Can J Diabetes xxx (2015) 1e3
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Perspectives in Practice
Diabetes Case Management in Primary Care: The New Brunswick Experience and Expanding the Practice of the Certified Diabetes Educator Nurse into Primary Care Shelley L. Jones RN, BScN, CDE * Horizon Health Network, Moncton Area, New Brunswick, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 November 2014 Accepted 7 December 2014 Available online xxx
The role of the outreach diabetes case manager in New Brunswick, Canada, was first developed in the Moncton Area of Horizon Health Network in response to a physician-identified gap between patients’ diagnoses of diabetes and their attendance at the local diabetes education centre. This model of collaborative interprofessional practice increases support for primary care providers and people living with diabetes in that they are being provided the services of certified diabetes educators who can address knowledge gaps with respect to evidence-based guidelines and best practice, promote advancement of diabetes and chronic-disease management therapies and support adherence to treatment plans and selfmanagement practices. This report chronicles a review of the implementation, expansion and evaluation of the outreach diabetes case manager model in the province of New Brunswick, Canada, along with the rationale for development of the role for registered nurses in other jurisdictions. Ó 2015 Canadian Diabetes Association
Keywords: certified diabetes educator chronic disease diabetes case manager primary care registered nurse
r é s u m é Mots clés : educateur agréé en diabète maladie chronique gestionnaire de cas de diabète soins primaires infirmiers autorisés
Le rôle du gestionnaire de cas de diabète du Nouveau-Brunswick, au Canada, a été en premier développé dans le Réseau de santé Horizon e région de Moncton en réponse aux lacunes relevées par les médecins entre les diagnostics de diabète des patients et leur fréquentation d’un centre local d’enseignement sur le diabète. Ce modèle de pratique de collaboration interprofessionnelle accroît le soutien aux prestataires de soins primaires et aux personnes diabétiques en ce sens qu’ils reçoivent des services d’éducateurs agréés en diabète qui peuvent remédier aux lacunes dans les connaissances en ce qui concerne les lignes directrices et les meilleures pratiques fondées sur les données probantes, promouvoir l’avancement des traitements dans la prise en charge du diabète et des maladies chroniques, et soutenir l’observance des plans de traitement et des pratiques de prise en charge autonome. Ce rapport fait état d’une revue de la mise en œuvre, de l’expansion et de l’évaluation du modèle de gestionnaire de cas de diabète de la province du Nouveau-Brunswick, au Canada, et des raisons du développement du rôle des infirmiers autorisés dans d’autres provinces ou territoires. Ó 2015 Canadian Diabetes Association
Introduction The role of outreach diabetes case managers (ODCMs) in New Brunswick, Canada, was first developed in the Moncton area of the Horizon Health Network in response to a physician-identified gap between patients’ diagnoses of diabetes and their attendance at the local diabetes education centre. This model of collaborative interprofessional practice increases support for primary care providers
* Address for correspondence: Shelley L. Jones, RN, BScN, CDE, Horizon Health Network, 135 MacBeath Avenue, Moncton, NB E1C 6Z8, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.12.006
(PCPs) and people living with diabetes in that those people are being provided the services of certified diabetes educators (CDEs) who can address knowledge gaps with respect to evidence-based guidelines and best practice, promote advancement of diabetes and chronic disease management therapies and support adherence to treatment plans and self-management practices. Background During the first 4 years (2004-2008) of the Diabetes Case Management program in the Moncton area, we were able to demonstrate a mean decline in glycated hemoglobin (A1C) of
2
S.L. Jones / Can J Diabetes xxx (2015) 1e3
0.774% (p
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Perspectives in Practice
Diabetes Case Management in Primary Care: The New Brunswick Experience and Expanding the Practice of the Certified Diabetes Educator Nurse into Primary Care Shelley L. Jones RN, BScN, CDE * Horizon Health Network, Moncton Area, New Brunswick, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 November 2014 Accepted 7 December 2014 Available online xxx
The role of the outreach diabetes case manager in New Brunswick, Canada, was first developed in the Moncton Area of Horizon Health Network in response to a physician-identified gap between patients’ diagnoses of diabetes and their attendance at the local diabetes education centre. This model of collaborative interprofessional practice increases support for primary care providers and people living with diabetes in that they are being provided the services of certified diabetes educators who can address knowledge gaps with respect to evidence-based guidelines and best practice, promote advancement of diabetes and chronic-disease management therapies and support adherence to treatment plans and selfmanagement practices. This report chronicles a review of the implementation, expansion and evaluation of the outreach diabetes case manager model in the province of New Brunswick, Canada, along with the rationale for development of the role for registered nurses in other jurisdictions. Ó 2015 Canadian Diabetes Association
Keywords: certified diabetes educator chronic disease diabetes case manager primary care registered nurse
r é s u m é Mots clés : educateur agréé en diabète maladie chronique gestionnaire de cas de diabète soins primaires infirmiers autorisés
Le rôle du gestionnaire de cas de diabète du Nouveau-Brunswick, au Canada, a été en premier développé dans le Réseau de santé Horizon e région de Moncton en réponse aux lacunes relevées par les médecins entre les diagnostics de diabète des patients et leur fréquentation d’un centre local d’enseignement sur le diabète. Ce modèle de pratique de collaboration interprofessionnelle accroît le soutien aux prestataires de soins primaires et aux personnes diabétiques en ce sens qu’ils reçoivent des services d’éducateurs agréés en diabète qui peuvent remédier aux lacunes dans les connaissances en ce qui concerne les lignes directrices et les meilleures pratiques fondées sur les données probantes, promouvoir l’avancement des traitements dans la prise en charge du diabète et des maladies chroniques, et soutenir l’observance des plans de traitement et des pratiques de prise en charge autonome. Ce rapport fait état d’une revue de la mise en œuvre, de l’expansion et de l’évaluation du modèle de gestionnaire de cas de diabète de la province du Nouveau-Brunswick, au Canada, et des raisons du développement du rôle des infirmiers autorisés dans d’autres provinces ou territoires. Ó 2015 Canadian Diabetes Association
Introduction The role of outreach diabetes case managers (ODCMs) in New Brunswick, Canada, was first developed in the Moncton area of the Horizon Health Network in response to a physician-identified gap between patients’ diagnoses of diabetes and their attendance at the local diabetes education centre. This model of collaborative interprofessional practice increases support for primary care providers
* Address for correspondence: Shelley L. Jones, RN, BScN, CDE, Horizon Health Network, 135 MacBeath Avenue, Moncton, NB E1C 6Z8, Canada. E-mail address: [email protected] 1499-2671/$ e see front matter Ó 2015 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2014.12.006
(PCPs) and people living with diabetes in that those people are being provided the services of certified diabetes educators (CDEs) who can address knowledge gaps with respect to evidence-based guidelines and best practice, promote advancement of diabetes and chronic disease management therapies and support adherence to treatment plans and self-management practices. Background During the first 4 years (2004-2008) of the Diabetes Case Management program in the Moncton area, we were able to demonstrate a mean decline in glycated hemoglobin (A1C) of
2
S.L. Jones / Can J Diabetes xxx (2015) 1e3
0.774% (p
