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

Appendix A

Red Earth First Nation
Diabetes Home Care Program Model

Red Earth First Nation developed a program model which built capacity and expertise at the community level to increase access to diabetes services. Home Care nursing time was increased from one part time position to two full time nurses and the diabetes knowledge and skills were enhanced to support the program. The home care nurse(s) provide diabetes education and care and the coordination of other services for persons with diabetes.

Description of Model Diabetes Home Care Program - Red Earth First Nation

Management Structure

Supervision
The Senior Health Nurse supervises the Home Care Nurses. The home health aides report to the health director, but take some guidance from the home care nurses.

Project Staffing
Home care nursing time increased from two days per week to two full time home care nurse positions through this project. Home Health Aides also worked closely with the project team.

Diabetes Expert Support
Expert diabetes support is accessed from three different sources, the Tribal Council Diabetes team (Certified Diabetes Nurse Educator and Dietitian), the Nipawin Diabetes Team and the Diabetes Experts at the Tertiary Diabetes Centres in Saskatoon.

Services

Client Assessment
Home Care assessments are done to determine service needs and is done by the home care nurse. For persons with diabetes, a diabetes assessment is done through which a client establishes his/her own goals for self care. A diabetes assessment flow sheet was utilized for follow up care. An effective assessment protocol was developed.

Case Management
All persons with diabetes are assigned to the home care program. The home care nurses provide case management. Referrals are made as required for additional services.

Home Nursing
The full range of home care nursing services are available.

Home Care nurses provide case management, diabetes education one to one, teaching sessions, and treatment. All persons with diabetes are followed by the home care nurses.

Diabetes education starts with an assessment of the client's needs as identified by the client in a process guided by the home care nurse. The client sets his/her own goals. The nurse acts as a facilitator to assist the client to take control of his or her own health care through:

• individual goal setting; and
• ongoing follow up and support.

One of the home care nurses provides regular diabetes education mini classes.

Personal Care
Personal care is limited but will increase as home care workers are certified.

Home Support
Home support is provided by home health aides who are band employed. The processes are being considered to ensure the care given is based on a home care assessment by the home care nurse. The relationship between home care nurses and the home support staff is at this time not formalized.

Other Diabetes and Home Care Services Available

• A diabetes team of a certified diabetes nurse educator and dietician, employed by the Tribal Council, visit this community twice per year and are available for phone consultation. (This service was in place prior to the Project).
• Wellness clinics offered on doctors day to increase awareness and participation.
• Newsletters monthly - hand delivered to each home.

Integration and Linkages

Adult Care Program
The Adult Care (In-Home Component) Program is administered by the band and links with the nursing staff who are employed by the Tribal Council.

Mental Health, NNADAP and Recreation Director are referred to as needed.

Community Health
Information sharing on a regular basis informally and at regular staff meetings.

Clinics will be coordinated with CHN to assist with fall immunization program. Changes in nursing staff during the Project has necessitated redefinition of roles and responsibilities for all nurses.

Other Service Linkages

• Local physicians and pharmacist who visit the community twice weekly;
• North East Health District Diabetes Team;
• Physiotherapist and Occupational Therapist;
• Speech Therapist;
• Dietitian;
• Prince Albert Grand Council Diabetes Team - Dietitian service monthly;
• Saskatoon Tri-District Diabetes program as needed; and
• Diabetes Care Committee in Nipawin provides networking.

Infrastructure

Supplies and Equipment
The following supplies and equipment have been identified as required: (Office space, supplies (paper, pens, etc.);

• Computer with Internet access;
• Teaching tools equipment (overhead projector, TV and VCR); and
• Incentives for attendance to classes, workshops.

Other Support Needs

• Access to transportation for clients and staff.