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

Program Planning and Development

Home and Community Care Framework and Diabetes Services

One of the objectives of the Project was to observe whether the framework developed to guide Health Canada's First Nation and Inuit Home and Community Care Program had relevance to the development of diabetes care and treatment services. Although priority was given to the development of the diabetes services, the diabetes program models which were developed through the Project fit within the framework for the First Nations and Inuit Home and Community Care Program.

Administrative Structure

The leadership of each pilot community decided how the funding and administration should be managed. In two of the communities, funding flowed through an organization which coordinates services to a number of communities (a Tribal Council and a Health Commission). The funding and administration in the other two communities was administered through the band government health services.

"The follow up with podiatrist and other specialists (are) according to (Clinical Practice) guidelines. This was not done before. It takes a nurse coordinator. The patients by themselves are really discouraged by the system of follow ups. It helps that the nurse supports them with this."
Health Consultant - Wendake First Nation

Professional Supervision

Professional supervision was provided through a nursing supervisor at the Band, Tribal Council or Health Commission level. Advisory support from diabetes experts was accessed through diabetes education teams in nearby health districts or tertiary health organizations such as hospital diabetes teams or the Canadian Diabetes Association.

Client Assessment

The home support and home nursing services were, to some degree, based on the assessment of health needs by a Registered Nurse in all communities. There was a blurring of roles and responsibilities in relation to assessment and assignment of staff in communities where the home support services were under a different supervisory structure than the home care coordinators. Some communities have identified this as an area to be strengthen in the future.

"I learned that through a systematic follow up that nurses do make a great difference for the doctors in the community because people talk to the nurse - they don't talk as well to the doctors - they don't listen as well to the patient but nurses do. I saw the confidence that clients have for nurses. This will make a big difference and help the doctors - because doctors are very stressed over number of patients. Recording blood sugars with the nurse makes a big difference for doctors."
Health Consultant - Wendake First Nation

Home Care Nursing

All pilot communities added nursing staff to coordinate and develop the program. In three of the communities, the Home Care Nurse was the key provider of diabetes coordination, education and care. One pilot community added the diabetes coordination and follow-up duties to their Community Health Nurses who had a joint community health/home care job description.

The work description for the nurses involved in the Project differed from site to site and evolved as the Project progressed from a planning and development focus to service delivery. A close working relationship with the community health nurse(s) (and clinic nurses in the remote isolated site) was essential for the success of the Project. There was a need to redefine roles and responsibilities of the nurses in all the communities. In some communities, the chronic care monitoring and follow up of persons with diabetes became the responsibility of the diabetes home care nurse.

Acute home care nursing was available in all four communities. In one community it was accessed through the provincially funded services.

Personal Care

The personal care available was limited by lack of trained staff in some of the communities. The staff providing personal care generally received professional, but not day to day, supervision from the home care nurse.

Home Support Services

Adult care home support services existed in all communities. The self assessments identified the need to develop closer ties between the home support services and the Home and Community Care Program.

Case Management

A case management approach for the clients with diabetes was utilized in all of the pilot communities. Client services were coordinated to improve the continuity of care for clients receiving health care from a variety of providers.

Linkages

New linkages were developed to improve access to services and the communication with other health care professionals providing services to the clients. These linkages included service contracts and improved communication channels with local health districts, third-level hospital services, on-reserve health and social services and private healthcare providers. There was a reported increase in access to lab results and increased alignment of care with the Canadian Diabetes Association's Clinical Practice Guidelines (1998) in all communities.

"We proceeded in a respectful manner and clearly established that participation in the Project was voluntary, that nothing would happen without their consent, and that we were prepared to wait until they were ready or felt more confident about the program. This proved to be the best approach: the clients who participated are now promoting the services of the Centre."
Project Coordinator - Wendake First Nation

Supportive Infrastructure for Program Delivery

The communities were asked to identify the supportive structures that they needed in order to provide home care diabetes services. In addition to adequate staffing, education and training, the following were identified:

• educational tools and equipment for teaching;
• program policies and procedures;
• transportation for clients and staff;
• resource materials for clients and staff;
• professional supplies such as foot care instruments;
• clerical support;
• office space and office equipment;
• a budget for incentives and special projects related to diabetes;
• revision of the client charting system;
• new tools for client assessment and follow up;
• new flow charts to track variables in follow-up care and service.

"If starting over again, I would probably assign the diabetes home care management to one nurse. I have found that because diabetes is a chronic condition, other 'urgent' situations often detract the Home Care Nurse Coordinator from being proactive in diabetes outreach and management."
Sliammon First Nation - Project Coordinator

As the pilot communities developed and implemented their diabetes programs, there was a corresponding advancement of the essential elements of the Home and Community Care Program. Several areas, however, were identified for further enhancement. Those mentioned by the communities included; the need to coordinate the new Home and Community Care Program with the existing Adult In-Home Care Program funded through the Department of Indian Affairs and Northern Development (DIAND), and the need to form closer connections among diabetes services, nursing care, home support and personal care services. Other improvements mentioned included nursing services for clients other than persons with diabetes, and expansion of palliative care and respite services. All sites indicated plans in their self assessment to continue to strengthen the Home and Community Care Program.

"Following the loss of our professional nutritionist in July 1998, our clients were required to visit private clinics in order to access nutritional services. In some cases, this led to frustration and a loss of motivation. This Project accentuated the importance of making nutritional services available at the health centre. It is now generally recognized: these services will remain in place in the future." Project Coordinator - Wendake First Nation