions, such as Registered Nurses, Registered Dieticians or Pharmacists. As part of the project, the CDA will develop: practice level tools (e.g. reports, queries and audits); provider level tools (e.g. flowsheets, dashboard, widgets); and patient level tools (reports, action plans and resources). The Family Health Teams and clinical champions will first help to test the tools and then implement the program. Evaluation of the program will happen in 2017, six months after implementation. The teams will provide an EMR-generated practice report and review it with the clinician so the providers can see how the addition of EMR tools and decision support has affected their practice. This type of project has already been implemented in Saskatchewan as a collaboration between the Saskatchewan provincial government, EMR vendors and a steering committee with which CDA is engaged. This practice-level clinical registry will also give an overview of the entire practice, which could potentially assist in the delivery and monitoring of patient care in Ontario. Ideally, provincial- and national-level registries would be implemented, which are essential for benchmarking, tracking diabetes trends, determining the effect of Quality Improvement programs and resource planning. RECOMMENDATION: The Canadian Diabetes Association recommends that the Government of Ontario implement decision support making tools for diabetes management in electronic medical records systems across the province, following the results of the CDA s pilot projects in Ontario and British Columbia. 7

8 Conclusion The recommendations contained in the Canadian Diabetes Association's submission represent our priorities for creating a more patient-centred health care system that will meaningfully improve the lives of people living with diabetes. For the full suite of recommendations on Organization of Diabetes Care, please see the 2013 Clinic Practice Guidelines for the Prevention and Management of Diabetes in Canada. Thank you for the opportunity to provide these recommendations. For more information, please contact: Amanda Thambirajah Director of Government Relations and Advocacy, Ontario Canadian Diabetes Association Shojania KG, Ranjii SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006;296:427e40. 2 Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and metaanalysis. Lancet; 2012:12e21. 3 Pimouguet C, Le GM, Thiebaut R, et al. Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ 2011;183: e115e27. 4 Borgermans L, Goderis G, Van Den Broeke C, et al. Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project. BMC Health Serv Res 2009;9: vanbruggen R, Gorter K, Stolk R, et al. Clinical inertia in general practice: widespread and related to the outcome of diabetes care. Fam Pract 2009;26: 428e36. 6 Davidson MB, Blanco-Castellanos M, Duran P. Integrating nurse-directed diabetes management into a primary care setting. Am J Manag Care 2010;16: 652e6. 7 Saxena S, Misra T, Car J, et al. Systematic review of primary healthcare interventions to improve diabetes outcomes in minority ethnic groups. J Ambul Care Manage 2007;30:218e30. 8 Willens D, Cripps R, Wilson A, et al. Interdisciplinary team care for diabetic patients by primary care physicians, advanced practice nurses and clinical Pharmacists. Clin Diabetes 2011;29:60e8. 9 de Belvis A, Pelone F, Biasco A, et al. Can primary care professionals adherence to evidence based medicine tools improve quality of care in type 2 diabetes? A systematic review. Diabetes Res Clin Pract 2009;85:119e O Connor PJ, Sperl-Hillen JM, Rush WA, et al. Impact of electronic health record clinical decision support on diabetes care: a randomized trial. Ann Fam Med 2011;9:12e Goderis G, Borgermans L, Grol R, et al. Start improving the quality of care for people with type 2 diabetes through a general practice support program: a cluster randomized trial. Diabetes Res Clin Pract 2010;88:56e Clark CE, Smith LFP, Taylor RS, et al. Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis. Diabet Med 2011;28:250e Katon WJ. Collaborative care for patients with depression and chronic disease. N Engl J Med 2010;363:2611e Hahn K, Ferrante C, Crosson J, et al. Diabetes flow sheet use associated with guideline adherence. Ann Fam Med 2008;6:235e8. 8

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