Health Transition Fund Project NA012: Diabetes Community/Home
Support Services for First Nations and Inuit
Validation of the Aboriginal Diabetes Strategy
The needs assessment process gathered information regarding the
need for diabetes services in each community. The communities then
put together and implemented a plan to respond to these needs.
The following section summarizes the common themes of needs,
the services developed and the early impacts of the services. The
findings in this section are discussed from the perspective of
the Aboriginal Diabetes Initiative First Nations On-Reserve and
Inuit Program Framework elements.
Care and Treatment
Definition
"Services will begin to address the needs of First Nations and
Inuit people already diagnosed with diabetes by providing them
with direct services to help monitor their diabetes status, screen
for and prevent further complications from developing, and provide
diabetes education to clients to encourage selfmanagement. Creative
ways to remove service barriers should be examined and linkages
be established to help ensure that the fullest continuum of care
services may be realized." (Aboriginal Diabetes Initiative First
Nations On-Reserve and Inuit Program Framework)
"Clients receive much more intense
follow up and support with this Project. People were only
seen by health professional periodically. Now they are seen
every few weeks." Rigolet Pilot Team
Needs Identified
The community needs assessment identified the following concerns:
- Direct Services and Diabetes Education
- few people in the First Nations/Inuit communities had the
opportunity to receive diabetes education in the past year;
- all communities identified the need for regular dietitian
services;
- only one community had a diabetes education team (nurse
educator/dietitian) that visited the community; and
- some communities already had a working relationship with
the local diabetes education services while others did not
have easy access to this service or had not established a
relationship.
- Screening for Complications
- in each community, 40-50 % of those with diabetes also
had high blood pressure;
- monitoring for possible complications was incomplete and
could be related to several variables - physician practice,
amount of documentation and/or clients not attending for
follow-up appointments and/or tests;
- many community members with diabetes were already demonstrating
diabetes complications; and
- the results of the Haemoglobin A1c testing were usually "sub-optimal" or "inadequate".
- Removal of Service Barriers
- documentation about client health information such as lab
work, was located in several places (local health centre,
physicians' offices, diabetes programs, hospitals). There
was minimal or no coordination of care and services using
standards such as the Clinical Practice Guidelines.
Activities and Services Initiated
Four areas of activity and service will be described in terms
of the categories of needs identified: direct services, screening
for complications, diabetes education and removal of service barriers.
- Direct Services In all communities, dedicated
staff had been made available for the diabetes service within
Home and Community Care. This was the first time that staff resources
with appropriate expertise had been allocated to a service specifically
for people with diabetes. The model of staff allocation and service
varied in each community and is described in detail in Section
2.1. Communities augmented their nursing services, but also added
other staff with a diabetes focus. In the needs assessment, a
common theme was the absence of follow-up care and coordination
of care for people with diabetes. All communities implemented
systems and processes to ensure the ongoing follow-up that is
needed for this chronic condition.
- Diabetes Education Education about diabetes
was provided to people with diabetes and their family members
through a variety of methods and strategies, including:
- diabetes workshops - sessions for persons with diabetes
and families;
- one-on-one - assessment/education/counselling with individuals
who identified their own needs and set their own goals, with
health care staff facilitating the process and supporting
client-directed change;
- development of teaching manuals and materials for clients
who cannot read; and
- Wellness clinics.
"Both clients and health district
have expressed gratitude for the diabetes education available
on reserve." Home Care Nurse - Red Earth First
Nation
- Screening for Complications The chart audits,
which were completed as part of the community needs assessments,
compared the client data available in the charts against the
Canadian Diabetes Association's Clinical Practice Guidelines
(1998). All the sites are using the Guidelines to establish and
continue regular screening programs for diabetes complications.
Some examples include:
- initiation of screening for all clients by the optometrist
(no screening had been done previously);
- blood glucose metres for all clients and ongoing regular
testing by clients or their family members;
- regular Haemoglobin A1c and other screening lab tests and
monitoring of results on a long term basis (these results
will also be part of future evaluations);
- communities receiving lab reports back from other health
professionals so they are aware of results and can both
communicate with clients and continue appropriate follow-up;
and
- more referrals to follow-up abnormal test results.
- Removal of Service Barriers and Promotion of the Continuum
of Care Prior to the initiation of the Project, all
communities had identified a number of service barriers. While
these were not totally eradicated, there were significant improvements
toward their removal. The needs assessment identified several
barriers to diabetes care and support which were present in
the communities. The program plans for the communities were
designed with the identified barriers in mind.
- Lack of access to diabetes expertise within
the community. All communities addressed this by either bringing
diabetes expertise to the community or developing diabetes
expertise within staff at the community level, or both.
- Lack of coordination and follow-up care
for persons with diabetes. This was addressed by improving
case management and follow-up of persons with diabetes within
the community. Linkages were established to share information
between caregivers to improve the continuity of care. Clinical
Practice Guidelines were utilized to standardize expectations
for care of persons with diabetes.
- Transportation Issues. Difficulties with
access to care and follow-up because of transportation and
distance were addressed in several ways. It was partially
dealt with by bringing expertise to the community and thereby
reducing the need for off-reserve travel to services outside
the community. For example, one community had their community
health nurses trained to take blood for laboratory work.
- Culturally Inappropriate Diabetes Services. The
pilot communities utilized various strategies to make the
diabetes services more culturally appropriate. The following
are a few examples:
- the service delivery planning and identification of
needs was a collaborative process with health staff and
community members who guided the development of the services;
- the development of more appropriate teaching aides,
for example, materials were developed for persons who
do not read and a workbook was developed to assist with
teaching;
- the utilization of persons who are familiar with the
community members; and
- teaming outside health professionals with a trained
home health aide to provide cross cultural guidance and
interpreting services.
Prior to the pilot project all communities identified service
barriers. While these have not been totally eradicated, there have
been significant improvements. One fundamental initiative to decrease
the barriers has been the tremendous effort to build health teams
working together and on behalf of clients and families with diabetes.
These teams are both within the community and bringing in external
partners and developing relationships that benefit people with
diabetes.
The introduction of pilot and sometimes new staff members has
meant the re-definition of roles, particularly between Home Care
and Community Health nurses. Some examples of the 'teaming'
within communities included:
- Community Health Nurse and Home Care Nurse work closely as
a team, sharing the workload and supporting each other's programs
and working together on joint programs;
- the team took time to establish a vision and philosophy and
this common understanding help to build the team; and
- placing the diabetes services within an existing community
health program with all nursing staff becoming skilled in the
full range of community health and diabetes skills and knowledge.
"People with diabetes regain
a measure of control over their lives and are eager to selfmanage
their condition: they need the kind of support which this
program can provide." Multi-disciplinary Team
- Wendake First Nation
The other aspect of 'teaming' has been to bring into the
community services and health workers who are key partners in the
diabetes program. The partners have included:
"I've learned a lot. Very educational.
I didn't know much about diabetes. After the first meeting
I became interested. I have started exercising, and monitoring
my blood sugars two or three times a day and recording them.
I have changed the way I eat and read labels when I shop... I
know what to do when my blood sugar is high or low. I've
been doing really well. My sugar stays around 6 to 7. I have
lost weight too... I've really changed my life and feel
better. I enjoy life better." Client from Sliammon
First Nation
Impacts of Care and Treatment Services
Although the Project clearly resulted in a number of changes and
additions in the services for persons with diabetes in all of the
pilot communities, it will take a considerable length of time to
see longer term impacts regarding reduced complications and sustained
improvements in blood sugar and blood pressure control. Nonetheless
in the short time of the Project, significant impacts were observed
that indicated that the Project had moved care and treatment in
the right direction to achieve the longer term outcomes.
As part of the evaluation, clients had the opportunity to provide
input through a satisfaction survey. Clients reported not only
changes in their self care practices, but also greater confidence
in their abilities and belief that diabetes can be controlled.
Three areas of improvement were evident in all the communities:
- more knowledge about food and its impact on blood sugar, and
changes in eating habits with increased awareness of how foods
eaten can influence blood sugar;
- more people had the capacity to monitor their blood sugar and
are beginning to understand the meaning of the results. In some
cases, this led to further change in treatment such as changes
in oral medication or a willingness to start insulin therapy;
and
- a general sense of "taking better care" of oneself
and understanding of diabetes.
"Since the beginning of the Project,
there have been decreases in the HgA1c lab results of several
clients."
Rigolet Project Coordinator (Note: HgA1c is a blood test which
is considered one of the best indicators of reduced risk of complications)
Some communities indicated that family members were also impacted
by the Project. Family members gained a better understanding of
diabetes and were able to provide more support to the person with
diabetes.
Although it is much too early to assess the impact of the Project
on rates of diabetes complications, health staff in the pilot communities
noticed a trend in reduced Haemoglobin A1c results. This test represents
the overall quality of diabetes control and the needs assessment
indicated a high percentage of sub-optimal and inadequate results.
Diabetes research has shown that any reduction in the Haemoglobin
A1c reading can reduce the risk for diabetes complications.
|
