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Inter-Professional Collaboration and Diabetes Outreach Clinics: Optimizing Health?

Posted in Body & Soul, Featured

Published on May 01, 2015 with No Comments


Rafat Saleemi RN CDE, Meghana Chansarkar RD CDE, Bonnie Loranger RN CDE

As healthcare professionals, we all know that diabetes is on the rise. Peel Region in particular has amongst the highest rates in the province. The Diabetes Atlas for the Region of Peel (2014) sites that between 1995/96 and 2004/05, the prevalence of diabetes in Peel increased by more than 50% from 5.9% to 9.2%. Peel has a growing number of immigrants with a higher susceptibility to diabetes which may further be compounded with additional lifestyle, socioeconomic and physiological risk factors.

As part of a Diabetes team practicing within Peel Region for WellFort Community Health Services, our team realised that the number of clients coming to our Diabetes program wasn’t reflective of the statistics from reports and literature. Though we knew from interactions at community outreach that many people were living with Pre-Diabetes or Type 2 Diabetes, we were not successful in reaching them. From anecdotal feedback from neighbours, clients, friends and family, we learned that there were many possible barriers preventing people from attending our program. These included, lack of awareness of Diabetes Education programs, literacy/language barrier, socioeconomic challenges, mobility limitations, co morbidities, work/family responsibilities and lack of access to transportation. What could our team do to address these barriers to provide holistic, individualized care using a self management approach to optimize client self care of their own Diabetes?

New Beginnings….

Call it fate if you may, but at an outreach health fair, we met a family physician, Dr. Visual Midha practicing in the local area. Dr Midha’s enthusiasm and interest in diabetes management and support was infectious. This chance meeting at the health fair led to an outreach pilot diabetes clinic at Dr. Midha’s office for half day a month.

A team of one Diabetes Nurse Educator and one Registered Dietician provided the same diabetes management, resources and support that would be provided at the Diabetes Education Program at our Community Health Centre.


Inter-Professional Practice to Diabetes Care: Who’s Involved?

The inter-professional staff comprises: Certified Diabetes Nurse Educator (Rafat Saleemi), Registered Die titian (Meghana Chansarkar), Family Physicians (Dr. Vishal Midha and Dr. Jaspaul Singh Dulku), Diabetes Program Coordinator (Bonnie Loranger) and clinic front desk staff. It is the collaboration of this inter-professional team that allows for integrated and individualized diabetes care for clients that otherwise may not access a Diabetes Education program. Any suggestion or clarification related to a client’s diabetes management can be done on the same day of appointment. If any prescriptions or follow-ups are needed with the doctor, same day appointments are facilitated to provide a “one stop” service for clients.


Weighing the benefits

The outreach diabetes clinic thus far has shown numerous benefits. A big benefit is the verbal and written feedback from clients. We have seen a difference in the blood sugar numbers via client daily self monitoring logs as well as improvement in client’s HbA1C and other blood work results.

Other advantages of the diabetes clinic at the physician office includes: the location is closer to home for clients and thus they can walk to appointments, avoid having to use transit and thereby save money, and are not reliant on a family member to drive them to appointments. Having the family physician at the same location means there is ease in getting access to client’s electronic medical record (EMR) and any suggestions and/or clarifications regarding Diabetes management can be immediately addressed. Prescription renewals and/or follow ups with the doctor can be facilitated on the same day.

Various resources and supports that enhance care provided by the Diabetes team include, having a separate room to see clients as well as space for storing supplies and resources. In addition, clinic front desk staff assists with electronic scheduling to book appointments, provide access to a locked drawer for confidential information as well as scan and photocopy resources.


Where we are now

We started out with one-half day outreach Diabetes clinic per month. As the number of clients grew, we increased our clinic days to two twelve hour days per month. To further accommodate the learning needs of clients, Shared Medical Appointments (SMA’s) were introduced. The SMA is a collaboration of the Inter-professional team (RN, RD and MDs) in providing care and information on a variety of topics like: What is diabetes and management, diabetes and foot care, cholesterol and diabetes, diabetes and physical activity. The SMA is a fun and interactive way to impart information to clients.

The interest has been phenomenal. Clients have been requesting not only an increase in the frequency of days we provide onsite Diabetes clinics; but additional SMA days as well.

In addition to the outreach Diabetes clinic at Dr. Midha’s office, we have since partnered with two other family physicians in providing similar outreach clinics at their offices.

So…… Inter-Professional Collaboration and Diabetes Outreach Clinics: Optimizing Health?          

Inter-professional collaboration and Diabetes Outreach Clinics: Optimizing Health? Yes, we definitely do think that the inter-professional collaboration via the Outreach Diabetes clinic has improved; and in fact, optimized the health of clients. We see improvement in blood work results. Above all, we see the increase in client awareness, knowledge and self management of their diabetes.

Next Steps: Evaluating Success

We have seen positive responses and received encouraging verbal and written feedback from clients. Our next step will be to more formally evaluate the effect of the diabetes clinic on diabetes care and client outcome. We will evaluate whether the Diabetes Self Management via Inter-Professional Team (RN, RD; both CDE and family physicians) approach helps to improve glycemic control as evidenced by HbA1C and other blood work results in adult clients living with Type 2 Diabetes.

Stay tuned for further updates in the future !!!

At the WellFort’s Diabetes Education Program a team consisting of a Registered Diabetes Nurse Educator and a Registered Dietitian will help you learn to better manage your diabetes.



For more information please call    905-451-6959




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