Diabetes is a primary care-sensitive condition desiring a personalized approach & an ambulatory care-support system. Integrating care across disciplines around the needs of the person with diabetes has been proposed as an approach that could improve care while reducing overall cost in the long-term & increasing the quality of life in individuals. Based on this philosophy, DAY has set up a specialized diabetes care centres – Integrated Diabetes & Gestational Diabetes Clinics (IDGDC) utilizing a multidisciplinary diabetes team to provide patients with highly individualized care by integrating their skills to facilitate improved management and outcomes under a single roof. The exclusive mantra of these clinics is to encourage effective self-management and patient autonomy which is delivered by the Diabetes Educators (DE). The role of the DE is to promote and facilitate necessary behavior change across all areas of diabetes self-management based on our own curriculum from the Certificate Course in Diabetes Education (CCDE).
The objectives of IDGDC are:
- To anticipate possibilities of / recognize the onset of complications through comprehensive diabetes care
- to forestall the development of complications through effective diabetes care.
- show our impact on a paradigm shift of dealing with acute care issues to a system that is prevention based.
The IDGDC model encompasses a number of components viz.
- Medical care;
- Individualized diabetes education through counselling on Nutrition, Exercise and lifestyle coaching
- Monitoring of glucose, drug effects & analysis of the results to rectify the problems
- Device training and adapting technology to improve
The IDGDC model is based on two essential subthemes of – i) Personalized Care encompassing care environment, shared decision making and one-on-one care; and ii) Ambulatory care support from a patient-provider relationship that encompasses respect, supportive interaction and facilitating patient engagement.
Our approach encourages ongoing communication and interaction between multiple members of the care team thus ensuring comprehensive continued care of the patient leading to wellness and prevention of complications. As a corollary to such Diabetes Empowerment Education Programme (DEEP), there is this basic understanding of a holistic mission in IDGDC where referred patients are transitioned back to the care of their PCPs along with clear communication of their individual goals, results and barriers to care. If necessary, patients are also referred to the Super Specialty Department for longer term care of complications.
Our DEs help patients develop personalized diabetes management plan by imparting knowledge on pathophysiology of diabetes, care for eyes, heart health, feet and nutrition including carbohydrate counting, reading and understanding nutrition labels, healthy portion sizes, meal planning, and weight management. The DE is geared to provide all necessary information and training to allow the patient to successfully self-administer insulin and then handhold the patient till he is fully confident & capable to adjust & adapt to the new adoption strategy in life. Such patient education is imparted through individual sessions or group classes, or seminars.
Our first IDGDC became operational in _________ and its success has led to the establishment of three more clinics in ___________, ___________ and __________ in the state of West Bengal.