The epidemic of diabetes has increased pressure on specialized services. At the Foustanellas Endocrine and Diabetes Centre (FEDC) of The Ottawa Hospital, there are approximately 20,000 patient visits per year for diabetes and a wait list of approximately six months for routine consultations. Seeing patients in follow-up reduces the capacity for seeing new referrals, and wait lists grow. It is essential to improve the transition of stable patients back to their primary care provider to reduce the log jam in multidisciplinary clinics.
The Tools For Transitionâ˘ (TFTâ˘) Program was initiated to develop and evaluate tools to facilitate the transfer of patients with type 2 diabetes from FEDC specialist care back to the care of their primary care physicians (PCP) once diabetes management was optimized.
An extensive needs assessment/environmental scan was completed to gain a thorough understanding of the needs of all stakeholders â PCP, specialist team members and patients. This included PCP surveys and focus groups, a specialist team survey and chart audit. Semi-structured interviews with patients are underway at present. Results of a survey of 177 PCP, focus groups with 22 PCP, a survey of 23 specialist team members and the audit of 199 diabetes clinic charts have been published or presented at national conferences. Based on our work and an extensive review of the literature, a set of 5 tools for transition were developed.
The Tools For Transitionâ˘ tool set includes:
Since July 2010, each tool in the Tools for Transitionâ˘ tool set has been progressively implemented as a quality improvement project at the Foustanellas Endocrine and Diabetes Centre as follows:
Tool #1 – Structured, Customized Discharge Consult Letter: The template for this discharge consult letter is being used by the endocrinologists at the Foustanellas Endocrine and Diabetes Centre (FEDC) when dictating letters to Primary Care Physicians (PCP) of patients with type 2 diabetes at discharge. Unique features of this discharge consult letter:
This tool was pilot tested in July 2010 and fully implemented in September 2010.
Tool #2 – Rapid Re-entry Process and Rapid Re-entry Form: The Rapid Re-entry Process was implemented simultaneously with Tool #1 and includes 2 options for the PCP should they have a question or concern about a patient with type 2 diabetes they have received back from the FEDC. The 2 options are found at the end of the discharge consult letter. Option #1 is to use the section included in the letter to fax in a question to the specialist. Option #2 addresses the PCPâs wish to have the patient reassessed at the FEDC. The PCP will then use the Rapid Re-entry Form. This form is attached to each discharge consult letter sent to the PCP and it can also be uploaded from The Ottawa Hospital website.
Tool #3 – Multidisciplinary Diabetes Self-Management Progress Report: This report will be completed by the Diabetes Nurse Educator and Diabetes Dietitian Educator involved in the patientâs care and sent to the PCP as an interim report as well as when the patient is discharged from their care. Unique features of this progress report:
This tool will be pilot tested starting in April 2011.
Tool #4 – Diabetes Clinic Discharge Note (to the patient): This tool is a structured, customized discharge note completed by the endocrinologist at the patientâs last clinic visit and given to the patient. Patients will be encouraged to bring the note to their PCP to promote ongoing monitoring and follow-up of diabetes. This tool was pilot tested in October 2010 and fully implemented in March 2011.
Tool #5 – A 3-month Reminder Post-card: The 3-month Reminder Post-card is being mailed to patients 3 months post-discharge from the FEDC to remind them of the need to set an appointment with their PCP for follow-up diabetes care as well as what needs to be done to prepare for the appointment. This tool was implemented in December 2010.
Several evaluation projects are either underway or planned to assess the feasibility and effectiveness of the Tools For Transitionâ˘ tool set. For example:
Program Initiator and Steering Committee Chair:Â Dr. TC Ooi
Project Lead:Â Julie Maranger
Steering Committee Members:Â Dr. Erin Keely, Dr. Janine Malcolm, Dr. Clare Liddy, Dr. Monica Taljaard, Dr. Nadia Malakieh, Dr. Robert Reid, Sharon Brez, Sheryl Izzi, Kerri Cook
Past members:Â Dr. Christine Harrison, Dr. Chetna Tailor, Dominique Gendron, Edith Clouthier, Dr. Margo Rowan
TFTâ˘ Program has been funded through unrestricted educational grants from Novo Nordisk Canada Inc., LifeScan Canada Ltd., Merck Frosst Canada Ltd., Schering-Plough Canada Inc. and Merck Frosst/Schering Pharmaceuticals.
We received valuable advice from a panel of Primary Care Physicians consisting of Dr. Caroline Knight, Dr. Judy Chow, Dr. Monica Brewer, Dr. Lisa Rosenkrantz and Dr. David Montoya.
Dr. Jeremy Grimshaw acted as a consultant to the Tools For Transitionâ˘ Steering Committee.
For more information on the Tools For Transitionâ˘ Program, contact Julie Maranger, Tools for Transitionâ˘ Program Coordinator, email@example.com.