AGING, COMMUNITY and POPULATION HEALTH


Diabetes Action Canada continues to expand its research activities to meet the challenges of persons living with diabetes. Older adults have the highest prevalence of the diabetes of any age group. In addition, other chronic conditions such as heart disease, high blood pressure and arthritis are more common in older people. A 2012, an Ontario study from the Institute of Clinical and Evaluative Sciences found 217,446 Ontarians 65+ years had diabetes plus two or more additional chronic conditions.  Compared to diabetes alone, the addition of other chronic conditions is linked to higher mortality, reduced functionality, and increased acute care including hospitalizations.  With compelling statistics such as these, Diabetes Action Canada has partnered with McMaster University School of Nursing Aging, Community and Health Research Unit (ACHRU) co-led by Drs. Maureen Markle-Reid, Jenny Ploeg and Ruta Valaitis. The vision of ACHRU is “working together with older adults with multiple chronic conditions and their family caregivers to promote optimal aging at home.” They have launched a new specific research goal-directed program – Aging, Community and Population Health Program focused seniors living with diabetes and other chronic conditions.  

From the outset, Diabetes Action Canada has searched for opportunities to collaborate with health system researchers who design community-engagement models of care to improve health outcomes for those living with diabetes. Our collaboration with ACHRU will bridge the gap between research and direct patient care by implementing and evaluating a patient-informed approach to primary and community care for older adults.  Since 2013, ACHRU researchers have been working closely with patients, caregivers and community partners to co-develop and evaluate a novel intervention focused on improving diabetes management in community-living older adults with multiple chronic conditions.  This approach is a six-month evidence-informed intervention designed to support caregivers and integrate care across settings to improve health outcomes for seniors with diabetes. This intervention is delivered through an experienced interdisciplinary team from a primary care and a community-based organization, and consists of the following four components:

  1. Nurse-led care coordination and system navigation;
  2. Home visits by certified diabetes educators (Registered Nurses and Registered Dietitians) from Primary Care settings;
  3. Monthly community-based group sessions, jointly hosted by a community partner (e.g., YMCA) and a primary care setting;
  4. Monthly case conferences for the intervention team

Previous evidence has shown that older adults who received the ACHRU diabetes intervention in Ontario had significant improvements in quality of life – including mental health – and self-management, and a greater reduction in depressive symptoms compared to those receiving the usual diabetes care. The intervention was well received by patients, caregivers, and service providers. These improvements were achieved at no additional cost to the health system.  Preliminary evidence also suggests that the ACHRU diabetes intervention will provide benefits and be cost saving when implemented at scale.  Recently, Drs. Markle-Reid, Ploeg, and Valaitis were successful in obtaining funding to scale this program to other setting in Ontario, Quebec and PEI through the CIHR Operating Grant: SPOR PIHCI Network Programmatic Grant entitled, ACHRU Community Partnership Program for Diabetes Self-Management for Older Adults-Canada.  Diabetes Action Canada supported this grant application and looks forward to working together with the team at McMaster and their collaborators in Ontario, Quebec and PEI.

 

ACHRU Leads-Maureen Markle-Reid and Jenny Ploeg at DAC Annual Workshop 2018