Virtual Diabetes Centre. Chronic Disease Management

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Helen Reeves
7 years ago
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1 Virtual Diabetes Centre Chronic Disease Management

Type 2 Diabetes An exploding clinical problem Diabetes, as with other chronic diseases: A complex illness that requires: a comprehensive approach to manage ownership

2 Type 2 Diabetes An exploding clinical problem Diabetes, as with other chronic diseases: A complex illness that requires: a comprehensive approach to manage ownership by informed patients long term support by a multidisciplinary healthcare team continuous supervised monitoring, education, and modification of disease management plans. 2

3 The patient: What needs to be provided. People with pre-diabetes and diabetes must learn and understand: What is diabetes What lifestyle changes may be needed What are the medications and how do they work - What happens if they are not taken? How to take charge and assume responsibility for their own care Access to care 3

4 The healthcare professional What is needed Know how difficult it is to effect lifestyle changes. Needs help from many resources: Dietitian Nurse educator Family physician knowledgeable about chronic care delivery Specialist consultations: endocrinologist, cardiologist, nephrologist, and others No patient can end a visit without a follow-up appointment. 4

5 Community Based Approach: Diabetes and My Nation A community based health management program to achieve evidence based outcomes for the prevention and management of diabetes (Type 2 diabetes Mellitus T2DM) in First Nations communities. It applies culturally appropriate and holistic methods, and addresses all age groups. 5

Diabetes and My Nation Six integrated components: Awareness and Motivation, Education, Management and Monitoring, Treatment, Prevention, and Diabetes Management Software A pilot project at the Haisla

6 Diabetes and My Nation Six integrated components: Awareness and Motivation, Education, Management and Monitoring, Treatment, Prevention, and Diabetes Management Software A pilot project at the Haisla First Nation, British Columbia demonstrated considerable reduction in diabetes clinical parameters (A1c, Lipids, BP, etc.) which would be predicted to result in major reductions in renal impairment, cardiovascular disease, other disabilities, and hospitalization costs. 6

7 Was it Successful? The striking finding was the improvement in the same parameters in the community as a whole including in those who did not participate in the intense program, demonstrating the spill-over effect of such a program in the community as a whole. The entire community now demonstrates a remarkable understanding and awareness of the risks of this disease and of methods to reduce this risk. The community has kept the program running since 2008 with limited support and has expanded it to other health problems (Men s Health program) 7

8 A1c % OF OBSERVATIONS < 7.0% 80 DMN KVC Kitimat

9 How to Package Care for the Individual The Virtual Diabetes Center ( VDC ) is a comprehensive approach targeting both the receiver of diabetes education and health care providers in two integrated modules: 1. Healthcare Professional s Module 2. Patient s Module. VDC facilitates coordination among the integrated medical care team encouraging: patient self-management to provide better patient care, improve workflow, and enhance productivity of the health care system. 9

10 What is the VDC? VDC is a single database of patient information combined with knowledge base. incorporates a comprehensive library of multimedia information (medications, clinical guidelines educational materials for patients. equips specialists in taking a more active role in managing the health of large numbers of patients with chronic illness. 10

11 Virtual Diabetes Centre VDC monitors the patient s self-management Changes to lifestyle. Changes in home glucose monitoring Responses to treatment. Enables the health care team to review historical medical records, carry out detailed analysis, and make further recommendations. 11

12 The VDC Diabetes Medical Record Patient Registration Patient registration includes: patient demographics, diabetes history, medical history, family medical history, and cumulative profile. Diabetes Visit Detailed user friendly forms capture detailed, patient-specific clinical information in a format easily reviewed by clinicians. Information includes: life style, diet and exercise, physical exam, lab results, medication, glycemic monitoring and hypoglycemia,, cardiac and other illnesses,. Assessment and Recommendation This section gathers flow sheet data. Facilitates sharing of recommendations between care team members. Produces comprehensive reports, letters to patients and consulting doctors, and files existing forms which can easily be viewed by the entire team, all without need for secretarial assistance. This sharing of information improves efficiency, avoids duplication, and provides a comprehensive view of the patient s condition. (For example, currently completes BC CDM (Chronic Disease Management) forms). 12

13 Reports The reports section includes a series of standardized reports and almost unlimited customizable queries for outcome analysis. The healthcare team can obtain statistics regarding individual patients, their medications, laboratory results over time and the clinic and its productivity. These statistics and reports can be exported to pdf and Excel for integration into medical papers or for other uses. 13

14 Guidelines The VDC program gives the healthcare team instant access to Clinical Guidelines. (guidelines.diabetes.ca) Patient results that are outside the recommended values are highlighted for instant recognition. Education and Training VDC has a built in E-Learning feature for digital media delivery of educational contents and a Learning Management System for Continuing Medical Education. 14

15 Health Records Patients store information regarding their blood sugar levels, blood pressure, diet, physical activity, stress level, and other information related to life style that could have an impact on managing their diabetes. This information is accessible by assigned healthcare providers through a secure interface with the Virtual Diabetes Center. 15

16 Education My VDC includes a comprehensive library of multilingual interactive self-education modules. These modules can be customized on-line by the physician or Nurse Case Manager to improve a patient s skills in diabetes selfmanagement. Supervised Monitoring The program has a notification feature that contacts healthcare providers in cases where specific indicators such as blood sugar levels are out of range for an extended time. The indicators and time span are configured as per the healthcare provider recommendations 16

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18 Mobile Diabetes Telemedicine Clinics (MDTC) Sponsored by Aboriginal Diabetes Initiative, Health Canada Two Teams: Northern and Southern BC. Nurses, Vision technician, and clerk travel by prearrangement to First Nation communities. See all diabetic patients in the community who wish assessment. Utilizing the VDC, the team provides complete assessment. 18

19 MDTC Full history, physical exam, and 10 point laboratory point-ofcare, and retinal photographs adding information to previous records. Nurse teaching and recommendations Endocrinologist consultation recommendations Reports sent to Family physician. Follow-up by Nurse where possible. Has seen over 2000 patients in the North since 2003 (Carrier Sekani Family Services) and 1000 by the newly organized Southern Team (Seabird Island First nations). 19

20 Activity to Date Over 2000 people with diabetes and/or pre-diabetes have been seen. Analysis has shown improved clinical care indices. Analysis has shown it to be cost effective. But: there are some areas for improvement 20

21 BC First Nations Mobile Diabetes Telemedicine Clinic (South) Table 4: Diabetic clients with two or more visits: Comparison of condition at first visit with condition at subsequent visits 01-Jan-2010 to 31-Dec-2012 Taking insulin At first visit: Number 158 Yes 38 24% At second or later visit: Number 183 Yes 45 25% Taking any pills for diabetes At first visit: Number 158 Yes % At second or later visit: Number 183 Yes % Hemoglobin A1c < 7.0% N Yes % Yes At first visit % At second or later visit : % Blood pressure < 130/80 At first visit: % At second or later visit : % LDL cholesterol < 2.0 mmol/l At first visit: % At second or later visit: % 21

22 Improvement The follow-up of these extensive interactions is limited by inadequate time and nurse resources Did the patients return as directed to their GPs? Were the recommended changes to the patient enacted by either the patient or the physicians? Was adequate follow-up completed by the physicians? Could telephone/electronic follow-up be instituted? Limited by communications problems in remote communities that may not have internet or even telephone communication capability 22

23 Thank You

Upstate New York adults with diagnosed type 1 and type 2 diabetes and estimated treatment costs

T H E F A C T S A B O U T Upstate New York adults with diagnosed type 1 and type 2 diabetes and estimated treatment costs Upstate New York Adults with diagnosed diabetes: 2003: 295,399 2008: 377,280 diagnosed