Organisational Challenges for Diabetes Education and Management Programs.

For context I should remind everybody that Chapleau Health Services is a small (13 acute beds, 23 LTC beds) and isolated rural hospital in northern Ontario. We are 2 hours by road from Timmins and the nearest large hospital. We have a small and aging population (ca. 2,300).

Speaking with my clinical colleagues, although our ageing population has a number of chronic diseases that we deal with, diabetes is at the top of everyone's list. We have a good education and management program (https://sschs.ca/hospital/diabetes.html), that has had a lot of impact. Through creative use of resources we are able to staff a full time dietitian and an full time RN in the diabetes program. In the past we have had a good partnership with the Family Health Team and local physicians, but there have been some recent organisational changes that have created some new challenges.

For 4 years we had a nurse practitioner as a hospital employee who worked closely with the family health team and the local physicians. " ... high-quality chronic care delivery was more likely with the presence of a nurse-practitioner. Quality of care decreased with patient load and in those practices with more than 4 full-time-equivalent family physicians. These factors outweighed any independent influence of model of care delivery." Russel et al (2009). Unfortunately the NP has left the community and we have not succeeded in recruiting another.

Despite this loss our Diabetes Self-Management Education and Support (DSME) program remains as an important part of CDM in Chapleau. "Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity, and medications. It also necessitates that the person be proficient in a number of self-management skills. In order for people to learn the skills necessary to be effective self-managers, DSME is critical in laying the foundation with ongoing support to maintain gains made during education." Powers et al (2017).

Unfortunately there is another challenge that has arisen - the local physicians have left the Family Health Team and opened private practices, which has brought an end to the easy sharing of EMRs among the different care partners. This is making the DSME program harder to run and we are starting to see higher rates of non-compliant patients, something that we already struggled with, especially in our (relatively) large local indigenous population.

So, a mixed story. Our experience clearly shows that an integrated approach involving primary care and hospital resources can have significant impacts on the community, but that re-fragmentation into private practices and the loss of the NP resource means we are starting to lose ground.

As I have continued to reflect on how our organisational structure and the ongoing changes impact on our Diabetes program delivery and on health outcomes for the community, I don't have access to any statistical information - my conversations with my clinical colleagues have been informal and the people who would have the numbers on our program are on summer vacation, but I do know anecdotally that our Dietitian believes that the withdrawal of the physicians from the Family Health Team and their refusal to participate in the shared EMR system is having a negative affect on DSME.

However, the Russel (2009) article that I cited above reports that this is not supported by research. "we found no evidence that a practice’s use of electronic medical records influenced the chronic disease management score. Similar findings in studies comparing chronic disease management in paper-based and electronic practices in the United States and Quebec suggest that although practice information systems can assist chronic disease management, using such systems is no guarantee of effective chronic disease care." (p. 317). The major caveat that I would take is that this study was published 10 years ago and it may be the case the EMR technology and its integration into practice was much different then. 

I'm going to have to go over this with the senior management team: Russell supports the notion that a Nurse Practitioner does have a significant impact on CDM, so that might be an area where we could more profitably focus our efforts, rather than constantly fighting over EMR usage.

Russell, G. M., Dahrouge, S., Hogg, W., Geneau, R., Muldoon, L., & Tuna, M. (2009). Managing chronic disease in Ontario primary care: the impact of organizational factors. The Annals of Family Medicine, 7(4), 309-318.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., ... & Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes Educator, 43(1), 40-53.

Hilliard, M. E., Powell, P. W., & Anderson, B. J. (2016). Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families. American Psychologist, 71(7), 590.