Health Transition Fund Project NA012: Diabetes Community/Home
Support Services for First Nations and Inuit
Appendix A
Project Program Models
Sliammon First Nation
Diabetes Home Care Program Model
Sliamon First Nation developed a model with
coordination and liaison services within the community and established
linkages to diabetes expertise from the local health district.
A community based team was formed to guide the project development.
Two additional full time staff were hired, a home care nurse to
co-ordinate the project and the diabetes services, a home health
aide provides a liaison function and a diabetes team was contracted
to provide diabetes expert support within the community.
Description of Model Diabetes Home Care Program - Sliammon
First Nation
Management Structure
Project Staffing
- One nurse for program coordination and development, assessment
and supervision of personal care.
- One trained home health aide to support the program through
client follow-up and liaison.
Supervision
The Home Care Nurse Coordinator is provided with professional
supervision from the intertribal authority and day to day supervision
from the health director.
The home makers and personal care workers are supervised by the
home and community care manager but receives professional supervision
from the Home Care Nurse Coordinator for personal care and diabetes
related tasks.
Diabetes Expert Support
Diabetes expertise is obtained from the contract with
the Diabetes Day Program, Powell River.
Services
Client Assessment
Assessment of home care client needs is provided by the
Home Care Nurse Coordinator. Before this Project this task was
part of the Community Health Nurse's responsibilities.
Case Management
Sliammon First Nation identified the need for a strong
team approach to diabetes care. The Home Care Nurse Coordinator
coordinates the care for persons with diabetes and maintains close
communication with the diabetes education team and the Diabetes
Home Health Aide. It was further identified that regular home care
team meetings are needed to consistently review the program and
the policies within it and the management of client care.
Home Nursing
Acute home nursing care has been provided by off reserve
health services from Powell River.
Personal Care
Personal care is provided by trained home health aides
under the professional supervision of the Home Care Nurse Coordinator.
Home Support
Home support is provided through home makers from the
(DIAND Adult Care) Home and Community Care Program.
Other Diabetes and Home Care Services Available
Diabetes Team from Powell River contracted two days per
month.
A trained Home Health Aide who supports the diabetes program as "The
eyes and ears of program" by maintaining very close contact
with the clients. This position is considered to be essential to
the success of the program. She has several areas of responsibility:
- to accompany diabetes educators (nurse and dietitian) on home
visits to persons with diabetes;
- to follow up clients with additional visits each week. During
these visits the client often ask for clarification of information;
- to inform community members of services encourages participation
in diabetes initiatives; and
- to liaise between the health services and community members.
Integration and Linkages
Adult Care Program
Funding and staff for home care services are managed by the home
and community care manager. Future plans have identified the
need to establish closer linkages of support and supervision
between the Home Care Nurse Coordinator and the aides who provide
personal care and respite.
Community Health
The Home Care Nurse Coordinator and the Community Health Nurse
work closely together. There has been some redefinition of roles
through the Project.
Other Service Linkages
Contracted services for 2 days per month with Diabetes Day Program
for diabetes education team to come to the community. The community
visits were a combination of home visits for one to one counselling
and group education.
Infrastructure Supplies and Equipment
Teaching Resources
- videos, educational pamphlets, educational games, food models,
blood sugar models, various glucometers and test strips.
Treatment Supplies
- dressing supplies, blood pressure monitors (digital self monitoring
kinds are very useful as they are user friendly for clients as
well as the home health aides), portable digital scale (very,
very useful), foot care equipment and lotions.
Other Support Needs
Equipment and/or funding to provide activities to promote exercise
and active living would be very useful.
Promotional activities for the use of sugar free drinks and artificial
sweeteners would also be of assistance to our clients.
Resources available to provide luncheons, prizes for games -
food coupons, samples of artificial sweeteners, sugar free drinks,
etc.
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