HOW IT WORKS
This program targeting older, diabetic adults living in the community embraces a patient-centered approach to care delivery, with a focus on self-management and patient engagement in developing care goals and decision-making. Patients enrolled in this current randomized controlled trial (RCT) do not have a need for palliative care and either have acceptable cognitive function or rely on a capable decision-maker. Premised on inclusiveness, the program accepts diverse patients with different needs. Potential participants are identified based on written or electronic medical records. If patients are randomized to receive the intervention, the program team connects with community partners. CPP works closely with a variety of social service providers. Nurses play a key role in communicating patient information to providers, acting in the role of a navigator or care coordinator. Care delivery includes in-home visits. The program also assesses the needs of caregivers.
This program has admitted 145 patients since 2012. It is awaiting additional funding to scale up to serve the same population, but with more flexibility. CPP aims to learn how to adapt the intervention to other regions in Canada. The ongoing RCT is being conducted across six sites.
Primary care providers are responsible for managing the care needs of patients. Other providers can include nurses, dieticians, kinesiologists and pharmacists. These providers communicate regularly with family doctors, other specialists, and social service providers. Nurses play a key role in navigation and care coordination. They follow up with patients during transitions and share information among providers. All providers are trained to use the same assessment tools.
CPP’s governance model has an embedded role for patients, with caregivers serving on the steering committee. There also is a patient and family advisory council. Patients and caregivers are coinvestigators on the grant and provide program feedback. CPP requires an assessment of caregiver needs so the program can help empower and support them.
The innovative staffing model features nurse navigators. Interorganizational arrangements are encouraged across primary care and community-based agencies, such as community centers. The program also mandates active information-sharing, supported by the new nurse navigators.
Initial funding has been supported by a research grant. No new net operational funds have been provided to sites for implementation. This initial program has highlighted an increased need for the presence of primary care providers in the community. Health care providers are being deployed in novel ways, collaborating with community service providers and recreation centers to meet peoples’ needs.