Portal de Periódicos da CAPES

Organization of Diabetes Care

2018; Elsevier BV; Volume: 42; Linguagem: Inglês

10.1016/j.jcjd.2017.10.005

2352-3840

Maureen Clement, Pierre Filteau, Betty Harvey, Susie Jin, Tessa Laubscher, Geetha Mukerji, Diana Sherifali,

Diabetes Management and Research

Key Messages•Diabetes care should be:◦Organized around the person living with diabetes and their supports. The person with diabetes should be an active participant in their own care, be involved in shared-care decision making and self-manage to their full abilities.◦Facilitated by a proactive, interprofessional team with training in diabetes and the ability to provide ongoing self-management education and support.◦Organized within the context of the expanded chronic care model and delivered using as many of the components of the model as possible (in particular, self-management education and support; interprofessional team-based care with expansion of professional roles; collaboration with the primary care provider and monitoring with medication adjustment and case management).◦Structured, evidence based and supported by clinical information and decision support systems that include patient registries, clinician and patient reminders, facilitated relay of information, audits, feedback and benchmarking.•Any of the above strategies may be facilitated with telehealth technologies.Key Messages for People Living with Diabetes•Know the members of your diabetes team and stay connected with them.•Remember you are the most important member of the team.•Be prepared to learn how to care for your diabetes on a daily basis. Also, be ready to share in decision making regarding how you will care for your diabetes and health.•Prepare for visits with your diabetes health-care team:◦Have laboratory tests done prior to the visit so the results will be available to review at the visit.◦Be prepared to set and update your personal goals for caring for your diabetes and health. Be prepared to share any issues that may affect your ability to care for your diabetes on a daily basis, including any fears or anxiety you may have.◦Bring your medication bottles or an up-to-date medication list, including nonprescription drugs and supplements. Also, bring your glucose meter and insulin pen device if you use one.◦Bring or upload your most recent glucose monitoring results as well as other health behaviour records (e.g. food and exercise diary), as well as a health-care diary in which you have recorded important health events (e.g. visits with health-care providers, surgeries, illnesses, vaccinations).•Share the information you learn during your visits with your diabetes health-care team with all of your health-care providers and diabetes team members.•If travel distance or time is a barrier to your care, ask your team about telehealth (telephone, web-based or virtual) diabetes support and visits.Helpful Hints Box: Organization of CareRecognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes.Register: Develop a registry for all of your patients with diabetes to track care.Resource: Support self-management through the use of interprofessional teams, which could include the primary care provider, diabetes educator, registered dietitian, nurse, pharmacist, specialists and self-management supports, including linkage to community services.Relay: Facilitate information sharing between the person with diabetes and the health-care team for coordinated care and timely management changes.Recall: Develop a system to remind your patients and caregivers of timely review and reassessment. •Diabetes care should be:◦Organized around the person living with diabetes and their supports. The person with diabetes should be an active participant in their own care, be involved in shared-care decision making and self-manage to their full abilities.◦Facilitated by a proactive, interprofessional team with training in diabetes and the ability to provide ongoing self-management education and support.◦Organized within the context of the expanded chronic care model and delivered using as many of the components of the model as possible (in particular, self-management education and support; interprofessional team-based care with expansion of professional roles; collaboration with the primary care provider and monitoring with medication adjustment and case management).◦Structured, evidence based and supported by clinical information and decision support systems that include patient registries, clinician and patient reminders, facilitated relay of information, audits, feedback and benchmarking.•Any of the above strategies may be facilitated with telehealth technologies. •Know the members of your diabetes team and stay connected with them.•Remember you are the most important member of the team.•Be prepared to learn how to care for your diabetes on a daily basis. Also, be ready to share in decision making regarding how you will care for your diabetes and health.•Prepare for visits with your diabetes health-care team:◦Have laboratory tests done prior to the visit so the results will be available to review at the visit.◦Be prepared to set and update your personal goals for caring for your diabetes and health. Be prepared to share any issues that may affect your ability to care for your diabetes on a daily basis, including any fears or anxiety you may have.◦Bring your medication bottles or an up-to-date medication list, including nonprescription drugs and supplements. Also, bring your glucose meter and insulin pen device if you use one.◦Bring or upload your most recent glucose monitoring results as well as other health behaviour records (e.g. food and exercise diary), as well as a health-care diary in which you have recorded important health events (e.g. visits with health-care providers, surgeries, illnesses, vaccinations).•Share the information you learn during your visits with your diabetes health-care team with all of your health-care providers and diabetes team members.•If travel distance or time is a barrier to your care, ask your team about telehealth (telephone, web-based or virtual) diabetes support and visits. Recognize: Consider diabetes risk factors for all of your patients and screen appropriately for diabetes. Register: Develop a registry for all of your patients with diabetes to track care. Resource: Support self-management through the use of interprofessional teams, which could include the primary care provider, diabetes educator, registered dietitian, nurse, pharmacist, specialists and self-management supports, including linkage to community services. Relay: Facilitate information sharing between the person with diabetes and the health-care team for coordinated care and timely management changes. Recall: Develop a system to remind your patients and caregivers of timely review and reassessment.