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
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