1. 99.98% of the time patients are on their own “The diabetes self-management regimen is one of the most challenging of any for chronic illness.” 0.02% of the time patients are with their healthcare team The person living with diabetes must live every day with the management of this disease – there is no time off! The Burden of Diabetes: Life-long Self-management Schillinger D et al. JAMA 2002; 288:475–482.

2. Self-Management Education (SME) A systematic intervention that involves active patient participation in self-monitoring and/or decision-making

3. Elements of the Chronic Care Model 1. Delivery Systems Design: The Team 2. Self-Management Support 3. Decision Support 4. Clinical Information Systems 5. Community 6. Health Systems

5. The following quality improvement strategies should be used, alone or in combination, to improve glycemic control: Organization of Care - CPG 2013 Electronic patient registries Patient reminders Audit and feedback Clinician education Clinician reminders (with or without decision support) [Grade A, Level 1A] Promotion of self- management Team changes Disease (case) management Patient education Facilitated relay of clinical information

6. Case Management – a QI Strategy Case Managers embedded in Primary Care can promote and facilitate: Promotion and support of self-management Team changes Patient education Facilitated relay Entry point to more directed care; dietary resources (DEP and community) Social services (DEP, Mental Health, Social Development)

7. Program Objectives of Case Management Implementation in New Brunswick Provide support to both the Primary Care Providers and their patients with timely access to a Certified Diabetes Educator in the community setting. Enhancement of assessment, planning and implementation of best practice guidelines. Identify the knowledge and practice gaps of the patient with diabetes and the Primary Health Team. Recommendation of appropriate treatments, referrals, or changes to therapy and, utilizing the skills of motivational interviewing and patient empowerment, support patient self- management practices in a patient centred-chronic disease model of care

8. Evaluation: New Brunswick Health Council 51% of patients seen by Case Managers are >65 years of age: suggests a higher burden of chronic illness for this population 44% of patients seen are between the ages of 45-64 years of age: This is largely a working and busy population where early intervention for the assessment, intervention, and management of vascular co-morbidities related to diabetes will have a positive impact for future health considerations both for the patient and the health care system

9. Approximately 70% of patients followed by a Case Manager achieved an A1C between 6 & 8% and, that from 3 months prior to the first visit with a Case Manager to after one year, the mean difference in A1C was a decrease of 0.82

10. Evaluation New Brunswick Health Council Report noted that better outcomes for people living with diabetes were influenced by the following elements: Strong relationships between the patient and the team A team focus on meeting individual needs through sensitivity to values, preference and expressed needs Good accessibility and flexibility in offering services Good coordination and integration of internal team members with external team members Case Managers demonstrate high levels of patient- centred care and alignment with the Expanded Chronic Care Model that will enhance the “shared care” aspect of any Health Delivery System.