Health Transition Fund Project NA012: Diabetes Community/Home Support Services for First Nations and Inuit

Appendix A

Wendake First Nation
Diabetes Home Care Program Model

The Wendake First Nation pilot team has developed a unique model which has placed the home care diabetes services within the existing community health program and has added existing staff from other disciplines to round out the multi-disciplinary team. The concept is to have all nursing staff skilled with the full range of community health, home care and diabetes skills and knowledge. The nurses in effect become the case managers who coordinate care and provide services for persons with diabetes who enter the program. The program clientele are those persons with diabetes and their families who have been formally admitted to the program although it is open to all community members.

Description of Model Diabetes Home Care Program - Wendake First Nation

Management Structure

Supervision
The Project Coordinator manages the program and provides professional and day to day supervision of the nurse coordinators. For the Project another nurse has been hired to provide supervision of nursing care.

Diabetes Expert Support
Quebec City diabetes education centres. are used for education of staff and expertise on diabetes care.

Staffing

• Project coordinator (Nurse Supervisor);
• 4 FT Community Health Nurses already working - Systematic follow up added to work - one additional CHN hired Sept 2000;
• A part time nutritionist was hired in January 2000; and
• A psycho-social worker already working full time has taken training in diabetes and now provides support for persons with diabetes.

Services

Client Assessment

• Persons with diabetes are admitted though referral or from other medical professionals, or they can self refer. Requests for service are forwarded to the nurse or the psycho-social worker depending if the request is for nursing or home support.
• An initial screening is completed and forwarded to the nurse supervisor.
• A worker is assigned to visit the home for the initial assessment using the Levels of Care in Continuing care form (or a shortened form). A nurse does the assessment for primarily nursing clients, the psycho-social worker does the assessment for primarily home support services.
• A plan for care is then established, serviced implemented, then reviewed within three months.
• Clients are discharged when they no longer require service.

Case Management
A systematic client follow-up was developed through this program. The nurse is responsible for coordinating the follow-up services and to establish a communication network among various external and internal care providers. Her role is also to ensure client care is consistent with the clinical practice guidelines.

Home Nursing
If the request for services is primarily for nursing care, the nurse fills out the McGill data collection model to assist in determining the kind and level of care and services required.

Diabetes education and care is provided in part by the nurse coordinators.

Acute nursing care is provided as required.

Personal Care
Personal care is provided by trained health workers.

Home Support
Home Support services are administered through the social services. The services provided are based on assessed need of the individual clients.

Other Diabetes and Home Care Services Available

• Nutrition counselling service;
• In-home respite;
• Institutional respite available at on reserve continuing care facility;
• Mental health services;
• Transportation services;
• Palliative care is available when needed, however further staff training is required; and
• Physical rehabilitation services through agreements with provincial health system.

Integration and Linkages

Adult Care Program
The home support services are supervised by the social services. There is a collaborative relationship between the social services and the health services.

Community Health
Community health and home care are totally linked, as the same staff do both home care nursing and community health nursing. There is no separation in management or supervision.

Other Service Linkages
Linkages have been established with the physician who works on reserve, with the continuing care facility, and other expert diabetes services available in Quebec City.

Service agreements are in place for rehabilitative services, weekend and evening care from the provincial system.

Infrastructure

Supplies and Equipment identified as needed for the Project

• Secretarial support;
• Program coordination time and human resources;
• Foot care equipment;
• Examination room for foot care and diabetes treatment, visiting specialists;
• Education tools and skills;
• Data collection tools; and
• Policies and procedures manual.

Training

• Client assessment;
• Basic and advanced diabetes education; and
• Foot care.