Diabetic Patients Receive Full Circle of Care Thanks to Partnership Between Campbellford Memorial Hospital and Trent Hills Family Health Team

Joyce Ellis, 73, has been living with diabetes for 12 years. The disease was detected following a routine urine test for a bladder infection. With her disease confirmed by her family physician, it was suggested she get in touch with Campbellford Memorial Hospital (CMH) to participate in the 5-day diabetes disease management program they offer.

“There is no history of diabetes in my family. My initial diagnosis was upsetting to me. Participating in these workshops with others who also had the disease made me realize that I was not alone and that there were many things that I could do in terms of lifestyle changes to help me stay healthy. We were also able to talk about our own experiences and share what we’ve learned about managing the disease,” Ellis explains.

Fortunately for Ellis, she listened to the advice of her physician and by participating in the workshop offered by CMH, was able to use the information shared and counselling offered to effectively manage her disease without drugs or insulin until just recently.

Not everyone shares Ellis’ experience. One of the biggest challenges associated with diabetes is disease management. When you are a diabetic with a hectic lifestyle, the need to monitor your disease can occasionally take a back seat to other more pressing priorities. Attitudes towards the disease can range from indifference to fear and agitation. Several factors support the successful management of the disease – patients need to submit to the regular care of a health care professional and take prescribed medication. They need to adopt a healthy lifestyle and mindset vital to success. As well, eating wisely, managing weight and increasing physical activity also make diabetic management possible.

Thanks to a new partnership focused on early prevention between CMH and the Trent Hills Family Health Team (THFHT), patients who need diabetic care and counselling are assured in knowing the two organizations are working closer together to provide the full scope of care and hands on assistance required to effectively manage their disease before complications develop. 

While both programs have coexisted for some time, a new, more formalized partnership between the two organizations began in April 2010.  That partnership works this way:

  • Patients see their physician at the Trent Hills Family Health team for initial screening and testing for the disease. The launch of the THFHT Diabetes Program now means that people with the disease are being identified earlier before complications develop.
  • If the disease is confirmed, then a health care professional from the THFHT contacts the CMH Diabetes Education Coordinator to book an appointment for that patient to receive counselling and education on lifestyle changes that will help monitor the disease. Previously this step was left up to the patient to complete – and often the call to book a personal appointment was delayed or not made – making it difficult to monitor the patient’s progress in managing the disease or resulting in undetected symptoms or complications due to the disease’s progression.
  • Patients participate in a 5-day disease management program offered by the hospital and receive on-going counselling throughout the year. The Diabetes Education Coordinator at the hospital will also refer the patient back to the THFHT for consultation with a dietician, foot care and other support should they require it.

Recognizing there was an opportunity to work together to more effectively manage patient referrals between the two organizations, a team comprised of medical professionals from both met to work out the necessary steps to provide patients with a full cycle of care and disease management. It was agreed that rather than leaving it up to patients to contact the hospital to book their consultation following disease diagnosis by a physician at the THFHT – that initial appointment for counselling would instead be booked by a health care professional from the THFHT. It is a simple step, but one that clearly benefits the patients supported by both organizations.

“Thanks to this approach, more people are being referred to the hospital’s diabetes education program and through the counselling they’re receiving, these patients have a better understanding of how to manage the disease and delay any long-term complications,” explains Wendy Toms, Registered Nurse and CMH Diabetes Education Coordinator, adding: “Because nurses at the THFHT are making the appointments on behalf of patients – we are more likely to see these patients in a timely way and give them the necessary guidance on managing the disease while it is in its early stages.”

“The true beauty of this partnership is the fact that the two programs are truly complementing each other, each bringing different components of disease management and support to our patients. The medical experts at the THFHT provide the diagnosis and treatment, while we provide the supporting education. Patients get a comprehensive program, including a strong follow-up system which is not always found in other programs,“ says Linda Bradshaw, Program Director of Ambulatory Care for CMH.

“This is really a collaborative approach to diabetes disease management with the patient benefiting from the full aspect of care – education and medical treatment. We’re seeing patients and making sure they get the appropriate feet and eye examinations, they receive their insulin injections and their immunization is up to date,” explains Jennifer Petherick, Diabetes Screening Program lead for the THFHT.

Now on insulin, Ellis recently received instruction on how to administer her needles from Petherick. “While I’m not happy about being on insulin, I was reassured by Jennifer and she helped me give myself my first needle. Being able to see my doctor for regular physician exams and having the support of the education provided by the hospital – both close to home – has really helped me manage my disease and feel better,” she says.

Since the changes were introduced, CMH has provided counselling on disease management to 150 new patients in the past 12 months – with up to over 343 patients now participating in their 5 day disease management program and getting follow-up care throughout the year depending on the individual and their needs.

Submitted by Jennifer Garland,  a communications consultant working with Campbellford Memorial Hospital.