Professional Documents
Culture Documents
January 2008
TABLE OF CONTENTS
Introduction ...........................................................................................................1
Roles and Responsibilities...................................................................................2
Chronic Disease Prevention and Management Diabetes Program – Key
Tasks......................................................................................................................3
Chronic Disease/Diabetes Program – Key Tasks & Actions .............................4
1. Identifying Patients....................................................................................................4
Appendix A ..........................................................................................................12
Appendix B ..........................................................................................................16
References...........................................................................................................19
Document contributed by:
Document created as part of the work of the Diabetes Tool Kit Task Group
The Diabetes Tool Kit Task Group is one of four task groups formed as part of the
project ‘Interprofessional Clinical Program Development for a Network of Family
Health Teams’.
Project Sponsor:
Project Funder:
Introduction
The objective of this Task Group is to provide a tool for use by Family Health Teams (FHTs) in
Ontario to aid in developing their own chronic care management programs for type 2 diabetes. The
principles for care provision and support to patients/clients with diabetes by primary care team
practices include being: proactive, consistent, comprehensive and flexible.
Due to the different stages of development of FHTs, as well as the varying resources available, this
tool focuses on enabling individual FHTs and family practice teams to make decisions within their
team based on their organization’s goals, patient needs and staffing capacity.
This document provides FHTs with a resource from which key tasks can be designated to the
participating members of the diabetes team.
The first step is to outline the scope of practice of the various team members. This ensures that all
members are aware of the roles and responsibilities of the different disciplines when creating an
interdisciplinary team. The Ministry of Health and Long Term Care (MOHLTC) has prepared a
guide1 as part of its Family Health Team information series that outlines the roles and responsibilities
of most of the professions. It describes what each Practitioner can do in terms of: Assessment,
Treatment/Management, Education/Advocacy, and Referrals/Collaboration. In addition to the health
professionals listed, we have provided information on other potential team members such as Diabetes
Nurse Educator, Heath Promoter, and Patient Educator Specialist, not described in the MOHLTC
guide. Please see appendix A.
The second step is to develop a diabetes program within the Ministry approved Chronic Disease
Prevention and Management framework.
The MOHLTC has outlined steps for FHTs to develop Chronic Disease Management Programs2. The
Task Group has further refined these functions to describe the necessary components of a diabetes
program, and have outlined the Key Tasks that each team should consider and/or implement.
Each FHT can use this resource to assign the key tasks to members of their diabetes management
team. We have provided a Roles Matrix to assist in this process. Assignment of actions to specific
team members ensures accountability and improves service delivery. The designation of who
completes the Key Tasks can apply uniformly to all patients/clients identified for diabetes
management, or can be adjusted for an individual patient/client. This flexibility takes into account
patient/client preferences for certain care providers as well as complexities of care for certain
individuals.
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Defining Roles For Interprofessional Diabetes Teams
• Family Physicians
• Nurse Practitioners
• Nurses
• Nurse Educators
• Patient Education Specialists
• Dietitians
• Pharmacists
• Social Workers
• Health professional trainees
Some teams also have either full time, part time or preferred access to chiropodists, occupational
therapists, physiotherapists, health promotion specialists, psychiatrists and other consultants.
It is assumed that health professional trainees may perform the same roles as fully certified colleagues
under appropriate supervision.
FHTs creating programs around diabetes management should include one or more professionals who
have the Certified Diabetes Educator status (or have team members working toward this designation).
The MOHLTC document “Family Health Teams Advancing Primary Health Care: Guide to
Interdisciplinary Team Roles and Responsibilities”1 is an important resource. It outlines the regulated
scope of practice of most of the professionals currently working within FHTs. Having an
understanding of what the various members can do under their Regulatory body or Professional
Association allows the team to avoid duplication of services delivered by its members and also
enables insights into the possible extent of services a practitioner may be able to offer. Within teams,
individual members of the practice may have refined their own scope of care delivery based on
expertise, preference and skill set. It is the assumption of this Task Group that these important
discussions will occur within each team and within the context of the design and implementation of
specific programs.
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Defining Roles For Interprofessional Diabetes Teams
• Identifying patients
• Understanding patient needs and available resources
• Developing a chronic disease management program
– Adopting evidence-based guidelines
– Translating guidelines into action
• Delivering a chronic disease management program
– Educating patients
• Coordinating a chronic disease management program
• Measuring success – evaluating chronic disease management programs
The Task Group has refined these steps for development of a diabetes program by identifying Key
Tasks under each section. The Key Tasks are the action statements that the diabetes team must
consider and/or implement when developing their diabetes program. They are based on the
MOHLTC requirements,2,3,4 Guidelines Advisory Committee recommended guidelines5, research on
quality improvement strategies6 and input from the Task Group.
Most of the Key Tasks can be performed by different members of the diabetes team, and it is up to
each FHT to distribute the tasks at their local site. Task assignment can be made for each individual
patient/client, or globally for all patients/clients. We have provided a Role Matrix chart which the
team can use to assign the Tasks to the various members. As some tasks can be performed by
multiple members of the team, there will be some differing approaches from the pilot sites.
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Defining Roles For Interprofessional Diabetes Teams
Tasks:
Choose a standardized flow sheet to be used by the team (see Tools section for examples)
• Ensure the flow chart incorporates all of the MOH and CDA4,5 recommended elements
• Ensure all clinicians are familiar with and comfortable using the flowsheet
• Standardize how and when information will be recorded on the flowsheet
• Decide where the flowsheet will be placed
• Decide on who will maintain the flowsheet
• Decide on where new flowsheets can be accessed (hard copies versus electronic copies)
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Defining Roles For Interprofessional Diabetes Teams
5
Defining Roles For Interprofessional Diabetes Teams
Tasks:
Initial assessment of patient-centered determinants of health and how these may impact
compliance with care plan and goals
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Defining Roles For Interprofessional Diabetes Teams
The Guidelines Advisory Committee has provided a summary of the recommended guidelines (see
Evidence section) for diabetes care.
All team members should understand and apply the guidelines relevant to their patient care.
Individual team members need to maintain competency in their designated professions and engage in
self-directed learning. Team-based learning, trainee supervision and research all promote on-going
evaluation and integration of best practices.
Tasks:
Consider developing education committee/sub group to facilitate meeting the learning objectives.
Clinician education includes interventions designed to “promote increased understanding of
principles guiding clinical care or awareness of specific recommendations for a target condition
or patient population. Subcategories of clinician education include conferences or workshops,
distribution of educational materials, and educational outreach visits” such as academic detailing
initiatives.6
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Defining Roles For Interprofessional Diabetes Teams
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Defining Roles For Interprofessional Diabetes Teams
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Defining Roles For Interprofessional Diabetes Teams
Tasks:
Horizontal referral between team members (with the exception of referral to specialty care);
external referrals to be coordinated by case manager or physician (as OHIP number may be
required).
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Defining Roles For Interprofessional Diabetes Teams
Tasks:
Foster team champions to continue iterative quality improvement despite changes in team
membership for sustainability
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Defining Roles For Interprofessional Diabetes Teams
Appendix A
For descriptions of the roles of other professionals within FHTs, we have ‘borrowed’ job
advertisements from Family Health Team recruitments. There will be differences observed
among FHTs in terms of focus for qualifications and job profile in these areas. These are
intended as examples only.
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Defining Roles For Interprofessional Diabetes Teams
Position Profile:
The PES will play a key role in patient education, health promotion, disease prevention and chronic
disease management. As a member of the inter-professional team, the key role is the development of
high quality primary care patient education initiatives geared towards both individual and group
activities. The PES is accountable for the development and implementation of short-term and long-
term strategic education plans that support the goals of the FHT initiative.
The candidate will promote and enhance the delivery of evidence passed primary care services
through promotion of excellence in primary care and the development, implementation and evaluation
of primary care indicators and outcomes that are impacted by educational initiatives.
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Defining Roles For Interprofessional Diabetes Teams
Full Time:
We are presently looking for a Health Promoter with a holistic focus on newcomer and immigrant
health to join our Family Health Team. The Health Promoter will provide mental health and
addictions outreach, education, community development and advocacy to newcomers and immigrants
within our catchment area with an emphasis on residents of social housing and people who are
homeless. This is an exciting opportunity to work as a member of an interdisciplinary care team to
develop and provide a diverse and varied service in a community based setting.
The Health Promoter utilizes adult education, community development, research/evaluation and
policy strategies to enhance the mental well being of communities with a broad range of mental
health, emotional health and substance use issues. S/he makes the links between mental health and
substance use problems and trauma, violence, settlement, family or relationship issues, loss, coming
out, and transitioning.
Qualifications:
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Defining Roles For Interprofessional Diabetes Teams
A Certified diabetes educator (CDE) is a health care professional who is specialized and
certified to teach people with diabetes how to manage their condition.
Typically the CDE is also a nurse or dietitian who has further specialized in diabetes
expertise. Formal education and years of practical experience are required, in addition to
formal examination, before a diabetes educator is certified. In the US, certification is
awarded by the National Certification Board for Diabetes Educators. In Canada, certification
is awarded by the Canadian Diabetes Association.
The CDE is an invaluable asset to those who need to learn the tools and skills necessary to
control their blood sugar and avoid long-term complications due to hyperglycemia. Unlike an
endocrinologist, the CDE can spend as much time with a newly diagnosed person as is
needed both for educational purposes and emotional support.
[edit] References
• American Association of Diabetes Educators
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Defining Roles For Interprofessional Diabetes Teams
Appendix B
The tools provided in this section are included as examples only. The task group recognizes
that a broad range of tools exist and others are being developed/adapted by individual
organizations to best suit the needs of their patients.
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Defining Roles For Interprofessional Diabetes Teams
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Defining Roles For Interprofessional Diabetes Teams
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Defining Roles For Interprofessional Diabetes Teams
References
1 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to interdisciplinary team roles and responsibilities. 2005
2 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to chronic disease management and prevention. 2005
3 Ministry of Health and Long Term Care. Family Health Teams Advancing Primary Health Care:
Guide to collaborative team practice. 2005
4 Ministry of Health and Long Term Care. Diabetes management incentive fact sheet, 2006.
5 Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of
diabetes in Canada. Canadian Journal of Diabetes. 2003, 27(suppl 2).
6 Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK.
Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-
regression analysis. JAMA 2006;296:427-439.
7 Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease
management programmes: Are they consistent with the literature? Managed Care Quarterly, 1999.
7(3):56-66.
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