University of Toronto - Faculty of Medicine

 

Author
The revision of this chapter was prepared by Jacqueline James, MD, MEd, FRCPC

 

• Prevention and treatment of acute and chronic complications of diabetes is highly dependent on a set of complex self-management skills of the person with diabetes and a structured approach to health care provision.
• An interdisciplinary team of health care professionals is essential to provide education and ongoing support for the person with diabetes, his/her family members and caregivers. This team is referred to as the diabetes health care team.
• Core team members include: the person with diabetes, a primary care physician, diabetes educators (nurses and dieticians), in some cases the diabetes specialist (endocrinologist or internist).
• Case managers or coordinators may be involved to help improve the care of patients with difficult to manage diabetes or complex management issues.
• Expanded team members include other health professionals depending on the needs of the individual: ophthalmologist, cardiologist, nephrologist, neurologist, foot care specialist, obstetrician, social worker, psychologist/psychiatrist, community care worker, pharmacist, surgical specialist, dentist.

 

• To provide comprehensive, shared, patient centered care.
• To incorporate current clinical practice guidelines into daily management practices, including timely medical follow-up and complication surveillance.
• To provide initial and ongoing education as an integral part of diabetes care, with a focus on self-management skills.
• To use organizational tools such as clinical flow sheets and electronic databases (where available) to facilitate reminders for the patient and health care team members to ensure timely follow-up and management.
• The structure/membership of the diabetes care team should be flexible, based on individual and community needs.
• To maintain excellent communication between all members of the team.

References

1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008; 32 (suppl 1):S20-24.