659 Dundas Street London Ontario N5W 2Z1 Tel: (519) 660-0874 Fax: (519) 642-1532 bharvey@lihc.on.ca
WINNER FOR 2002
The London InterCommunity Health Centre provides sensitive, equitable health and social services, especially to those who experience barriers to care.
Our unique approach offers a link, resource, and service model for our clients and community partners.
The mandate of LIHC is to:
·provide accessible health care to those who do not or cannot gain access to appropriate services due to linguistic and cultural barriers, poverty, isolation or other special needs;
·take a comprehensive approach in responding to health needs that consider the individual’s physical, social emotional, and financial situation;
·be proactive in maintaining and enhancing individual and community health by focusing on wellness and illness prevention, not just illness care;
·support the empowerment of individuals and communities to take responsibility for and active control of their own health and health care.
About the Innovative Winning Program
All levels of the Health care system were preparing for the 'Diabetes Epidemic':
·An estimated three million Canadians will have been diagnosed with Diabetes by 2010.
·Currently 5% of adult Canadians have been diagnosed with Diabetes, a serious health problem costing an estimated 9 billion dollars annually
·Diabetes is the 7th leading cause of death in Canadians.
Plans for the 'Diabetes Epidemic' were ignoring Canada’s Global village reality:
·The disproportionate Diabetes health Burden for certain ethnic groups was not being factored into Provincial and National diabetes planning.
·Rates of Diabetes among several Canadian ethnic populations (Latino, South-east Asian and African) are up to six times higher than the rate observed in the general population.
·Health planners were implementing a diabetes strategy that reflected the orientation of English speaking, Anglo Saxon, middle class Canadians making it largely inaccessible to these high risk ethnic groups.
·Without access to appropriate levels of diabetes care the diabetes health burden for ethnic communities is staggering.
Health care providers at the LIHC were seeing the impact of the Diabetes service gap for Latinos in particular resulting in:
·higher rates of diabetes in younger individuals
·high rates of Diabetes related complications occurring at an earlier age
·inaccessibility of mainstream diabetes services to help curb the tide of this Diabetes disaster for this group of new Canadians. Mainstream services had reached capacity serving only 17% of all of Ontario’s Diabetics with a six-month waiting list for access to diabetes education services.
·No extra funding for Diabetes education Centres (DEC) to accommodate the needs of Ethnic groups with even the basic requirement like translation.
·The diabetes care 'system' was at max and unable to accommodate the needs of Ethnic groups.
Latinos were a high-risk group in need of a targeted, comprehensive Diabetes Strategy:
·80% of Canada’s 1.5 million Latinos were living in Ontario.
·London was home to the fastest growing Latino community in Ontario.
·Latinos represented 5% (20,000) of London’s population, growing at a rate of 3-400% annually.
·With a 10% incidence rate and a 40% life-time prevalence rate for Diabetes, nearly four times the incidence & prevalence rates for Canadians in general, this high risk ethnic community was in need of a targeted diabetes strategy or risk a disaster in the years to come where as many as 40% of Latinos over age 65 will have diabetes.
·The projected cost for diabetes related kidney complications for Ontario’s 1.5 million Latino population has been estimated to be $33 million dollars.
·Fifty percent of these cases of kidney complications can be avoided with improved diabetes control at a savings of $16 million dollars.
It was essential that a strategy to address the Diabetes issue in this group be developed.
There was no extra money: Provincial health planners were overwhelmed and had no extra dollars. Stretched to the max to serving less than 17% of Ontario’s diabetics, there was no money to support any 'special interest groups.'
What were the Key Challenges or Critical Needs?
The critical need was for a cost effective of Diabetes self-care capacity development model for high-risk ethnic communities designed to address the following:
a)A linguistically, Culturally and Socially realistic program
--The mainstream approach to caring for people with diabetes was fragmented, expensive, and difficult to negotiate and did not equip our Latino patients to take on the responsibility of caring for themselves, a capacity critical to avoiding the crippling complications of Diabetes.
--A more accessible, simplified, supportive, linguistically, culturally and socially modeled approach to Diabetes care was needed if we were to help our Latino patients be able to control their diabetes and avoid the devastatingly high rates of diabetes related complications we were seeing.
--Traditional diabetes programs focus on 'education' reflecting the assumption that information is the critical requirement in order for patients to take on the complex demanding task of 'self-care.'
--In keeping with this notion, diabetes programming has a very educational orientation with specialized Nurses and Nutritionist taking on the role as educators.
--The curriculum content and delivery pace reflected the values, capacities and resources of English speaking, middle class Canada.
--This model was not working with the clients we were serving who needed more than 'education' to be able to take on their new self-care functions.
--Detailed dietary exchange information, in English, about muffins and pasta and how to handle eating out were of no value to the populations we were serving.
--To meet the needs of the population we were serving we needed a fundamentally different approach, one that focused on a simple, realistic, supportive, multi disciplinary program designed to help participants develop their capacity to care for them selves.
b)Cost effective
--Traditional models of Diabetes care were very expensive owing largely to the fact that all services tended to be offered 1:1 by high-priced professionals. For example, the mainstay of the traditional diabetes program is a 3-hour 1:1 session with a Nurse and a Dietician called a 'survival program' where the 'basics' of diabetes self care are covered. This one time 3-hour session costs $212.00 (with translation). We did not have access to this kind of money and so needed a fundamentally different approach to delivery of the services.
c)A Prevention Focus
--Recent Research has confirmed that type 2 Diabetes can be prevented if at-risk individuals can be identified and the modifiable risk factors of obesity & physical inactivity can be targeted.
--Although Diabetes experts are calling for prevention programs targeting high-risk groups, little has been done in Canada to date.
--Prevention is key to any long-term solution to the Latino diabetes issue and so it was critical that we have a Prevention focus in addition to the treatment and disease management
d)Access to Diabetes screening and timely diagnosis:
--Diabetes is a silent disease and most have had the disease for up to 10 years before there is enough damage to produce symptoms that bring the patient to the attention of their Physician.
--With the shortage of Family Physicians, many individuals us walk-in clinics and do not have access to comprehensive health care and risk not being diagnosed until the disease is well established.
--Most Canadian Physicians are not aware that Latinos have a diabetes risk profile similar to that of our First nation’s population and so do not aggressively screen their Latino patients resulting in late diagnosis.
--We needed to offer diabetes screening and early case finding reducing the risk of damage resulting from delayed diagnosis.
e)Access to Specialized Clinical Services:
--Specialize services (Endocrinologist, Nutritionists, Nurses) are essential to effective treatment and management of Diabetes and were inaccessible to our patients for a variety of reasons including language barrier, cultural issues, transportation, the challenge of negotiating a western health care system and most importantly lack of cultural capacity on the part of service providers. We needed specialized diabetes services to be more accessible.
f)Engage the Community:
--The language, images and messages used to target mainstream were not reaching the Latino community. Messages, media and images need to be adapted to the language, health belief system and social context of the Latino community.
--Diabetes carries with it a tremendous social stigma for many Latinos.
*A focus group team from London discovered this on a trip to Guatemala to study prevalence rates of Diabetes amongst Latinos. They found that Diabetics were least likely to get hired for gainful employment because of the cost of medicine to the employer, the higher incidences of premature death amongst Diabetics, and the cost of sick days to the employer. Often Latino Diabetics would lie about their health to get hired. The stigma led some families to not tell other families if their children were Diabetic for fear that no one would want to marry their children. The team also found there was a lot of confusion around 'transmission of Diabetes'. Therefore the Diabetics were singled out and ostracized from others for fear that they could 'catch' the disease from them. Providing a new image of life with Diabetes for Latinos living in the London community was critical. Diabetes conjured up frightening images from their countries of origin where without treatment they saw loved ones endure a horrible existence and premature death with diabetes. It would be essential that we communicate a new vision of what it means to have diabetes - one of hope and vitality. The message that diabetes can be prevented would also be key for the community to hear.
g)Systemic Advocacy:
--Current diabetes surveillance systems relied heavily on telephone surveys & questionnaires, data collection techniques that often miss the multi-cultural populations.
--We needed to find a way of getting multi cultural diabetes and Latino diabetes in particular on the agenda of Diabetes health planners and service providers.
--This growing, silent segment of the diabetes epidemic risked continuing to go unnoticed unless population health data could be generated to confirm to health planners that in fact we do have a Multi cultural diabetes issue that needs addressing.
The Innovation was the creation of a 'Latin American Diabetes Strategy,' a comprehensive, cost-effective, socially modeled, multi-disciplinary, community based, culturally and linguistically adapted approach to the Latino diabetes issue.
The purpose of the Latin Diabetes Strategy was to improve the diabetes outcomes for the Latino community by: Raising awareness within the community about diabetes and its prevention.
For those already living with diabetes, offering a message of hope, disease control and prevention of diabetes related complications; and finally engaging the community’s participation in the specific services offered through the strategy targeting Diabetes prevention and Diabetes complication prevention
Program Components included a:
a)community awareness campaign;
b)Saturday morning breakfast take- the- test diabetes screening program;
c)diabetes risk management & prevention program;
d)Diabetes self-care capacity development program; and a
e)satellite endocrinology diabetes clinic.
Key Innovations
a)Program delivery innovations
--The use of trained, supervised, and paid community members for program delivery was a key innovation that resulted in significant cost effectiveness, grass roots ownership and commitment, all critical to sustainability of the work.
--Within most Ethnic communities there are many health care professionals unlicensed to work in Canada but representing a huge community resource, which often goes unnoticed.
--We brought this work force together and arranged our program delivery to coincide with non-working hours so that community members would be available.
--After interviewing we matched individuals with various role functions we need for delivering the Diabetes programming and services.
--We have been able to attract 4 Physicians, 3 Nurses, a child Psychologist, and a host of other talented offshore licensed Latinos who are working in factories to support them selves and have been thrilled to be given a chance to do some healthcare related work.
--Rather than offer a volunteer honorarium we translated that very modest sum of money into a service 'contract' with average hourly rates between $8-10.00/ hr. for set program delivery times.
--The impact of paid Canadian experience versus. 'volunteer' experience was dramatic in terms of how this commitment was valued by those doing the work and by outside employees.
--Provision of top quality training and professional development for our community team or 'Lay Diabetes Health Promoters' was also an important investment.
--We used the high paid professionals (Physicians, Nurses, nutritionists) to train and supervise the lay diabetes health promoters.
We also developed unique program delivery models.
--In our prevention work offering a free breakfast on a Saturday morning has been a stroke of genius. People have very busy lives and to ask them to go for a fasting blood test that takes 2 hours to complete was not acceptable to most, greatly limiting traditional early case finding and screening approaches. We designed a service that has patients coming at 0800 a.m. on Saturday, fasting, offering a free breakfast for screening participants. It has been a smashing success at a cost of about $6.00 per person and we have screened nearly 12% of the population in the last 8 months. This program is the first non-Aboriginal diabetes prevention program in Canada and has resulted in our being sought after for consultation, including an invitation by health Canada to sit on a committee of 4 advising the National Diabetes Strategy on directions for Multicultural diabetes.
We have designed a unique approach to service delivery to Latino with diabetes.
--We have come up with a combination of a group and 1;1 service delivery model that allows us to serve 30-40 individuals in a 3-hour period compared to the mainstream model that can only serve 1-2 clients per 3-hour time block.
--Participants attend a group session then move through 1:1 Diabetes 'monitoring' station and they are sent onto other 'stations' for individualized help as necessary.
--Other 'stations' include a Nutritionist, specialized Diabetes Nurse, foot car specialist or social worker.
--Clinical issues identified at the monitoring station are referred back to the patient’s family Physician.
--With this model of service delivery we have been able to serve more patients at a fraction of the cost of mainstream programs. Our program costs $18.00 per person per visit compared to $212.00 per person per visit in the mainstream program models.
Note: Our unique program model has been identified by the Ontario Ministry of Health as a demonstration model for community-based diabetes programming for high-risk populations. Several regional health authorities in Ontario are adapting our model for use in their districts and we have several satellite programs in operation (Hamilton, Kitchener) in communities serving large Latino populations.
b)Program model innovation
--Traditional models of diabetes care provide medical consultation, a one-shot diabetes education session and the rest is up to the patient.
--Access to Physicians, diagnostic testing and therapy is not enough, individuals need to have food, money to buy medicines, money for bus tickets to get to the Medical appointment and a myriad of things the traditional systems assume all Canadians have in place.
--Many of our ethnic communities in Canada, through the Refugee or immigration experience, have lost everything, status, family supports and are the 'working poor' without drug plans, stressed, alone and isolated by language and cultural barriers.
--Our model of diabetes care provides the support of a multi-disciplinary team and is achieving improvement in diabetes outcomes that have brought our program national attention.
--Most Diabetes care models are 'medically' modeled, a model which risks treating the disease and ignoring the social context and broader determinants of an individual’s health with diabetes.
--We have designed a more inclusive, comprehensive model of diabetes care delivered by a multi-disciplinary team in this way ensuring that the broader determinant of health (food, shelter, supports, employment, financial support etc.) is built into our approach.
--For example, in a Medically modeled approach the patient would be given a prescription but there would be no determination or help available to ensure that the patient had the resources to purchase the medicine.
--In our system, we systematically assess the 'determinants of health' at each visit and have the support team to mobilize if a patient is found not to have the resources to pay for medication, or has lost their job, or housing or some other key element of that individuals capacity to care for themselves.
--Our services are available for ongoing support through a once a month format allowing patients to come back as often as they need or return whenever they need
--The cost of attending our 3-hour per month service every month (36 hours total) for a year is only $4.00 more than one 3-hour session in the mainstream system.
Another innovative aspect of our model is:
--The fact that we have diabetes specialists (endocrinologists etc) coming to our clinic supported by our multi-disciplinary team and have created access to services other wise not available to our clientele. The exchange of knowledge, skill and expertise between the specialist and our team has been fantastic and has impacted capacity on both sides.
Another area of innovation is in our self-care regime.
--We have developed a very simple self-care regimen that involves no food exchanging, carbohydrate counting or forbidden food lists. At their first visit participants are given a home glucose testing meter and are taught how to use their after meal results to evaluate their food choices and adjust their food selections in order to keep their blood glucose within range. No foods are forbidden, greatly enhancing patients’ sense of well being and quality of life compared to traditional care models which require complicated often overwhelming food exchange systems that involve measuring calculating the carbohydrate content of every meal.
--Our approach allows individuals to continue to eat their traditional foods while adjusting portion size and selections to keep there after meal blood glucose levels within a healthy range.
--Traditionally home glucose blood testing has been reserved for patients on Insulin.
--Providing patients with an immediate system of feedback was key to helping individuals’ make healthy decisions and maintain control.
--We also are unique in that we teach our patients to test 1-2 hours after eating, once per day, at different meal times each day.
--The after meal test results are most closely correlated with achieving glucose control and avoiding diabetes related complications and so serve as a better barometer for the patient for how they are doing balancing food, activity and medications.
--We teach patients to eat what they want but to keep their after meal blood sugar less than 10 mmol/L. If their level is above 10 then they must go for a walk to bring their blood sugar level down and they must examine their food choices and portions and make adjustments in any starchy foods next time they eat that meal.
--The daily testing helps individuals remember that they have diabetes and helps to keep them on track compared to patients who do not test blood sugars.
--The use of home glucose monitoring has been a key innovation and success factor in our program.
Specific Clinical Outcomes
--Large trials in the United Kingdom and the United States have confirmed that tight blood sugar control is key to preventing the devastating vascular complications of Diabetes.
--As a result we have developed a model of care that is simple, inexpensive to deliver and is effective for reducing diabetes-related complications.
--This program measures the amount of glucose that has accumulated on red blood cells in the preceding 3 months using the "gold standard" HbA1c lab test to evaluate our participants we reported:
a)an average 11% - 15% drop in their HbA1c within their first 6 visits (6 months time) to our program.
b)98% of program participants were brought within the "ideal" HbA1c range.
c)for each 1% drop in HbA1c, heading toward the "ideal" range, there is a 12% decrease in cardiovascular risk. The 11%-15% drop in HbA1c achieved by our participants translates in a dramatic 60-80% reduction of cardiovascular risk. Most diabetes medications on the market only achieve a 1-2% drop in HbA1c.
We are also able to report that:
--health care savings for these individuals and families with Diabetes in our program is dramatic and comes at a cost savings of $18.00 per month!
--of the 48 individuals that we have continued to follow over the past 3 years ALL have been able to maintain their HbA1c within the ideal range, suggesting that our model assists individuals to achieve long-term improvements in their diabetes control and complication prevention.
--participants in our program have also achieved clinically significant improvements in blood pressure control, weight loss, cholesterol, walking behaviors, self-care behaviors (home glucose testing, attending medical follow up, annual eye exam etc.)
The clinical outcomes for our program are attracting a great deal of attention.The program is being featured for the second year in a row at the National Canadian Diabetes Convention.
