Guiding principles of this diabetes management program

This program considered the Diabetes Canada 2018 Guidelines.

• Principles:
  1. Patient self-management. This program aims to empower the patient towards self-management as an active participant in team decisions.
  2. Team-based management. The patient is introduced to updated information by registered experts, who are available to provide personalized support as required. Team members follow a patient-centered approach.
  3. Access to information and clinical care. The program is designed to provide timely access to information (administrative quarterback) and clinical care through the nurse (clinical quarterback) as first clinical contact. Appropriate referrals will be arranged as required.
  4. Ongoing support: Diabetes patients often feel isolated from social support and optimum care, so this program is designed to provide ongoing patient support. Diabetes care does not come in a condensed ‘package’.

• Team member selection:

Three criteria are suggested:
  1. Who cares?
    The goal is to provide health ‘care’. This ensures a culture that will be therapeutic for patients and providers.
  2. Who knows?
    Team members should be interested in and understand the latest evidence-based information on diabetes management.
  3. Who can?
    Team members should demonstrate skills in interprofessional collaboration, motivational interviewing, and communication. These skills should be observed and not assumed due to professional registration or certification.
• Measuring progress:

Team members, in consultation with patients, should identify both process and outcomes measures. These measures should be used to provide feedback and set realistic goals.

This is best achieved through short Plan-Do-Study-Act (PDSA) cycles to ensure quality improvement.

For the journal article

For full guidelines