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

Integration and Coordination of Services

In response to the identified need for improvements in the continuity of care, the pilot communities made tremendous efforts to build strong unified health teams working on behalf of clients with diabetes and their families. These teams included both community health staff and external health professionals and resources. The introduction of new staff members associated with the Project also meant the re-definition of roles, particularly between Home Care and Community Health Nurses.

Some examples of "teaming" within communities included:

• Community Health Nurse and Home Care Nurse working closely as a team, sharing the workload and supporting each other's programs and working together on joint projects;
• establishing a vision and philosophy during the planning process that helped to strengthen the team; and
• placing the diabetes services within an existing community health program and all nursing staff became skilled in the full range of community health and diabetes skills and knowledge.

"Through its active involvement and interest in professional development, our nursing team has made slow but sure progress: we are confident in our knowledge and know our limits, as well as when and how to offer support to persons dealing with diabetes. We work as a team with the nursing staff, the nutritionist, the psycho-social support worker, the homemakers and our own colleagues." Project Coordinator - Wendake First Nation

The other aspect of "teaming" was to bring external partners as resource people to community services and workers. These partners included physicians, dietitians, mental health professionals and diabetes nurse educators. Furthermore, some professionals who were already coming to the community were included in the diabetes program in new ways. The involvement of physicians was particularly significant. The following are some examples of these new linkages with physicians:

• in one community, clients received improved care based on the Clinical Practice Guidelines from their physicians, more systematic follow-up by the nurses and improved communication linkages between local nurses and offreserve physicians; and
• in another, improved linkages to a local doctor resulted in improved information sharing and changes in the clients' treatment plans to improve blood glucose or blood pressure control.

Concentrated efforts to find ways to surmount the barriers to services led to the establishment of new means of delivery and new linkages with other service providers both within and outside the community. These innovations in the
program planning resulted in effective initiatives to improve the services for persons with diabetes and their families in the four pilot communities.

"Take the time for public relations and involve all stakeholders to ensure that we are all working for the goal of quality client care. Good communication is a must." Rigolet - Public Health Nurse