Organization of Diabetes Care

1. Organization of Diabetes Care Key messages • Diabetes care depends upon the daily commitment of the person with diabetes to self-management practices with the support of an integrated diabetes healthcare (DHC) team. • The DHC team should be multi- and interdisciplinary, and should establish and sustain a communication network among the health and community systems needed in the long-term care of the person with diabetes.

2. Organization of Diabetes Care Key messages • Diabetes care should be systematic and, when possible, should incorporate organizational interventions such as electronic databases, automatic reminders for the patient and DHC team to enable timely feedback.

3. Organization of Diabetes Care 2008 CPG Recommendations • Diabetes care should be organized around the person with diabetes using a multi- and interdisciplinary DHC team approach centred on self-care management [Grade B, Level 2]. • Diabetes care should be systematic and incorporate organizational interventions such as electronic databases and clinical flow charts with automatic reminders for the patient and DHC team, to enable timely feedback for management changes [Grade B, Level 2].

4. Organization of Diabetes Care 2008 CPG Recommendations • The DHC team should facilitate the transfer of information among all members of the team as appropriate to ensure continuity of care and knowledge transfer [Grade B, Level 2]. • Members of the DHC team should receive support and education, which can vary from indirect input to direct involvement from a diabetes specialist as part of a collaborative care model [Grade C, Level 3].

5. Organization of Diabetes Care 2008 CPG Recommendations • The role of DHC team members, including nurse educators [Grade B, Level 2], pharmacists [Grade B, Level 2] and dietitians [Grade B, Level 2], should be enhanced in cooperation with the physician to improve coordination of care. The DHC team should facilitate and/or implement timely diabetes management changes without unnecessary delay [Grade B, Level 2]. • Case management or care coordination by health professionals with specialized training in diabetes should be considered for those individuals with difficult-to-manage diabetes [Grade B, Level 2].