NARRARIVE LITERATURE REVIEW AND GAP ANALYSIS OF DIABETES
SERVICES IN A COMMUNITY SETTING
by
Jennifer Shaw
BSCN, University of Victoria, 2004

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
February 2021
© Jennifer Shaw, 2021

ii
ABSTRACT
The goal of this project was to outline best practices regarding the organization of diabetes care and
services in the community in relation to the local context of services in Squamish, BC, Canada to
create a foundation for future quality improvement work. The theoretical framework of personcentered care is essential to chronic disease management and underpins this work. The methods
include: 1) A narrative literature review consisting of a database search, and 2) A gap analysis
consisting of local data and an environmental scan. The Chronic Care Model is an evidence-based
integrated care framework used to organize the findings of the narrative literature review and the
gap analysis and to frame the recommendations (Clement et al., 2018). Based on the findings,
evidence-based recommendations were created specific to the context of diabetes care in Squamish,
BC creating the opportunity for meaningful future quality improvement work.

iii
TABLE OF CONTENTS
Abstract

ii

Table of Contents

iii

List of Tables

iv

List of Figures

v

Chapter 1

Introduction
Positioning Self in the Context
Purpose of the Project

1
3
4

Chapter 2

Background

6

Chapter 3

Theoretical Framework

14

Chapter 4

Narrative Literature Review
Methods
Findings
Discussion

17
17
19
33

Chapter 5

Gap Analysis
Local Context
Methods
Findings
Discussion

40
40
42
45
54

Chapter 6

Conclusion
Recommendations

63
65

Chapter 7

Reflection

71

References

72

Appendix A

Narrative Literature Review Matrix

86

Appendix B

Environmental Scan Results: Community Resources

98

Appendix C

Semi-Structured Interview Questions

102

Appendix D

Preparation Timeline for the Key Stakeholder Meeting

103

Appendix E

Sample Email Invitation

104

iv
LIST OF TABLES
Table 1

Inclusion and Exclusion Criteria

19

Table 2

Number of Diabetes Referrals to Home Health in 2020 by Month 46

Table 3

Recommendations and Evidence

65

Table 4

Agenda for Stakeholder Meeting

70

v
LIST OF FIGURES

Figure 1

Age-Standardized Prevalence per 100 Population for Diabetes

10

Figure 2

Age-Standardized Incidence per 1,000 at Risk for Diabetes

10

Figure 3

A Model for Effective Chronic Illness Care

22

1
CHAPTER 1
Introduction
Diabetes is a one of greatest growing health challenges worldwide with the global
prevalence growing from 4.7% in 1980 to an estimated 8.8% of the population in 2020
(International Diabetes Federation, 2019; World Health Organization, 2020). The World Health
Organization (WHO) (2016a, 2002) advocates for a shift away from the current organization of
health care systems where patients are passive recipients of care to an integrated person-centered
approach. Current health care systems are not organized to support chronic disease management;
systems are fragmented, disease-centric and oriented to acute problems (World Health
Organization, 2016a, 2016b, 2002). In order to achieve high quality, effective and cost-efficient
care, chronic disease management requires patients to become active collaborators in integrated
systems (Goodwin et al., 2012). This person-centered approach is critical to improvements in
diabetes management and therefore, is the key theoretical perspective framing this project (BC
Ministry of Health, 2015c).
Type 2 diabetes is a largely preventable and treatable condition requiring multifaceted
care occurring predominantly in primary and community care settings (Diabetes Canada Clinical
Practice Guidelines Expert Committee, 2018; International Diabetes Federation, 2019). There is
significant research and literature supporting best practices in diabetes care; however, there is no
standardized framework for the delivery of care in BC, Canada (Diabetes Canada, 2019).
Furthermore, rural communities often lack services associated with improved outcomes for type
2 diabetes such as multidisciplinary team-based care and specialized diabetes care services
(Ricci-Cabello et al., 2013). Competing priorities for resources have resulted in changes in how
diabetes care is delivered in Squamish, BC – a rural community situated 64 km from Vancouver.

2
A potential gap in services for type 2 diabetes management prompted this inquiry into
understanding: What evidence-based standards exist regarding the organization of diabetes care
and services, what services are we currently providing in Squamish, BC, and finally, what
recommendations can be made to enhance the quality of care?
This paper consists of a narrative literature review and gap analysis. The narrative
literature review outlines current themes regarding how diabetes care is organized and delivered
for optimal outcomes in a rural community setting. The review sets the foundation for a gap
analysis between the current services offered in the community and the desired state of diabetes
care in Squamish. The gap analysis includes local data and an environmental scan to provide
context to the current state of diabetes care and to identify community resources beyond the
services provided by the Home Health program in Squamish. The findings are organized under
the six elements of the Chronic Care Model created by Wagner et al. (1999): self-management,
delivery system design, decision support, clinical information systems, community resources and
health system organization. This model is an evidence-based framework designed to support
quality improvement efforts to optimize chronic disease management (Clement et al., 2018;
Wagner et al., 2001). The Chronic Care Model is one of the most widely adopted integrated care
models to improve outcomes for individuals with chronic disease (World Health Organization,
2016b). Optimization in each of the six elements of the model are associated with improved
diabetes outcomes (Clement et al., 2018; Elissen et al., 2013b).
Recommendations were developed based on the results of the literature review and gap
analysis and create the foundation for future quality improvement work. Part of the key
recommendations include future work to integrate the perspectives of community members
living with type 2 diabetes and key stakeholders. This is planned via a focus group session and a

3
key stakeholder meeting. This participatory planning allows community members and
stakeholders to be collaborative partners in reorienting care to a person-centered integrated
approach.
Positioning Self in the Context
Working as the clinical resource nurse (CRN) for the community home health team in
Squamish, BC, I was placed in the unique position where I was aware of the potential gap in
diabetes services for the community, yet I was not directly responsible for the care of clients with
diabetes. This awareness led to a responsibility to support any required change to improve
diabetes services. I was fortunate to be working alongside many of the key stakeholders
responsible for diabetes care services such as the community dietician and the manager for the
community Home Health program. This allowed for conversations regarding the current state of
services and what they imagined as ideal. Since my area of practice was focused on supporting
the role of the community health nurses who were not directly involved in diabetes management,
I felt less attached to the results of the gap analysis and quality improvement ideas. I was able to
maintain a curious attitude. Without a professional background in diabetes care, I had little
experience from which to begin the project, but this also provided less bias. Therefore, the
literature review began as a broad discovery of the guidelines, concepts and themes that govern
and influence diabetes care around the globe, and then focused on utilizing the Chronic Care
Model as a framework to further refine the search. Reflexivity still remained key as ideas and
conversations evolved. Referral rates for diabetes services were requested from the program
manager and dietician to provide context and scope to the problem. As part of the role of CRN, I
had access to the electronic medical record (EMR) and the DASH: Decision Analytics Solutions
for Health website from Vancouver Coastal Health to obtain local data on referral rates. No

4
personal identifiers were included, and the data is presented without jeopardizing anonymity to
maintain confidentiality. While informal team dialogue and emerging data highlighted the need
to improve diabetes care services in Squamish, competing priorities throughout the COVID19
pandemic have made more structured key stakeholder engagement challenging. Management and
physician groups have expressed enthusiasm to improve diabetes services but have lacked
commitment to participate in planning meetings. This was frustrating as I envisioned the project
to be more participatory when identifying gaps in service and planning recommendations;
however, community member and key stakeholder involvement will occur once there is the
opportunity, and their involvement has been outlined in the recommendations. My role allows
for continued attempts to spark interest in my colleagues to improve our services by addressing
gaps identified in this project and to remain accountable to our community to optimize diabetes
care.
Purpose of the Project
The burden of chronic disease is considerable and requires a proactive approach to
support people over long periods of time rather than reactive acute and episodic care (Reynolds
et al., 2018). This long-term approach makes investing in reorienting health policy and health
care for chronic conditions such as diabetes in the community and primary care a priority for
innovative health care. This shift is promoted by the World Health Organization, International
Diabetes Federation and Diabetes Canada and grounded in person-centred care (Diabetes Canada
Clinical Practice Guidelines Expert Committee, 2018; International Diabetes Federation, 2019;
Reynolds et al., 2018; World Health Organization, 2002). The suspected gap in diabetes services
offered in the community and rising diabetes incidence rates prompted this inquiry into diabetes
care services within Squamish. The purpose of this paper is to lay the foundation for a quality

5
improvement project to improve diabetes care by addressing service gaps in Squamish. The
theoretical lens of person-centered care underpins the work of this project. The paper includes: 1)
a narrative literature review to identify elements that contribute to effective diabetes care
organization and delivery in a community setting using the Chronic Care Model as a framework
to organize the findings; 2) a gap analysis including local data to identify what services are
currently offered by the Home Health program in Squamish, community resources outside
Squamish as well as local policies and service plans; 3) recommendations for future quality
improvement work including a focus group and key stakeholder meeting to address service gaps
and optimize diabetes care and services for people living with diabetes in Squamish. This project
is focused on community-based diabetes support and management delivered in Squamish, BC;
however, there is the opportunity to expand the results and recommendations of this project to
support the Sea to Sky corridor including the communities of Squamish, Whistler, Pemberton
and Mount Currie.

6
CHAPTER 2
Background
The following section outlines the global, national and local context of diabetes. The
impact and different types of diabetes are noted while type 2 diabetes is the focus and examined
in greater depth. Wider global data is narrowed to the Canadian and provincial context.
Impact of Diabetes
The International Diabetes Federation (IDF) (2019) quantifies diabetes as one the fastest
growing health challenges of this century with the number of adults living with diabetes having
more than tripled over the last 20 years. Therefore, with approximately 9% of adults living with
diabetes around the world this equates to 463 million people. This rapid increase has surpassed
the original projections from the IDF (International Diabetes Federation, 2019) . In 2010, the
IDF projected 438 million or 7.8% of the adult population worldwide to have diabetes in 2030,
these projections have been exceeded by 2019 (International Diabetes Federation, 2009).The
majority of the increase is due to type 2 diabetes (International Diabetes Federation, 2019).
Type 1 diabetes is an autoimmune disease with unknown etiology influenced by people’s
genotype and environmental factors (Diabetes Canada Clinical Practice Guidelines Expert
Committee, 2018; International Diabetes Federation, 2019). Whereas developing type 2 diabetes
is influenced by several factors including obesity, ethnic background, family history, and
environmental factors (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018;
International Diabetes Federation, 2019). Type 2 diabetes usually develops in adulthood, but it is
increasingly prevalent in young adults and youth (International Diabetes Federation, 2019). The
rise in related type 2 diabetes risk factors in youth and adults including unhealthy eating habits,
physical inactivity and obesity correlate with this increase in prevalence (International Diabetes

7
Federation, 2019). Preventive medicine is not a factor in the management of type 1 diabetes
since the underlying cause remains unclear; however, for type 2 diabetes the WHO clearly offers
“close to 90 per cent of type 2 diabetes cases can be prevented” (Diabetes Canada, 2019, p. 2).
Evidence to support strategies to prevent or even delay type 2 diabetes include: healthy
behaviour interventions, such as physical activity and weight loss, certain dietary patterns and
pharmacotherapy (Houlden, 2018).
Both type 1 and type 2 diabetes carry a significant disease burden, but because of the
different underlying factors that influence type 2 diabetes and the greater prevalence around the
globe, type 2 is the focus of this project. Self-management is a key concept to promote personcentered, culturally appropriate strategies tailored to the individual and community which is
linked to both prevention and management of this chronic condition. Many factors play a role in
the development and management of type 2 diabetes including social and economic factors.
These examples of the social determinants of health are important elements influencing health
care outcomes and ongoing patient self-management decisions (Dinca-Panaitescu et al., 2012).
Factors such as social inclusion, education, and health literacy are examples of how variations in
the social determinants of health can further influence health outcomes. While necessary to
recognise and address the impact the social determinants of health have on type 2 diabetes care
and patient outcomes, an in-depth focus on the social determinants of health is outside the scope
of this paper.
The impacts of diabetes on the wellbeing of individuals, families and communities are
considerable. Complications from type 2 diabetes include hypoglycemia, diabetic retinopathy,
nephropathy, neuropathy and cardiovascular disease (Diabetes Canada Clinical Practice
Guidelines Expert Committee, 2018; World Health Organization, 2020). Furthermore, diabetes

8
has grave consequences on major biological systems and “contributes to 30 per cent of strokes,
40 per cent of heart attacks, 50 per cent of kidney failure requiring dialysis, 70 per cent of nontraumatic lower limb amputations and is a leading cause of vision loss” (Diabetes Canada, 2019,
p. 2). Diabetes is the third highest modifiable risk factor for premature mortality after
hypertension and smoking (Houlden, 2018; International Diabetes Federation, 2019). Diabetes is
also closely linked to mental health conditions with 30% of individuals with diabetes at risk of
developing clinical depression, and conversely people with depression have a greater than fifty
percent chance of developing type 2 diabetes (Diabetes Canada, 2019; Houlden, 2018). The
impact of diabetes related complications on premature mortality and quality of life also result in
a significant economic impact for countries and their health care systems (International Diabetes
Federation, 2019).
The International Diabetes Federation estimates global diabetes related health
expenditures to result in the equivalent of 760 billion USD (International Diabetes Federation,
2019). In Canada alone, diabetes contributes to thousands of preventable hospitalizations every
year (Diabetes Canada, 2019). Over an individual’s lifetime, diabetes and its complications place
a significant burden on Canada’s publicly funded health-care system as a result of the direct cost
of treatment, the increased acute and community care services use, the loss of social productivity
in the workforce, and the increased need to finance pharmacological or other support aids
(Houlden, 2018). Despite individual’s with diabetes having access to diagnosis and treatment
options as part of a publicly funded health care system, inequalities in service provision exist
(Ricci-Cabello et al., 2013). The variation in treatment options available to individuals with
diabetes, their caregivers and the wider community results in less than optimal care for some
Canadians, especially for vulnerable and high risk groups of individuals such as Indigenous

9
peoples (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018). This challenge
is exemplified in smaller and more rural communities as diabetes education programs and
multidisciplinary diabetes care teams are absent or more difficult to access when compared to
larger urban centers (Ricci-Cabello et al., 2013).
Global, National and Local Context
The International Diabetes Federation (2019) quotes the global prevalence of diabetes in
urban areas as 10.8% and in rural areas it is lower, at 7.2%, this gap however, is closing, with
rural prevalence on the rise. In 2017, 7.3% of Canadian adults reported being diagnosed
with diabetes (Statistics Canada, 2018b). In addition, Canadians have high rates of associated
risk factors that contribute to type 2 diabetes: For example, only 2 out of 10 Canadians meet the
Canadian physical activity guidelines and 63.1% of Canadian adults are considered overweight
or obese (Public Health Agency of Canada, 2016; Statistics Canada, 2019). The prevalence of
diabetes within our BC communities is consistent with these changes, it is increasing.
Approximately 8% or 460,000 British Columbians have diabetes with 29,000 individuals newly
diagnosed in 2017/18 (BC Centre for Disease Control, 2020). Diabetes Canada (2019) estimates
the cost to the provincial health care system is an average of $509 million per annum. This rise is
likely reflected in the Sea to Sky corridor within the mainly rural communities of Squamish,
Whistler, Pemberton and Mount Currie.
Population data specific to diabetes rates is not available for the community of Squamish,
but available for the Health Service Delivery Area of North Shore/Coast Garibaldi region from
the BC Centre for Disease Control (BCCDC); this region includes the communities of North and
West Vancouver, Squamish, Whistler, Pemberton, Mount Currie, Bella Coola Valley, Sunshine
Coast and Powell River (BC Ministry of Health, 2018). North Shore/Coast Garibaldi covers

10
51,800 square kilometers with a total population of 284,000 in 2016 (Statistics Canada, 2017).
Overall, North Shore/Coast Garibaldi is a healthy community with lower rates of chronic
diseases such as diabetes when compared to all of BC (PHSA, 2019). In 2017/18, diabetes
prevalence rates in the North Shore/Coast Garibaldi region were 6.25% compared to 8.03% for
all of BC (see Figure 1) (BC Centre for Disease Control, 2020). When you consider the
population of Squamish reported as 20,404 in 2019 (BC Stats, 2019) with a prevalence of 6.25%,
the total number of adults living with diabetes in the community equates to approximately 1,275
individuals.
Despite having lower rates of chronic disease, in order to understand a population risk for
diabetes over time, it is important to consider annual incidence rates. The incidence rate refers to
the number of new diagnosis during a period of time. Interestingly, although the rise in
prevalence for North Shore/Coast Garibaldi has mirrored the rise in prevalence in BC, the
incidence rates are increasing at a higher rate in North Shore/Coast Garibaldi (see Figure 2) (BC
Centre for Disease Control, 2020). From 2014 to 2018, the rate of diabetes increased from 4.26
to 5.5 per 1,000 people in North Shore/Coast Garibaldi (BC Centre for Disease Control, 2020).
In 2019, with an incidence rate of 5.5 per 1,000 population at risk, there would be an estimated
112 people newly diagnosed with diabetes in Squamish (BC Centre for Disease Control, 2020).

11
Figure 1
Age-Standardized Prevalence per 100 Population for Diabetes

Rate (per 100 population)

Age-Standardized Prevalence per 100 population for
diabetes

2014/2015

2015/2016
BC

2016/2017

2017/2018

North Shore/Coast Garibaldi

Figure 2
Age-Standardized Incidence per 1,000 at Risk for Diabetes

Rate (per 1,000 population at risk)

Age-Standardized Incidence per 1,000 at risk for diabetes

2014/2015

2015/2016
BC

2016/2017

2017/2018

North Shore/Coast Garibaldi

12
Note: Data was collected for the North/Shore Coast Garibaldi region as there is no data specific
to the community of Squamish where the quality improvement project will be taking place.
Diabetes prevalence data varies from the sources used to collect the data. The BC CDC uses data
collected from the BC Ministry of Health including Registration and Premium Billing (R&PB),
HealthIdeas Fiscal Year Client Roster, Medial Service Plan (MSP) Physician Billing Data,
PharmaNet Drug Dispensing History, and Hospital Discharge Abstract Databases (DAD);
whereas, Statistics Canada diabetes rates are collected from the Canadian Community Health
Survey (Statistics Canada, 2018a). Data for figure 1 and 2 are from the BC CDC chronic disease
dashboard (BC Centre for Disease Control, 2020)
The variations in prevalence and incidence demonstrate the complex nature of the
disease. Furthermore, health care providers need to recognize the importance of understanding
the community’s needs as they may differ significantly from other community profiles and
understanding the causative and contributing factors.

13
CHAPTER 3
Theoretical Framework
The theoretical perspective of person-centered care is a key attribute in chronic disease
management (BC Ministry of Health, 2015c; Canadian Academy of Health Sciences, 2017). Yet,
despite a person-centred approach being well described in health care literature, the paradigm
shift from a paternalistic medical model where the patient is a passive recipient of care to an
empowered active participant continues to evolves and requires deliberate inclusion when
reorganizing health services (Olesen et al., 2020; Pulvirenti et al., 2014). Person-centered care is
described by Epstein and Street (2011) as a “quality of personal, professional, and organizational
relationships” (p 100) that requires care to be centered around the person, their families,
clinicians and health systems. It is a concept promoted in clinical practice and examined in
research paradigms, thereby a bridge across the theory-to-practice gap (Santana et al., 2018).
Therefore, person-centered care provides a conceptual framework underpinning the current
project. In this chapter, person-centered care is defined, and explored in relation to current work
in chronic disease management and diabetes care to provide the theoretical context for the
project. While the term person-centered is used throughout this document, various terms such as
patient-centered and client-centered are used in the literature to represent the concept of care
centered around the individual.
Person-centered care is grounded in the work of Carl Rogers (1951) in humanistic
psychotherapy. Rogers saw the value of therapeutic relationships where the patient’s capacity for
self-direction was respected and nurtured. Santana et al. (2018) suggest the conceptualization of
person-centered care originated with the work of Edith Balint in 1969 that acknowledged the
patient as a unique individual. Person-centered partnerships promote self-esteem and self-

14
efficacy and are therefore key in the self-management for individuals with chronic disease
(Morgan & Yoder, 2012). Person-centered, caring relationships have become central to nursing
practice; however, the shift away from a paternalistic model of health systems continues to
require purposeful effort and is noted as an integral concept at a global and local level.
The World Health Organization (WHO) (2016a) Framework on integrated, peoplecentered health services outlines the need “to reorient health services, putting individuals,
families, carers and communities at their centre” (p. 3). The WHO (2016a) emphasizes the need
to move away from hospital-based and curative care models in order to obtain equitable, highquality and financially sustainable care. This shift focuses on empowering and engaging
individuals thereby creating the opportunity for individuals to become active participants in their
care, making choices and directing care specific to their needs.
The Canadian Academy of Health Sciences (2017) was commissioned by Veteran Affairs
Canada to create a report on the best practices and new and emerging trends in the care of
chronic diseases. One of the five key messages focused on patient-centered care: “patientcentered primary care is required for the effective management of chronic health conditions to
ensure comprehensiveness, coordination and continuity of care” (Canadian Academy of Health
Sciences, 2017, p. 3). This emphasis on the value of person-centered care for optimizing chronic
disease management necessitates its inclusion when planning and implementing diabetes
services.
At a provincial level, person-centered care is also central to BC’s health care priorities.
Person-centered care is identified as the first of eight priorities in the BC Ministry of Health
Strategic Plan (BC Ministry of Health, 2014). A person-centered care framework was created by
the BC Ministry of Health (2015b) “to build on existing efforts and accelerate the adoption of

15
patient-centered care practices in B.C. by creating a common understanding of what patientcentered care is and a shared vision for adopting patient-centered care” (BC Ministry of Health,
2015c, p. 1). Adopting person-centered care means shifting current health system priorities from
disease-centered and provider-focused to person-centered care (BC Ministry of Health, 2015c).
The framework is built on the principles of dignity and respect, information sharing,
participation and collaboration.
A distinction between person-centered care and patient-centered care is important
because person-centred care honors the notion of the person, from a holistic perspective
including the person’s context, preferences and beliefs (Santana et al., 2018). Whereas patientcentered care reduces the person to their role as patient with a focus on their illness or disease
(Santana et al., 2018). Santana et al. (2018) created a conceptual framework to support health
care organizations to integrate person-centered care into practice. The framework identifies
practical implementation strategies to reorient health system structures and health care provider
interactions resulting in high quality person-centered care and improved health-care system
efficiency and effectiveness (Santana et al., 2018). In order to prevent losing sight of the person
in the service, strategies include creating a person-centered culture that values patient
engagement, co-designing education and health promotion programs with key stakeholders and
community members, integrating clinical information systems to coordinate and share
information across providers and patients, engaging patients in the management of their care
through shared decision-making and setting goals, cultivating respectful communication through
listening and sharing information, and creating culturally sensitive care that respects the beliefs
and preferences of individuals (Santana et al., 2018). When integrating a person-centered
approach to care, the impact on outcomes can be measured with Patient-Reported Outcome

16
Measures (PROMs), Patient-Reported Experience Measures (PREMs) and Patient-Reported
Adverse Outcomes (PRAOS) (Santana et al., 2018).
Even with good intentions, it is easy to develop programs or organize care around the
needs of the provider or to accommodate the current system in which care takes place. Therefore,
there is a need to overtly acknowledge adopting a person-centered approach to avoid system or
provider focused models of care. This creates the opportunity for improved patient care
experiences and improved chronic disease management (Olesen et al., 2020; World Health
Organization, 2016a).

17
CHAPTER 4: NARRATIVE LITERATURE REVIEW
Methods
The intent of a narrative literature review is to describe and synthesize key literature
pertaining to a specific area of interest (Green et al., 2006). A narrative literature review
methodology was chosen for this project since the goal was to identify and summarize best
practice regarding the organization of diabetes care in a community setting. A narrative literature
review is not a formative appraisal of the evidence typical in a systematic review, but a synthesis
of peer reviewed evidence-based literature collated to describe the current state of knowledge,
practice, or care delivery (Ferrari, 2015). Further, a narrative review has a place in emerging
quality work since this approach has value in education by providing the audience with up-todate knowledge about a specific topic, here type 2 diabetes care in rural contexts in BC, Canada.
Therefore, narrative methodology was used since the focus of the project was to compare the
current state of diabetes care in the community of Squamish with current best practice standards
and governing principles in type 2 diabetes management, in order guide future local service
improvements. A systematic approach to examining the literature was adopted in order to ensure
that peer-reviewed literature and grey literature informed future discussions.
The first step in writing a narrative overview is to perform a preliminary search of the
literature to identify work published on diabetes care management in the community. An initial
literature search was conducted using CINAHL, Medline, and PubMed. The term ‘diabetes’ was
used with the Boolean operator AND with the terms ‘service delivery’, ‘care delivery’,
‘organization’ or ‘integrated’; AND/OR ‘model’, ‘framework’; AND/OR ‘community’,
‘community health’ or ‘home health’. The search was limited to articles in English from January
2010 to September 2020. The initial search yielded thousands of results; therefore, the search

18
was narrowed by focusing on systematic and integrative reviews, as well as grey literature from
the World Health Organization, Improving Chronic Illness Care and Diabetes Canada. The initial
search resulted in identifying the Chronic Care Model as the most prevalent and widely adopted
model to organize diabetes care and services in the primary and community care settings with
improved outcomes for diabetes management (Clement et al., 2018; Wagner et al., 1999, 2001).
It provides a comprehensive framework focused on preventative, person-centered, communitybased and integrated approaches to care (World Health Organization, 2016b). The six domains of
the Chronic Care Model provide a framework to organize the findings of the literature review
and base quality improvement work; the six components include: self-management, delivery
system design, decision support, clinical information systems, community resources and health
system organization (Wagner et al., 2001).
First level screening included reading the title and abstract with a focus on the term ‘type
2 diabetes’ and ‘chronic care model’. Second level screening was completed for relevance based
on the title and then abstract to focus on the articles related to the organization of type 2 diabetes
care and the Chronic Care Model in a community setting. Key documents were also identified in
the grey literature from multiple sources including: Diabetes Canada; World Health
Organization, and the International Diabetes Federation. These are examples of organizations
with comprehensive pieces of literature that have undergone their own systematic reviews of
current research on diabetes care. Citation searching was used to identify relevant literature
based on key themes and concepts, as well as, to identify original sources. A preference was
chosen for articles based in Canada and they were reviewed for relevance to the project
objectives. See table 1 for inclusion and exclusion criteria.

19
Table 1.
Inclusion and Exclusion Criteria
•
•
•
•
•
•

•

Inclusion Criteria
Type 2 diabetes
Adults – age >19 years
Chronic Care Model elements
Diabetes service delivery, design or
organization
Primary or community care settings
Peer reviewed articles, systematic
reviews, integrative reviews or key
documents from WHO, IDF, Diabetes
Canada, Government of Canada, BC
Ministry of Health, or Vancouver Coastal
Health.
Articles from 2010-2020 with the
exception of original works from outside
this date range.

•
•
•
•

Exclusion Criteria
Other types of diabetes including type 1
and gestational diabetes
Diabetes inpatient services
Surgical services
Ophthalmology

The literature search was an iterative and intuitive process as key search terms were
identified, reviewed, refined and searched again. The results were organized through a narrative
synthesis into the 6 components of the Chronic Care Model.
Findings
After screening and identification, 26 articles were included in the narrative review. In
depth review of the selected papers are discussed in the following section. Thirteen of the studies
were systematic reviews, integrative or scoping reviews. The references ranged from 2010 to
2020 and most were conducted in Western countries. The Chronic Care Model is the most
commonly referenced model for chronic disease management and more specifically for diabetes
care (Grover & Joshi, 2015). Ten references reviewed the outcomes of implementing one or all
of the elements of the Chronic Care Model (Alharbi et al., 2016; Baptista et al., 2016; Bongaerts
et al., 2017; Busetto et al., 2016; Elissen et al., 2013b; Grover & Joshi, 2015; Lim et al., 2018;

20
Reynolds et al., 2018; Ricci-Cabello et al., 2013; Stellefson et al., 2013). A number of the
references did not specifically refer to the Chronic Care Model but evaluated individual
interventions found withing the Chronic Care Model for chronic disease management such as
self-management support or integrated care (Chrvala et al., 2016; Forbes et al., 2011; O’Brien &
Hardy, 2003; Penn et al., 2015; Siminerio et al., 2014).
Other key documents include the original articles outlining the Chronic Care Model
(Wagner et al., 1999, 1996, 2001); the Diabetes Canada 2018 Clinical Practice Guidelines
(Clement et al., 2018; Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018;
Sherifali et al., 2018); the Review of Chronic Care (Canadian Academy of Health Sciences,
2017) and the World Health Organization Framework on integrated, people-centered health
services to provide global context for the organization of health services (World Health
Organization, 2016a). This broad selection of literature was to obtain an overview of how
diabetes services are organized. A more detailed review of the papers is noted in Appendix A:
Narrative Literature Review Matrix.
The narrative review findings are organized using the Chronic Care Model. The six
elements of the Chronic Care Model provide a framework for best practice to organize diabetes
care and services and to focus quality improvement work. Not all studies evaluating diabetes
management refer to the Chronic Care Model or include all 6 elements of the model; however,
the majority of interventions to optimize chronic disease services and care can be categorized
within one of the six major components of the Chronic Care Model. For this reason, the Chronic
Care Model was selected to organize the literature findings.

21
Chronic Care Model
There are various models to support the improvement of chronic care; however,
Wagner’s (2002) Chronic Care Model is the most widely accepted and adopted (Canadian
Academy of Health Sciences, 2017; Grover & Joshi, 2015; Improving Chronic Illness Care
(ICIC), 2020). Wagner et al. (1999) worked with support from the Robert Wood Johnson
Foundation to develop a guide to chronic care improvement; the result was the Chronic Care
Model. The model became an integral part of the US National Improving Chronic Illness Care
program and involved a large number of diverse health care delivery organizations which
provided the original evidence supporting the adoption of the model to improve outcomes in
chronic disease management (Wagner et al., 2001). Variations of the Chronic Care Model exist
as research projects and organizations tailor the elements of the framework to best meet their
needs, but this paper is focused on the original version by Wagner et al. (1999, 2001).
The majority of the care for people with diabetes occurs in the primary care setting and
the Chronic Care Model provides the framework necessary to structure an evidence-based
redesign to encourage high-quality chronic disease care and quality improvements opportunities
(Canadian Academy of Health Sciences, 2017; Clement et al., 2018).
The Chronic Care Model includes six components: 1) self-management; 2) delivery
system design; 3) decision support; 4) clinical information systems; 5) community resources; and
6) health system organization (see Figure 3) (Wagner et al., 1999, 2001). These components
work together to create high quality chronic disease care (Barr et al., 2003; Clement et al., 2018).
The Chronic Care Model provides an integrated approach to care (World Health Organization,
2016b). A systematic review of chronic disease management interventions in primary care
supports the Chronic Care Model as the most frequently used model associated with statistically

22
significant improvements for diabetes management (Grover & Joshi, 2015; Reynolds et al.,
2018). There is a significant amount of literature evaluating one or more components of the
Chronic Care Model for diabetes care with positive results including decreased hemoglobin A1C
(HbA1C) levels (Barr et al., 2003; Clement et al., 2018). Diabetes Canada advocates using the
Chronic Care Model as the organizational framework to address the changes required to better
meet the goals outlined in the evidence-based guidelines (Clement et al., 2018; Diabetes Canada
Clinical Practice Guidelines Expert Committee, 2018).
The 6 components of the Chronic Care Model provide a focus for quality improvement
work (Clement et al., 2018). These elements are evidence-based and have been shown to
improve care (Clement et al., 2018; Improving Chronic Illness Care (ICIC), 2020).
Figure 3
A Model for Effective Chronic Illness Care

Wagner et al. (2002). A survey of leading chronic disease management programs: Are they

23
consistent with the literature? Journal of Nursing Care Quality, 16(2), 67–80. Reprinted with
permission from Wolters Kluwer Health Inc.
Self-Management
Self-management education and support is a critical component of diabetes management
(Sherifali et al., 2018). It is a prevalent theme in the majority of literature on chronic disease
management and diabetes care, and highlighted in the Chronic Care Model (Barr et al., 2003;
Grover & Joshi, 2015; Olesen et al., 2020; Penn et al., 2015; Reynolds et al., 2018; Sherifali et
al., 2018). Self-management is a complex concept. It is a critical factor in achieving positive
patient outcomes and is linked to health literacy and service delivery. Self-management in type 2
diabetes includes: self-monitoring blood glucose levels, healthy eating, physical exercise,
pharmacotherapy, prevention and management of hypoglycemia, prevention and surveillance of
complications, stress management and relaxation techniques, coping strategies, and goal setting
(Sherifali et al., 2018). These can be delivered in variety of settings by a variety of methods.
There is variation in the language and meaning associated with self-management which
allows for specificity. For example, the terms self-management, self-management education and
self-management support are used interchangeably, but there are differences between the
education and support of self-management. Diabetes Canada delineates between the two terms
because of the growing evidence reinforcing the necessity to include self-management education
with support for optimal results (Sherifali et al., 2018). Self-management education “is defined
as a systematic intervention that involves active participation by the individual in self-monitoring
of health parameters and /or decision-making with the application of knowledge and skills”
(Sherifali et al., 2018, p. S36). Whereas self-management support “includes activities that
support the implementation and maintenance of behaviors for ongoing diabetes self-

24
management, including education, behaviour modification, psychosocial and/or clinical support”
(Sherifali et al., 2018, p. S36). It is important to differentiate between the two types of selfmanagement when planning diabetes services in an effort to meet both self-management
objectives: 1) education to guide self-monitoring and decision-making, and 2) support to sustain
behaviors.
The evidence supporting the benefits of self-management education include: improved
glycemic control, improved cardiovascular risk factors, and reduced foot related complications
(Chrvala et al., 2016; Sherifali et al., 2018). However, glycemic control is the most consistently
evaluated outcome. For example, the systematic review of 118 unique randomized controlled
trials (RTCs) by Chrvala et al. (2016) evaluated the impact of diabetes self-management
education on improving HbA1C results. The overall mean reduction in HbA1C for participants
in the intervention groups who received various types of self-management education was 0.74
compared to a mean decrease of 0.17 for the control groups who did not received selfmanagement interventions. Out of the 118 RCTs evaluated, 61.9% of interventions resulted in
statistically significant reductions in A1C (Chrvala et al., 2016). A combination of group,
individual and remote diabetes self-management education achieved the greatest improvements
in outcomes compared to individual or group education alone (Chrvala et al., 2016).
Self-management education was more effective when delivered by a multidisciplinary
team that included a nurse who has received specific diabetic educator training (Chrvala et al.,
2016; Sherifali et al., 2018). Although there appears to be no agreed upon ideal length of session,
frequency, or duration of program, the systematic review by Chrvala et al. (2016) identified
statistically significant changes in HbA1C to be greater for self-management education
interventions with greater than 10 hours of contact time. The integrative review by Olesen et al.

25
(2020) identified multiple studies where positive outcomes were achieved through group-based
self-management programs. The authors found the peer support from group-based programs
enhanced diabetes management and suspected personal sharing and group interactions led to
maintaining motivation (Olesen et al., 2020). Improvements in HbA1C were more likely to be
maintained when self-management support was added to the education (Sherifali et al., 2018).
In addition to peer support noted by Olesen et al. (2020), other methods of providing selfmanagement support resulting in reduction of HbA1C levels include follow-up telephone calls
from a diabetes educator at least 4 times per year and ongoing support from community health
workers (Sherifali et al., 2018). For long term change to be sustainable, self-management support
should include cognitive behavioral therapy interventions to increase participants personal
awareness of the barriers and promoters for personal change (Sherifali et al., 2018).
Delivery System Design
In order to achieve high quality chronic illness care, team-based multidisciplinary care is
essential to the delivery system design (Wagner et al., 2001). Diabetes care demands planning
and coordinating the actions of multiple care providers; therefore, effective multidisciplinary
teams are key to improvements in care. Team-based cared is not a new concept, but chronic care
continues to be delivered primarily by primary care physicians, especially in rural or remote
areas (Gucciardi et al., 2015).
The value of multidisciplinary team-based care was emphasized in the 2002 Romanow
Report, and it continues to be prominent in the literature on chronic disease management
(Romanow, 2002; World Health Organization, 2016a). The World Health Organization (WHO)
(2016a) calls for multidisciplinary teams to provide comprehensive care to better meet
population health needs. Barrett et al. (2007) reported multidisciplinary models provide a broader

26
range of services, coordination of care and better access to services resulting in more efficient
use of resources, greater patient satisfaction, improved self-care and improved provider job
satisfaction (Barrett et al., 2007). Enhanced interprofessional collaboration as part of integrated
care systems is especially relevant for groups such as individuals with chronic disease who
require the integration of multiple providers and services (Barrett et al., 2007; Siminerio et al.,
2005). The terms multidisciplinary, interprofessional, and interdisciplinary are used
interchangeably in this paper and throughout the literature; there are subtle differences in the
terms, but that discussion is beyond the scope of this paper.
Diabetes Canada supports the integration of team-based care for diabetes care and
management because “patients who are part of interprofessional teams have better outcomes and
fewer hospital visits than patients who are not” (Clement et al., 2018, p. S28). Diabetes Canada
emphasizes the importance of members of the interprofessional team having specific training in
diabetes and work collaboratively with the primary care provider (Clement et al., 2018). Team
members may include physicians, nurses, nurse practitioners, dieticians, pharmacists and
providers of psychological support (Clement et al., 2018). Case management led by a nurse or
dietitian with specialty diabetes training has been reported to improve both glycemic control and
cardiovascular risk factors (Clement et al., 2018; Wagner et al., 2001). The role of the case
manager often includes self-management support and education, close follow-up to assess
response to therapy and the adjustment of treatments using guidelines and protocols.
Szafran et al. (2019) found family physicians who were part of multidisciplinary primary
care networks reported involving other health care professionals in the care of their patients with
diabetes more than physicians who worked in traditional family practice environments. Providers
in the primary care network also perceived improved patient care from the interdisciplinary

27
involvement such as by more time allocated to teaching self-care and monitoring and adjustment
of diabetic medications (Szafran et al., 2019).
One of the barriers to implementing multidisciplinary teams includes most primary care
services do not support renumeration for team-based care. For example, fee for service is often
tied to a particular care provider such as the physician (Canadian Academy of Health Sciences,
2017). Other barriers to implementing collaborative practice include the providers’ willingness to
overcome traditional professional roles, and their ability to adapt to the changes and challenges
associated with sharing patients, space, and costs (Gucciardi et al., 2016; Szafran et al., 2019).
Gucciardi et al. (2016) affirm government resources and educational support need to be provided
where multidisciplinary collaboration is a fairly new process. This would ensure the team has the
knowledge and skills required for interprofessional collaboration and result in positive outcomes
for providers and patients.
Decision Support
Decision support refers to the integration of evidence based guidelines into care (Clement
et al., 2018; Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018). Wagner et
al. (2001) affirm guidelines become effective change agents only when they can be successfully
integrated into routine practice. Guidelines can be incorporated in a variety of ways such as
embedding them in a patient registry, using flow sheets, and in patient assessment and
documentation tools (Baptista et al., 2016; Stellefson et al., 2013; Wagner et al., 2001). These
tools prompt providers to refer to the guidelines during key interactions or interventions. It can
be challenging to change existing practice; therefore, system alerts, reminders, and audit and
feedback are useful to support change when integrating guidelines (Baptista et al., 2016; Clement
et al., 2018).

28
The systematic review by Stellefson et al. (2013) identified training for providers on
evidenced-based guidelines and the methods for implementing the Chronic Care Model resulted
in better adherence to clinical practice guidelines, and improved HbA1C levels and cholesterol
markers. In addition to better adherence to guidelines, Stellefson et al. (2013) reported investing
the resources to support providers in implementing evidence-based guidelines resulted in better
informed and more engaged providers which the authors suspected led to improved patient
engagement and positive health outcomes. The key to guidelines having an impact on quality of
care is their integration throughout all decision-support interventions including during provider
interactions, specialist involvement, and guiding education and case management activities with
evidence-based treatment algorithms (Clement et al., 2018). Interactive computer technology
creates the opportunity for best-practice information to be available at point of care to support
decision making.
Telemedicine is an innovative decision support strategy that has the power to expand the
reach of health care by enabling providers and patients to have access to a greater variety of
resources and care (Alharbi et al., 2016; Dorsey & Topol, 2016; Siminerio et al., 2014). This is
especially true for areas that are geographically isolated. Telemedicine, also known as telehealth,
is a quality improvement strategy with evidence for improving glycemic control and
cardiovascular risk factors in people with diabetes (Clement et al., 2018; Riazi et al., 2015).
Clements et al. (2018) found the frequency of contact with clients has been shown to be
important when managing diabetes in the community and telehealth may facilitate regular
contact especially in a rural setting where access to resources may be limited. Telehealth can be
used for conferencing with health care team members, education in an individual or group
setting, consultations with specialists, and optimizing self-management.

29
For example, mobile apps are an accessible and often inexpensive tool people can utilize
to support their health and wellbeing. Many glucose meter companies now have apps that allow
easy downloading, trending and sharing of blood glucose levels and can act as an adjuvant to
support diabetes management (Doyle, 2020). A systematic review by Hou et al. (2016)
concluded mobile phone apps can be effective at improving glycemic control. The authors
reported a reduction in HbA1C for participants in all 10 of the studies examined specific to type
2 diabetes (Hou et al., 2016).
In addition to mobile apps, other telehealth technologies have proven effective for
diabetes self-management such as computer and web-based interventions, and social networking
services (Clement et al., 2018; Hou et al., 2016). One of the barriers to using telemedicine is the
technological literacy of patients and providers (Siminerio et al., 2014), and the lack of standards
or policies to help guide programs looking to integrate telehealth apps for self-management
support (Hou et al., 2016).
Clinical Information Systems
Clinical information systems organize and store user data to facilitate efficiency and
effectiveness of the health care system (Wagner et al., 2001). In chronic disease management,
clinical information systems allow for a population-based approach to diabetes management and
include Electronic Medical Record (EMR) systems and patient registries (Clement et al., 2018).
Patient registries and EMRs have been shown to have a positive impact on diabetes care
(Baptista et al., 2016; Bongaerts et al., 2017; Clement et al., 2018; Stellefson et al., 2013;
Wagner et al., 2001). The systematic review by Riazi et al. (2015) indicates clinical information
system technologies are associated with a decrease in HbA1C levels. Clinical information
systems allow multiple providers to monitor and deliver care. These systems provide access to

30
diagnostic results and examination records to foster collaborative and integrated services, as well
as, identify gaps in care (Clement et al., 2018; Stellefson et al., 2013). Sites using EMRs for
diabetes care in the USA achieved better diabetes outcomes than sites that were paper-based
(Clement et al., 2018). Patient registries allow for tracking diabetes trends, benchmarking, and
evaluating quality improvement work which are all key to improving diabetes care services
(Clement et al., 2018).
Barriers to implementing clinical information systems in diabetes care include a higher
cost at initial implementation, challenges for health care providers in technological literacy, and
the perception by providers or patients that providers are spending more time with the computer
system than the patient (Riazi et al., 2015).
Community Resources
Improving Chronic Illness Care (2020) highlights the value of health systems looking
beyond themselves as many useful community resources exist and can enhance chronic illness
management. Wagner et al. (2001) recognized this benefit and included community resources in
the Chronic Care Model Framework. Creating linkages with effective programs in the
community is a cost-effective way to deliver a variety of services beyond what the health
organization is able to offer and maintain (Wagner et al., 2001). However, few studies were
found with a focus on the Chronic Care Model and diabetes care addressed through community
resources and policies (Baptista et al., 2016; Reynolds et al., 2018; Stellefson et al., 2013). Peer
led self-management support groups have been shown to be effective in improving diabetes
outcomes; therefore, this would be excellent community based resource to identify and partner
with the existing health care system services (Clement et al., 2018). Stellefson et al. (2013)
identified the need to create more community partnerships to address barriers to care and include

31
culturally appropriate services. For example, utilizing existing community exercise programs or
cooking classes is a potentially effective strategy to tailor care to the sociocultural preferences of
the community and to avoid unnecessary duplication of services. Partnering with community
services is especially important for smaller organizations or rural health service areas with
limited resources such as Squamish (Ricci-Cabello et al., 2013; Wagner et al., 2001). Barriers to
integrating community resources outside current health systems include the challenge of shifting
away from traditional health care models with siloed services, and the lack of awareness of what
services exist in the community that align with diabetes management best practices.
Health System Organization
Health system organization represents how the care and services supporting diabetes
management is organized at a system level. The Chronic Care Model views health systems as
part of the larger community (Wagner et al., 1999). For health services to better support chronic
disease management, chronic illness improvements must be included in the organization’s goals
or plan (Ricci-Cabello et al., 2013; Stellefson et al., 2013; Wagner et al., 2001). The systematic
review by Reynolds et al. (2018) identified a lack of studies with interventions focused on health
system organization, yet this is a key factor in the overall success and commitment to optimizing
diabetes care (Clement et al., 2018; Wagner et al., 2001). Fostering change at a systems level is
much more challenging than implementing a site-specific self-management program as part of a
quality improvement initiative based on the Chronic Care Model. However, this type of change
is what is being asked at a global level. The World Health Organization (2016a) calls for the
need to integrate health services in order to optimize care.
The World Health Organization (2016b) defines integrated care as the coordination of
health services across the continuum of care. Integration is a key concept at the global level to

32
support improvements in health care to improve the quality of patient care and control costs; it
requires a person-centered approach where there is collaboration between providers and between
provider organizations (Desmedt et al., 2016; World Health Organization, 2016b). It is driven by
the triple aim approach of: 1) cost savings, 2) better patient care experience, and 3) improved
health outcomes (Desmedt et al., 2016). The increasing prevalence of chronic disease and
escalating health care costs has prompted a shift away from the current emphasis on acute care
towards “prevention, self-care, more consistent standards of primary care, and care that is well
co-ordinated and integrated” (Goodwin et al., 2012, p. 2). Integrated care should be directed at
services and populations that would benefit the most such as people with chronic diseases
(Goodwin et al., 2012).
Primary Care Networks are an example of integrated health systems. The concept of
primary care networks (PCN) is currently being adopted in Alberta and BC. It is a promising
model with the structure to integrate team-based services with the primary care provider to
optimize diabetes care in the community setting (General Practice Service Committee, 2020).
PCNs were implemented in Alberta beginning in 2003 as a strategy to improve access to care
and access to multidisciplinary teams for patients with chronic disease (Manns et al., 2012). The
implementation of PCNs across BC is still in its infancy. Manns et al. (2012) evaluated the
outcomes for patients with diabetes enrolled in PCNs and found they had lower rates of diabetesspecific ambulatory care sensitive conditions, were more likely to see the ophthalmologist or
optometrist and had better glycemic control. The difference was small, but patients with diabetes
managed in PCNs had better clinical outcomes with lower rates of hospital admission and
emergency department visits (Manns et al., 2012). Another benefit noted in the study, includes
an increase in adherence to clinical guidelines by the primary care provider including laboratory

33
and retinal screening, as well as, medication management (Manns et al., 2012). PCNs have
similar features to Ontario’s family health teams and patient-centered medical homes; they all
have similar goals to improve access to care and to coordinate or integrate care (Manns et al.,
2012).
Some of the challenges associated with the implementation of integrated care models
such as PCNs include a reluctance from physicians to participate due to predominant
professional cultures and behaviours, an overreliance on electronic medical records as key to
transformational change, a lack of focus on the population that would benefit the most, and a
lack of support from the organization for change management (World Health Organization,
2016b).
Other models such as the Innovative Care for Chronic Conditions (ICCC) model
supported by the World Health Organization embody similar underlying theories or concepts to
the Chronic Care Model such as preventative proactive care, integrating care and creating
partnerships between community, health systems and the people using them, using clinical
practice guidelines and evidence-based changes (Canadian Academy of Health Sciences, 2017;
World Health Organization, 2002). This model can also be applied to a variety of chronic
conditions and health care settings. The World Health Organization (2016b) concludes there is
no single best model for integrated care. Integrated care is contextually bound and should focus
on improving the quality of care for the individuals and communities it serves.
Discussion
The organization of diabetes care is complex and multifaceted. Identifying where to
begin when attempting to reorient care is an overwhelming process. However, by organizing
interventions within the Chronic Care Model, a framework is created for a comprehensive and

34
systematic approach to restructure current models of care. Stellefson et al. (2013) found no single
component was imperative for improved outcomes, but it was the combination of components or
incorporating multiple components together that resulted in optimal outcomes.
The element of the Chronic Care Model most frequently attributed with statistically
significant improvements was self-management support (Alharbi et al., 2016; Reynolds et al.,
2018). Both delivery system design and then decision support showed evidence of benefit but
should be explored in combination with other elements of the Chronic Care Model to optimize
improvements (Reynolds et al., 2018). When examining combinations of elements, selfmanagement support and delivery system design interventions were the most frequent
combination of elements associated with significant improvements in outcome measures,
followed by self-management support and decision support (Reynolds et al., 2018). Regardless
which elements of the model are selected for quality improvement work, every component must
be viewed through of lens of person-centered care and the local context to be successful in
optimizing health outcomes. The local context will be explored further in the next chapter,
chapter 5: the gap analysis findings and discussion.
People with diabetes represent a diverse and heterogeneous group. People from diverse
geographical, cultural and socioeconomic groups are affected by this chronic disease (Houlden,
2018; International Diabetes Federation, 2019). Rigid guidelines may not incorporate the
uniqueness of the individual especially when attempting to support changes in behavior and
lifestyle (Houlden, 2018). Care must be tailored to meet the needs of the individual within their
sociocultural context by purposefully interweaving person-centered care in all elements of
system redesign. The theoretical perspective of person-centered care often underpins the
literature on diabetes even when it is not explicitly outlined.

35
A person-centered approach is evident throughout the Diabetes Canada Clinical Practice
Guidelines (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018). One of the
guiding principles repeated throughout the guidelines states care should be “organized around the
person living with diabetes and their supports” (Clement et al., 2018, p. S27). The guidelines
emphasize the importance of people with diabetes to be active participants in their own care.
This is evident in the simple, readable language directed at the person with diabetes and the use
of the pronoun ‘you’ instead of ‘they’ or ‘the person with diabetes’ used in the ‘Key Messages
for People Living with Diabetes’ at the beginning of each chapter (Diabetes Canada Clinical
Practice Guidelines Expert Committee, 2018). These key messages directed at people living with
diabetes set the tone and empower people to be at the center of their care and begin to shift the
ownership to the individual rather than the care provider (Clement et al., 2018; Houlden, 2018).
The chapter on Nutrition Therapy in the Diabetes Canada Clinical Practice Guidelines
(2018) is one example that emphasizes the importance of individualized care in selfmanagement. Nutrition therapy is a critical aspect of diabetes care and can be used to prevent
and treat acute and long-term complications. Nutrition therapy can improve glycemic control and
contribute to weight loss, a key strategy in managing type 2 diabetes (Diabetes Canada Clinical
Practice Guidelines Expert Committee, 2018). Person-centered nutrition therapy is necessary
when addressing the rich ethnocultural diversity in Canada, there is no singular dietary strategy
that would meet the distinct dietary patterns, foods and dining habits of all Canadians.
Penn et al. (2015) reported patients wanted more choice in the nature and content of their
self-management support. Diabetes self-management education and support appears inherently
person-centered; however, diabetes self-management education and support programs can be
inadvertently more teacher-centered rather than person-centered (Olesen et al., 2020). Providers

36
who facilitate self-management education and support must be knowledgeable in diabetes care
and management while tailoring the education to the individual and/or group; this includes
considering cultural preferences and individuals choices (Olesen et al., 2020; Sherifali et al.,
2018). Achieving a balance between delivering the required information to successfully manage
type 2 diabetes and individualizing the self-management education overlaps with personcentered care approaches. Baptista et al. (2016) outlined the central role of the patients in setting
priorities and creating plans of care to best support self-management. This collaborative
approach where the patient becomes an active partner is key to person-centered care. In the
integrative review by Olsen et al. (2020), the authors identified person-centered interventions
that lead to positive outcomes: “1) empowerment-based educational approaches to set personal
goals and plan actions; 2) self-efficacy theory to develop skills, confidence and knowledge
required for diabetes self-management; 3) motivational interviewing as an approach for HCPs to
build rapport, ask questions and understand participants’ needs and preferences; and 4) personcentred values, such as a non-didactic and collaborative patient–provider relationships” (p. 920).
Olesen et al. 2020 reported person-centered self-management interventions were successful in
improving psychosocial outcomes and glycemic control, yet less successful in creating behavior
and lifestyle changes such as diet and exercise; they did note there were no negative
consequences. The success of person-centered approaches depends on the health care providers’
communication and facilitation skills; therefore, training to promote collaborative relationships
and to integrate patient preferences and goals are required for positive outcomes (Olesen et al.,
2020; Pulvirenti et al., 2014).
Multidisciplinary teams geared towards meeting the unique needs of the individual with
type 2 diabetes reflect person-centered delivery system design. Case management allows one

37
provider the ability to review and organize care for patients based on the individual’s unique
goals within the clinical practice guidelines (Clement et al., 2018). Case managers can link
individuals to the resources best suited to their collaborative plan for disease management such
as the dietitian for nutrition management or the physiotherapist for individualized exercise
programs. It is impossible for primary care providers to be aware of all the community resources
available for all chronic conditions and health and wellness programs, but a case manager
specific to diabetes care has the ability to be knowledgeable of community resources specific to
diabetes and therefore has the ability to link patients with beneficial resources that already exist
in the community setting.
Telemedicine is developing rapidly and there is no singular technology or method that
appears superior which makes selection of the type of technology challenging and how to best
apply it (Clement et al., 2018; Hou et al., 2016). The application of telehealth to diabetes
management may require deliberate and careful planning to meet the intended goals of the
technology, but with such positive results from the literature, it is a tool that should be
considered for all diabetes care and management where appropriate.
Strategies such as automatic reminders via email or text, peer support groups, web-based
culturally sensitive exercise or diet programs, diabetes coaching or telemedicine are all creative
modalities with the potential to augment diabetes care and management (Hou et al., 2016;
Mignerat et al., 2014; Sherifali et al., 2018). Integrating these modalities into care involves a
person-centered approach to health system organization, delivery system design, and clinical
information systems. One method may not be effective for a specific group or individual
necessitating a person-centered approach for success. As quality improvements efforts begin in

38
one element of the Chronic Care Model, it becomes clear how the 6 elements are interrelated and
the increased value in making improvements in more than one component.
One of the challenges associated with evaluating the effectiveness of the Chronic Care
Model is the heterogeneity between the various studies including which components of the
model were selected to be evaluated, and the consistency with how outcomes are measured.
However, overall, systematic reviews from North America and Europe have found when more
than one element of the Chronic Care Model is implemented to support the redesign of care,
positive results have been extensively documented such as improved patient outcomes, quality of
care and cost savings (Bongaerts et al., 2017; Clement et al., 2018; Elissen et al., 2013a;
Stellefson et al., 2013; World Health Organization, 2016b). A version of the Chronic Care Model
suggested to better integrate population-based health promotion and prevention by addressing the
social determinants of health is the Expanded Chronic Care Model by Barr et al. (2003). Despite
the benefits of attending to the broader elements of population health and wellbeing by
generating new and novel approaches to the Chronic Care Model, creating new versions of the
model can make consistent implementation and evaluation of results challenging. The elements
of the Chronic Care Model are broad concepts that allow space for interpretation and application
to a variety of settings.
Comparing results from systematic reviews on self-management education and support
was especially challenging because of the heterogeneity of the methods used to deliver selfmanagement care and the outcome measures collected. This is important to note because of the
emphasis placed on the value of self-management. Therefore, clear guidelines based on evidence
should be available to guide quality improvement initiatives to ultimately improve care. The
challenge to accurately consolidate studies and compare results was noted by Chrvala et al.

39
(2016) and Olesen el al. (2020). Variations in the severity and complexity of disease as well as
individuals’ capacity for self-care also result in difficulties with generalization across
populations. The contextual nature of patients with type 2 diabetes influences study endpoints
which result in personal successes that are not transferable to a wider population with type 2
diabetes. The challenge with these differences may not be remedied with standardized
approaches and evaluation measures because of the individualized nature of diabetes
management. Self-management requires a person-centered approach and outcomes measures
beyond glycemic control.
Another challenge identified in the review of literature was that although studies used a
variety of indicators such as cholesterol levels, weight, patient satisfaction, and self-efficacy
tools such as the Diabetes Empowerment Scale, HbA1C was the most consistently used and
compared. This limits the ability to measure the success of other important outcomes such as
quality of life and compare or synthesize results between studies. Without a consensus on what
measures are collected, it will continue to be challenging to obtain consensus on what
interventions are of most benefit in the management of diabetes care in the community. This in
turn, makes it challenging to create best practice guidelines on how to best optimize care.
Despite these challenges, the Chronic Care Model provides an evidence-based framework to
focus quality improvement work in diabetes care. In the next chapter, the local context of
diabetes care and management services is outlined.

40
CHAPTER 5: GAP ANALYSIS
The gap analysis provides an overview of the current state of diabetes care and services
in the community setting of Squamish, BC. The gap analysis includes local data and an
environmental scan. The goals of the analysis include: 1) identifying the current state of diabetes
care provided by the Home Health program in Squamish, 2) identifying guidelines, policies and
plans directing local diabetes care and services, and 3) creating partnerships with community
resources outside the Squamish Home Health program to potentially address service gaps.
The Canadian agency for drugs and technologies in health CADTH (2015) describes the
purpose of the environmental scan report as a tool to provide a current overview of what exists in
relation to a specific topic and does not evaluate or provide recommendations. Therefore, the
goal was to begin to gather information about what is available and was not intended to be a
comprehensive evaluation of such services. CADTH also supports the environmental scan as a
process to establish networks with key stakeholders. It provides a snapshot of what is currently
taking place and identifies potential options to bridge the gaps in the current services offered
through the Home Health program. The results of the environmental scan along with the findings
of the literature review create the foundation for the recommendations outlined in chapter 6.
Local Context
Squamish is a rural community situated halfway between Vancouver and Whistler with a
population of 20,404 in 2019 (BC Stats, 2019). The community has experienced significant
population growth in the last decade with a population of 15,554 in 2011 and 17,587 in 2016
(Statistics Canada, 2017). Population growth continued until 2018, followed by a small
population decline of 2.6% from 2018-2019 (BC Stats, 2019; District of Squamish, 2015). The
median age for total number of residents is 37.6 compared to 43.0 for BC (Statistics Canada,

41
2017). The demographic is currently young with a greater percentage of the population under
the age of 15 years compared to greater than 65 years of age; however, this balance is projected
to shift by 2026 with more people over the age of 65 compared to under 15 years of age (PHSA,
2019). There are currently 950 people or five percent of the population who identify as
Aboriginal living within the Squamish District municipality, and 14.7% of people who consider
themselves a visible minority (Government of Canada, 2018; PHSA, 2019). Squamish is located
64 km from the nearest larger community of Vancouver.
The community of Squamish is part of the Sea to Sky corridor which includes the rural
towns of Squamish, Whistler, and Pemberton. The Sea to Sky corridor sits within the Coastal
Community of Care, one of three geographic health service regions, serviced by Vancouver
Coastal Health (Vancouver Coastal Health, 2019). Overall, Squamish has higher household
income rates, higher rates of post-secondary education, and lower rates of unemployment when
compared to BC (PHSA, 2019). Even though these socioeconomic indicators correlate with
higher levels of general wellbeing, diabetes incidence rates are rising in North Shore/Coast
Garibaldi region (BC Centre for Disease Control, 2020; PHSA, 2019). This demonstrates the
complex nature of the disease and the importance of understanding the community’s unique
context as they may differ significantly between other community profiles.
The community health unit in Squamish is comprised of a Home Health program that
includes home care nursing, home support services, rehab services, a dietitian, and a social
worker. Prior to 2018, the Home Health program had a nurse dedicated to chronic disease and
diabetes management who worked in collaboration with the community dietitian. However,
when the nurse clinician left the position, the position was not filled. Funding dedicated to the
role of chronic disease support was redirected by management and the director for Sea to Sky to

42
increase staff hours for community health nursing to meet the more acute demands of the
community such as wound care, palliative care and home IV therapy, and for these services to be
delivered in a community setting to alleviate the need for individuals to attend acute care
services. As a result of service reallocation, referral for chronic disease management for type 2
diabetes to the Home Health program, has become a sole responsibility of the community
dietician. Referrals to the chronic disease program come primarily from primary care providers
in the community. Despite population growth of 3.9% per year since 2011(BC Stats, 2019;
Statistics Canada, 2017), diabetes care services have been reduced due to the loss of the nurse
clinician. The need for improved diabetes services will continue to grow as the population in
Squamish is projected to shift to a larger proportion of older residents (PHSA, 2019).
Methods
The Chronic Care Model provides a framework for the findings of the gap analysis. The
gap analysis includes local data to provide baseline information regarding the current referrals
for diabetes services to the Squamish Home Health program, and an environmental scan. Data
for the environmental scan were collected through practice experience in the role of CRN for the
Home Health team including formal and informal communication with team members, and an
internet search for community resources, guidelines, policies and service plans. The findings of
the environmental scan are organized under the six components of the Chronic Care Model.
Formal community member and key stakeholder involvement will occur in the next phase
of the project as outlined in the recommendations in chapter 6.
Local Data Collection
The clinical information system used at the Squamish Community Health Unit is the
Primary Access Regional Information System (PARIS). PARIS is an electronic health records

43
system Vancouver Coastal Health uses for community-based programs. It is accessed by staff
involved in the delivery of a wide range of health services outside of acute care hospitals
including community health nursing, rehab services, dietitian services and communicable disease
control (BC Freedom of Information and Privacy Association, 2011). The personal information
contained includes diagnoses as well as the case notes by providers about the treatment they
provide to their clients. Clients are assigned a unique personal identifier in the system for data
retrieval and storage (BC Freedom of Information and Privacy Association, 2011).
Referrals for diabetes services to the community health unit come from primary care
providers in the community. Referrals are entered into PARIS under the referral category
‘Chronic Disease Management’. Metrics for ‘Chronic Disease Management’ referrals are
collected and available through the Decision Support Data Analytics Solution for Health
(DASH) website accessible through the secure VCH network (Vancouver Coastal Health, 2021).
This information is not specific to diabetes management but provides metrics for the entire
chronic disease management program. There is no referral code specific to diabetes referrals
preventing metrics to be collected regarding diabetes care and management from the DASH
website. To overcome the aforementioned challenges a manual search was required to identify
the number of ‘Chronic Disease Management’ referrals specific to type 2 diabetes. A manual
paper audit was proposed to the management team, approved and subsequently completed by the
author. No personal identifiers were included in the data collection to maintain anonymity and
confidentiality.
Environmental Scan
The environmental scan was completed by conducting an internet based search using
Google and Safari search engines and the terms: ‘diabetes’ AND ‘Squamish’. The search was

44
conducted between August 2020 and November 2020 to identify relevant community-based
resources and services (see Appendix B for results). The primary search yielded a small number
of results; therefore, the search was expanded to include community services identified in the
neighbouring communities of North and West Vancouver, and Whistler. These communities are
part of the Coastal Community of Care in VCH and lie between 50 and 60 km to Squamish
(Vancouver Coastal Health, 2019). Due to the limited results, the search was expanded a second
time and a broad search for ‘diabetes’ AND ‘Vancouver’ OR ‘support’ OR ‘self-management’
was completed to identify resources available virtually or by phone. Diabetes services available
in communities beyond the Coastal Community of Care, but within VCH such as Vancouver
proper were included if the services were available virtually or via the phone; however, in-person
services were excluded due to the distance required for participants to travel to access services
(greater than 60 km). The requirement to travel longer distances for specialized care has been
associated with poorer glycemic control (Strauss et al., 2006; Zgibor et al., 2011). Virtual and
telephonic services available through Diabetes Canada and the government of BC were also
included. Online resources available outside Canada or through private organizations were
exclude because confirming the validity of the content was beyond the scope of this project.
Resources specific to type 1 diabetes or gestational diabetes were excluded from the results. The
community resources identified were organized in a table according to the name of the program,
goal of the program, a description including the type of providers involved, information
regarding the duration or frequency of the program, referral criteria and the funding organization
(see appendix B).
An additional internet-based search was completed to identify guidelines and policy
documents informing diabetes care including: the service plans for VCH and the BC Ministry of

45
Health, diabetes guidelines for BC and Canada, and policy documents for home and community
care. Clinical experience as well as formal and information communication occurring during the
role as CRN allowed for an understanding of the current context of diabetes care in Squamish
such as the EMR used and the current practices of the community dietitian. The results are
identified in the findings below.
Findings
The findings for the gap analysis include local data and an environmental scan. The
environmental scan findings are organized under the six components of the Chronic Care Model:
self-management, delivery system design, decision support, clinical information systems,
community resources and health system organization (Wagner et al., 2001). This provides the
framework for understanding best practice as identified in the narrative literature review in
relation to the current context in Squamish.
Local Data
Data available through the DASH website are organized by fiscal accounting periods;
therefore the total number of referrals for ‘Chronic Disease Management’ was collected from
April 1 2020 to January 7, 2021 (Vancouver Coastal Health, 2021). This specified period of time
includes the first ten accounting periods for the 2020/2021 fiscal year. The total number of
referrals for ‘Chronic Disease Management’ from April 1, 2020 to January 7, 2021 is 177.
During this period of time, the median number of days between the referral date and the date of
first contact with a provider from the Home Health program as documented in PARIS was 28
days. This data is not specific to type 2 diabetes management; therefore, a manual audit for all
chronic disease management referrals from August 1 to October 31, 2020 revealed that from a
total of 63 ‘Chronic Disease Management’ referrals, 84% (n=53) were specific to all types of

46
diabetes. The diabetes referrals were then categorized into pre-diabetes, type 1 diabetes, type 2
diabetes and gestational diabetes for each month (see table 2). An average of 13 new referrals are
received each month to the Home Health program specific to type 2 diabetes management.
Table 2
Number of Diabetes Referrals to the Home Health Program in 2020 by Month
Type of Diabetes
Referral
Gestational Diabetes
Pre-Diabetes
Type 1 Diabetes
Type 2 Diabetes
Total Diabetes
Referrals

August

September

October

4
0
1
11
16

2
2
2
13
19

2
1
0
15
18

Average per
Month
3
1
1
13
18

This data provides a snapshot of the number and type of referrals, and the timeline for
when the clients first receive care in Squamish. Alone, the data suggests the volume of people
who require care and the likelihood of them receiving care in a specified timeframe. It provides a
basis for future comparison and benchmarking.
Chronic Care Model
Self-Management
The Home Health program provides self-management support and education for
individuals with type 2 diabetes via one-to-one in person or telephonic appointments with the
dietitian. A referral from a primary care provider is required. Paper based referrals are faxed to
the Home Health program requesting diabetes support. The dietitian receives a paper chart, and a
referral is opened in the PARIS clinical information system to allow the dietitian to document the
client encounter in a casenote which is a free text document. One-to-one self-management
support and education are key components of the care the dietitian provides and includes

47
elements of person-centered care (SC, personal communication, October 29, 2020). For instance,
plans of care are tailored to the individual based on the collaborative goals identified by the
client and the dietitian. The dietitian identified her strengths in self-management support and
education reside in the field of nutrition management and a bias towards nutrition counselling
reflects a large part of the care she provides to her clients (SC, personal communication, October
29, 2020). Another example of person-centered self-management includes culturally sensitive
food choices offered during sessions in nutrition planning (SC, personal communication, October
29, 2020). There currently are no group education or ongoing support provided by the Home
Health program. The dietitian states there is no standardized follow up with clients due to her
current caseload; clients are followed up on an individualized basis based on need identified by
the dietitian (SC, personal communication, October 29, 2020). The self-management education
and support provided by primary care providers will be explored in the future stakeholder
meeting to identify what is currently being delivered by primary care providers and what are the
gaps in self-management education and support.
Delivery System Design
Both the BC Ministry of Health (2020) and the VCH (2019) Service Plans prioritize
team-based primary care in their first objectives. The addition of team-based multidisciplinary
care aims at improving services tailored to the individual’s needs (person-centered care) along
with an emphasis on providing culturally competent care (BC Ministry of Health, 2020).
Currently, primary care providers must submit a referral to the Home Health program for
diabetes support to access the dietitian. There are no other disciplines routinely involved in
diabetes support at a local level. Access to other members of the Home Health program including

48
rehab services and social work is not routine. With the loss of the chronic disease nurse clinician,
there are no longer diabetes case management services provided.
Decision Support
In BC, we have two sets of diabetes clinical practice guidelines available to guide care:
Diabetes Canada 2018 Clinical Practice Guidelines, and Diabetes Care 2015 BC Guidelines (BC
Ministry of Health, 2015a; Diabetes Canada Clinical Practice Guidelines Expert Committee,
2018). The Diabetes Canada guidelines are extremely comprehensive and are intended to
improve health care outcomes for Canadians with diabetes as well as address clinical care gaps
between evidence-based knowledge and day-to-day clinical practice. The guidelines summarize
research and provide algorithms, flowsheets, charts, checklists and other tools for decision
making (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018). Guidelines and
recommendation are organized in chapters for topics such as physical activity, nutrition,
pharmacological glycemic management, hyperglycemia, mental health, macrovascular and
microvascular complication, and complementary or alternative therapies (Diabetes Canada
Clinical Practice Guidelines Expert Committee, 2018). The BC Guidelines describe the care
objectives for the prevention, diagnosis and management of diabetes in an adult population. The
BC Guidelines are focused, brief and include algorithms and flowsheets to support decision
making.
Currently, the dietitian refers to both sets of guidelines in practice; however, she does not
use flowsheets for documentation and there are no decision support tools or guidelines integrated
into the PARIS EMR. Both the Diabetes Canada Clinical Practice Guidelines and the BC
Guidelines have Diabetes Patient Care Flow Sheets available for clinicians to use as a decision
support tool (BC Ministry of Health, 2015b; Canadian Diabetes Association, 2018). The

49
Diabetes Canada flowsheet is more comprehensive with targets noted for each section including
glycemic control, health behavior intervention, cardiovascular risk assessment and management,
mental health, neuropathy and retinopathy (Canadian Diabetes Association, 2018). Whereas the
BC Guideline flowsheet is more concise and includes targets for some measures, but not all (BC
Ministry of Health, 2015b). The flowsheets are intended for primary care providers; however, the
tool is a useful guide for nurse or dietitian case managers supporting clients with diabetes to
coordinate care, support decision making, create plans of care and prevent duplication of
interventions (Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018).
Clinical Information System
The clinical information system used by the Home Health dietitian is the EMR system
PARIS. It is used to document client interactions, interventions and plans of care. The primary
care providers in the community use a different EMR system other than PARIS for client care.
There are no shared documentation systems; therefore, referrals and case notes are currently
faxed between providers and added to the client’s Home Health paper chart. There are no shared
paper-based documentation tools such as flowsheets or algorithms used collaboratively between
providers. Other barriers to using clinical information systems effectively include limitations in
the current system, PARIS. The metrics specific to diabetes are limited within PARIS because
client care is not categorized under diabetes support or management. Referrals for diabetes
support are collected under the larger umbrella category of ‘chronic disease management’ in
PARIS and are not coded specific to diabetes management. The data available pertains to all
chronic disease referrals which include care provided by any provider within the Home Health
team such as rehab staff as well as participants referred to the Healthy Heart program. Therefore,
PARIS does not include the functionality to compile patient registries specific to clients with

50
diabetes cared for by the dietitian. A manual audit was required to identify the number of
referrals specific to diabetes care for a specified length of time.
Community
The environmental scan identified there were no additional diabetes specific resources in
Squamish other than primary care providers and the Squamish Home Health dietitian. The
broader internet based search revealed diabetes services at the Diabetes Education Centre in
West Vancouver approximately 55 km from Squamish providing diabetes group education
(Vancouver Coastal Health, 2020b). Since the onset of the COVID 19 pandemic, the group
education is currently being delivered virtually via zoom (EM, personal communication, October
29, 2020). The Diabetes Education Centre also provides services such as case management from
a diabetes nurse specialist, a dietitian, a foot care nurse, an occupational therapist, and/or
physician; however, these services are only available to individuals living in North and West
Vancouver (EM, personal communication, October 29, 2020). Gathering information for the
environmental scan allowed for the development of a relationship with the registered dietitian on
the team in West Vancouver to support future planning for clients in Squamish to be referred to
the group education (EM, personal communication, October 29, 2020). The group education is
focused on self-management education and support as well as nutrition counselling (EM,
personal communication, October 29, 2020). The programs occurs in three hour sessions, once a
month for three months (Vancouver Coastal Health, 2020b). The Healthy Living Program
available through VCH is similar to the Diabetes Education Centre in West Vancouver, but it is
limited to Vancouver residents (Vancouver Coastal Health, 2020c).
The broader search for services available in Vancouver identified case management
services available to anyone in BC through BC Diabetes and the Diabetes Clinic at Vancouver

51
General Hospital (BCDiabetes, 2020; Vancouver Coastal Health, 2020a). BC Diabetes is a
tertiary team-based care facility in Vancouver dedicated to the management of diabetes
(BCDiabetes, 2020). Referrals must be completed by a physician and the program is covered by
MSP. The services include clinical care by case management, diabetes specialist, counseling, and
pharmacy services. They offer virtual care for clients who live outside Vancouver; however, the
service does not include group education or support (BCDiabetes, 2020). The Diabetes Clinic at
the Gordon and Leslie Diamond Centre in Vancouver also offers tertiary care support to
individuals with diabetes; however, they are focused on individuals with complex diabetes
management issues with specific inclusion criteria as part of the referral process. The service
consists of a multidisciplinary team with case management services and is covered by MSP.
Other options for self-management education and support specific to diabetes include
Self-Management BC, and the Canadian Diabetes Prevention Program (BC Self-Management,
2020, p.; LMC Healthcare, 2020). Self-Management BC includes a variety of free selfmanagement programs offered through the Province of BC and UVic including virtual and
telephonic support specific to diabetes. A diabetes specific workshop includes a resource book
mailed to the individual and six weekly sessions offered virtually or over the phone with a
program leader. Another option available through Self-Management BC includes a coaching
program where participants connect with a coach by phone once a week for three months to
support participants in choosing goals as well as initiating and maintaining change.
The Canadian Diabetes Prevention Program consists of a 12 month digital coaching
program via the phone to support individuals with diabetes or prediabetes make lifestyle changes
(LMC Healthcare, 2020). The online resource states the program is limited to certain cities in
BC; however, after email contact with the organizer, the geographic limitations of the program

52
are because the program is part of a research study requiring participants to access LifeLabs in
order to gather baseline labwork (B. Lang, personal communication, October 27, 2020).
Participants outside the cities noted on the website are able to participate if they are able to
access or travel to LifeLabs for their bloodwork to be completed at the beginning and end of the
program (B. Lang, personal communication, October 27, 2020).
The Sea to Sky Healthy Heart program is not specific to diabetes support; it is a
rehabilitation program for people with cardiovascular disease that also addresses additional risk
factors such as diabetes, COPD, and asthma (Vancouver Coastal Health, 2012). It was included
in the environmental scan findings because it is a program offered within Squamish that includes
self-management strategies applicable to chronic diseases such as diabetes including physical
activity and nutrition education (Vancouver Coastal Health, 2012). This program is run through
the Home Health program in Squamish and even though the program is not focused on diabetes
management, future planning to better support diabetes care in community may involve the
reorganization of the Healthy Heart program to address risk factors and behavior modification
for chronic diseases with shared risk factors such as diabetes requiring similar lifestyle changes.
Health System Organization
Service plans are an important element guiding health system organization as they help
direct health care design and set strategic priorities. Both the BC Ministry of Health and VCH
Service Plans identify integrated team-based primary care, culturally sensitive care, and
improved chronic disease supports in the community as key priorities (BC Ministry of Health,
2020; Vancouver Coastal Health, 2019). The VCH Service Plan for 2019/20-2020/21 identifies
the need to support health care providers to manage individuals with chronic disease in the
community to reduce complications requiring additional medical care such as emergency

53
department visits, hospitalizations and diagnostics tests (Vancouver Coastal Health, 2019).
Primary care networks are noted as a key strategy to meet this objective (Vancouver Coastal
Health, 2019). The work to implement PCNs has been occurring across the province of BC;
however, Squamish is not included in the communities where the model is currently being
implemented, reviewed for approval, nor has the community provided an expression of interest
(Colleen Moberg, personal communication, September 16, 2020; GPSC, 2020). The service plan
does not include other specific strategies directing improvements to diabetes management or
chronic disease care in the community, nor does the Home and Community Care policy manual
address services specific for chronic disease or diabetes management (BC Ministry of Health,
2021). This local policy gap leaves communities to organize services for chronic disease
independently. Other important policies to support diabetes management include national or
provincial strategies; however, neither Canada nor the province of BC have a formalized diabetes
strategy (Diabetes Canada, 2019).
The Vancouver Coastal Health (2019) Service Plan 2019/20-220/21 also addresses the
need to improve patient experience in their key priorities by systematically embedding cultural
safety as part of quality health services. Some of the strategies provided by VCH to better
support culturally competent care include the Indigenous Cultural Competency PHSA Aboriginal
Health education training, an online eight week facilitator led course; a VCH Aboriginal Cultural
Competency Policy; and an Aboriginal cultural practices guide for physicians and allied health
care professionals (Vancouver Coastal Health, 2015). These resources support providers towards
integrating culturally sensitive care in their practice; however, there are currently no culturally
sensitive diabetes group classes offered in Squamish.

54
Discussion
The Chronic Care Model can be used to direct quality improvement initiatives as the six
elements of the model provide an excellent guide to target change (Barr et al., 2003). The
findings from the narrative literature review were organized under the six elements of the
Chronic Care Model and provide a benchmark for the gap analysis in order to identify gaps in
service and areas for improvement. This discussion explores the results of the gap analysis in
light of the findings from the literature review. Person-centered care is the key theoretical
perspective guiding improvements. The WHO (2016a) identifies the need for a fundamental shift
towards person-centered integrated care. This means empowering people to be active participants
in their own health, putting the comprehensive needs of individuals and communities at the
centre of their health systems, and integrating fragmented health systems to improve continuity
and comprehensiveness of care (World Health Organization, 2016a).
Effective person-centered self-management is consistently identified in the literature as a
key element in diabetes management (Barr et al., 2003; Grover & Joshi, 2015; Olesen et al.,
2020; Penn et al., 2015; Reynolds et al., 2018; Sherifali et al., 2018). Literature supports the
adoption of both group and individual self-management for improved outcomes (Sherifali et al.,
2018). Effective self-management education and support is facilitated by a provider with
specialized diabetes training such as the dietitian in Squamish. For improved outcomes, the
provider must be skilled at delivering person-centered care by collaborating with the individual
to establish mutually agreed upon goals and actively engage the client in creating an
individualized plan based on evidence-based guidelines. Diabetes Canada (2018) created a
worksheet, Managing My Diabetes: My Action Plan, to support individuals and their providers at
identifying goals and creating a plan for success. This tool is not currently used by Home Health;

55
however, it is an example of a tool to support collaborative planning between the care provider
and the client that can be integrated into self-management care. Empowering the client to guide
their own care is key to sustained change and improved patient satisfaction (Sherifali et al.,
2018). Person-centered one-to-one care is being provided by the Home Health dietitian by cocreating individualized plans of care; however, group support is currently not provided.
Self-management education and support can be challenging to deliver in our current
health care context. Sherifali et al. (2018) acknowledge challenges such as expanding caseloads,
the complexity of individualized diabetes care and limited time and resources as barriers to
delivering effective diabetes self-management. These obstacles reflect the difficulties of the
Home Health program in Squamish to provide group education and ongoing supportive followup. These services have not been possible with the current caseload of the dietitian who receives
an average of 18 new referrals per month for clients with diabetes in addition to other work
priorities and referrals for other programs in a half-time position. If additional resources or time
cannot be dedicated to diabetes management, creative solutions must be explored to address gaps
in service such as partnering with other diabetes clinics including the Diabetes Education Centre
in West Vancouver for group education or drawing on community resources such as SelfManagement BC for group teleconference sessions or individualized coaching (BC SelfManagement, 2020; Vancouver Coastal Health, 2020b).
The environmental scan identified group education classes were being delivered through
the Diabetes Education Centre in West Vancouver; therefore, creating a partnership with the
team in West Vancouver has opened up the opportunity for individuals in Squamish to access the
group education in addition to the current one-to-one support provided by the dietitian
(Vancouver Coastal Health, 2020b). As part of the partnership, the dietitian will be able to refer

56
clients to the classes (E. Mackay, personal communication, October 29, 2020). The coaching
services and group workshops offered through Self-Management BC is another great opportunity
for clients to engage in person-centered self-management (BC Self-Management, 2020). The
coaching and groups are organized to meet the unique needs and goals of individuals with
diabetes with the support of a trained facilitator (Project Support, personal communication,
November 11, 2020). Olesen et al. (2020) identified group interaction and personal sharing from
peer support were important factors in self-management; therefore, for self-management support
to be successful, the responsibility needs to move beyond the care provider or program and
include strategies to support the individual with diabetes with self-management throughout the
duration of their lives. This may include fostering the client’s own support networks and linking
them with community resources for sustained support. These community resources provide
options to support the gaps in service related to self-management in Squamish.
Although referring clients to services outside Squamish is one solution to bridging
current gaps in service, it may not be suitable for all clients. The increasing number of Canadians
living with multiple chronic disease increases their treatment burden and reduces the likelihood
of their ability to comply with the complexity of uncoordinated responses to each of their
problems (Boehmer et al., 2018). Referring clients to additional services increases the number of
health care encounters and providers involved in their care. If these providers are not part of an
integrated team, there is an increased requirement to coordinate and communicate amongst
multiple clinicians with increased potential for duplication of tests and interventions increasing
the overall treatment burden for the client (Boehmer et al., 2018). This treatment burden is an
important factor in nonadherence to care (Boehmer et al., 2018). Clients with multiple
comorbidities may be overwhelmed by additional referrals outside their current circle of care,

57
reducing the likelihood of participating in potentially beneficial services. Shifting to a personcentered paradigm supports the reality of people living with multiple chronic diseases. A singledisease centric approach results in coexisting conditions becoming of less importance (Canadian
Academy of Health Sciences, 2017). A patient-centered approach accommodates concurrent
conditions and promotes a comprehensive, coordinated approach to care. Integrating selfmanagement education and support for multiple chronic conditions is a strategy that values a the
individual. The Healthy Heart program in Squamish is an example of a program that includes
self-management education and support for cardiovascular disease with the potential to integrate
the lifestyle and behavior change classes with diabetes care and management as many of the
lifestyle modification for risk factors are shared between chronic conditions.
Culturally sensitive care is essential to person-centered self-management. Squamish is a
diverse community with 14.7% of people who consider themselves a visible minority and five
percent of the population who identify as Aboriginal (PHSA, 2019). VCH has begun to
purposefully integrate culturally sensitive care by providing education for staff, but it needs to
become a reality at the local level by integrating it into service delivery and planning; it is
currently up to the provider to integrate culturally sensitive diabetes care into practice in
Squamish. The one-to-one support provided by the dietitian incorporates culturally sensitive
choices such as nutrition options; however, options for culturally sensitive peer support where
individuals are able connect with one another is missing from the health authority services
available. Identifying private community resources was beyond the scope of the environmental
scan; however, it is an area where partnerships could be actively identified and cultivated to
create this type of support in the community especially since peer support has been identified as
an important aspect for successful ongoing self-management.

58
Providing services in a variety of languages is another strategy to better support personcentered and culturally sensitive care. The Diabetes Education Centre offers diabetes education
classes in both English and Farsi to better serve their client population (Vancouver Coastal
Health, 2020b). During the COVID 19 pandemic from spring 2020 to present (winter 2021), the
Squamish health unit was provided tablet devises with access to an app for real-time interpreter
services in over 20 languages via video conferencing allowing clients to see the interpreter’s face
during the interpretation session. They have been used successfully for interpreting between the
client and the clinician for wound care and palliative support; however, this resource may be
beneficial for other programs in Home Health such as diabetes care and management. For a small
community, where creating services in multiple languages may not be a reality, this is an option
to better support minority groups.
The Canadian Academy of Health Sciences (2017) report outlined critical elements of
person-centered primary care including the importance of a multidisciplinary teams to provide
appropriate chronic disease services and to support self-management. Despite the evidence
supporting the integration of team-based care for optimal diabetes management, it is not yet the
norm (General Practice Service Committee, 2020; Gucciardi et al., 2015). The Home Health
program in Squamish includes various disciplines; however, their current workloads and
priorities do not involve diabetes management. With limited resources and time, work priorities
are decided by provincial, health authority and/or local policy. Chronic disease management is
included in the key priorities for the province and VCH, yet there are no guidelines to direct the
implementation of team-based care across BC except for PCNs which are not currently being
universally adopted (BC Ministry of Health, 2020; General Practice Service Committee, 2020;
Vancouver Coastal Health, 2019). BC is working to increase people’s access to multidisciplinary

59
teams through PCNs in the community; however, Squamish is not yet included as one of those
communities; therefore, alternatives to PCNs should be explored.
BC Diabetes, a tertiary care facility based in Vancouver, provides a team-based approach
to diabetes management and includes case management services (BCDiabetes, 2020). Its services
are available for individuals throughout the province; however, it does not provide group
education or peer support which are identified as key components of ongoing diabetes
management in the literature. The Diabetes Clinic at VGH includes a team-based approach to
care and education; however, their services are only available to clients with complex disease
management requirements (Vancouver Coastal Health, 2020a). Future work will include
identifying if clients are being referred to these services by their primary care providers and
evaluating their effectiveness in bridging gaps in service.
In the absence of team-based care, there is an increased need for decision support by
integrating evidence-based guidelines into routine care. Ricci-Cabello et al. (2013) report rural
areas often lack access to a multidisciplinary team which increases the burden on the primary
care provider to be responsible for all aspects of care including self-management education
within the time constraints of a traditional medical system. Braga et al. (2010) found significant
gaps in the treatment Canadians were receiving for type 2 diabetes even after the publication of
the Canadian Diabetes Clinical Practice Guidelines. Patients were not achieving guideline
recommended targets, nor receiving appropriate therapy (Braga et al., 2010). This gap between
the treatment outlined in the guidelines and the care received by Canadians with diabetes
encourages the need for a redesign of services to better meet the health care needs of individuals
living with diabetes. Part of the redesign to improve guideline adherence is integrating decision
support into practice (Clement et al., 2018). The PARIS clinical information system used by the

60
Home Health program does not include integrated guidelines; therefore, the responsibility for
integrating best practice information from the Diabetes Canada Clinical Practice Guidelines and
the BC Guidelines is up to the individual provider such as the dietitian (BC Ministry of Health,
2015a; Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018). Embedding
guidelines and decision support tools into the EMR system or using paper-based flowsheets and
algorithms improves outcomes and supports providers to deliver consistent, evidence-based care
(Clement et al., 2018; Stellefson et al., 2013). This assumes the guidelines are worth following.
Greenhalgh (2019) suggests criteria for guidelines that justify the push to applying them to
practice. These criteria include content that is based on a comprehensive and rigorous review of
the evidence, and the presentation and organization of the guideline that makes it easy to follow
(Greenhalgh, 2019). Both guidelines mentioned above include levels of evidence associated with
each recommendation and the inclusion of flowsheets and algorithms make them easier to
follow. The Diabetes Canada guidelines are significantly longer and more detailed including a
thorough systematic review of the evidence; the entire guideline is over 300 pages long making it
necessary to rely on the decision support tools to guide practice unless the provider has dedicated
time to becoming well versed in the entire contents (Diabetes Canada Clinical Practice
Guidelines Expert Committee, 2018).
The current clinical information system used by providers of the Home Health program
in Squamish has significant limitations preventing the team from benefiting from the positive
advantages of using EMR systems for diabetes care. The PARIS system lacks the ability to
compile patient registries specific to diabetes management and is unable to track diabetes trends.
This limits the ability for benchmarking and for evaluating quality improvement projects without
having to complete manual audits. The system does not allow for follow up visits to be

61
automatically flagged and subsequently booked. Collaboration between primary care providers
and the dietitian is reliant upon faxing information creating the need for paper charts in addition
to documenting in the EMR. This duplication of information increases the chances for error,
creates the potential for lost information and contributes to fragmented health services. These
challenges to collaborative care translate to barriers in providing person-centered care; care is no
longer organized around the individual, but around the system.
Diabetes outcomes improve when clinical information systems contribute to
communication and collaboration amongst health care providers, facilitate tracking of client
trends for benchmarking, and guide decision making by integrating decision support tools and
guidelines. However, the current system in Squamish is not functioning at this level of potential.
It is not clear based on findings of the gap analysis if these limitations are unique to how PARIS
is configurated for the Coastal Community of Care or if PARIS has the potential for increased
functionality. One of the future recommendations includes investigating the potential for
improvements to the current system and/or advocating for a change of clinical information
system.
The distance required for individuals from rural communities to travel for specialized
diabetes services is associated with poorer outcomes (Ricci-Cabello et al., 2013; Strauss et al.,
2006). Telemedicine is an evidence-based option to support diabetes management especially for
smaller communities with limited resources. It allows access to specialized services offered in
larger centers without individuals having to travel long distances. Since the onset of the COVID
19 pandemic, options for telemedicine services have increased. For instance, the diabetes group
education provided at the Diabetes Education Centre in West Vancouver was previously only
available in person, but now the sessions are available virtually or by phone (E. Mackay,

62
personal communication, October 29, 2020). Telemedicine can be used for conferencing with
health care team members and consultations with specialists (BCDiabetes, 2020; Clement et al.,
2018). This shift supports a person-centered approach to health care services, reducing the gap in
services available to individuals living remotely. There are a wide variety of telemedicine
resources available to support diabetes management such as online education through SelfManagement BC, apps to track glycemic control and to support lifestyle changes, and social
networking through group education (BC Self-Management, 2020; Clement et al., 2018; Hou et
al., 2016). Barriers to telemedicine include the technological literacy of clients; however, most
virtual platforms such as zoom also allow for telephonic service for clients who do not have
access to computers or the skill to navigate the service (Mignerat et al., 2014). However, when
planning telemedicine services, computer support should be included to assist populations with
low technological literacy to reduce barriers to accessing care.
Despite the World Health Organization recommending every country implement a
diabetes strategy, Canada has been without a formal strategy since 2013 (Diabetes Canada,
2019). Diabetes Canada created a comprehensive set of clinical practice guidelines (Diabetes
Canada Clinical Practice Guidelines Expert Committee, 2018), and the BC Ministry of Health
has its own set of clinical guidelines (BC Ministry of Health, 2015a), yet there is no unifying
strategy on how to organize diabetes care or service delivery. The BC and VCH service plans
identify priorities to improve chronic disease care in the community yet there are no strategies at
a local level regarding how to enact these priorities. This policy deficit at a local level shifts the
responsibility onto local health authorities and communities to address gaps in diabetes care.

63
CHAPTER 6
Conclusion
Type 2 diabetes is a worldwide challenge with significant health and economic impacts
(International Diabetes Federation, 2019; World Health Organization, 2020). With
approximately eight percent of British Columbians living with diabetes and 29,000 individuals
newly diagnosed each year, type 2 diabetes is one of the top preventable diseases impacting the
wellbeing of individuals and communities (BC Centre for Disease Control, 2020; Diabetes
Canada, 2019; International Diabetes Federation, 2019). Improvements to diabetes care can be
realized by optimizing services under the six elements of the Chronic Care Model from an
integrated person-centered approach (Clement et al., 2018; Grover & Joshi, 2015). The six
elements include self-management, delivery system design, decision support, clinical
information systems, community resources and health system organization. Improvements can be
focused on any element to optimize diabetes management in the community setting; however,
the greatest gains are achievable when improvements include multiple elements of the Chronic
Care Model and most notably self-management and delivery system design (Elissen et al.,
2013b; Grover & Joshi, 2015; Reynolds et al., 2018).
This project compared best practices for diabetes care and services with the findings from
the local environmental scan to identify gaps in service for diabetes management in the
community of Squamish, BC. The gap analysis identified these areas for improvement: creating
group self-management education and ongoing support through follow-up, building
multidisciplinary team-based care, adding case management services, integrating decision
support tools into practice, advocating for clinical information systems with patient registries for
tracking trends and collaborative documentation, connecting with community resources to fill

64
gaps in services and create peer support, utilizing telemedicine technology to support diabetes
care, and advocating for health system policy that supports diabetes services at a local level. A
balance between referring to outside services to bridge service gaps and avoiding increasing the
overall treatment burden should be taken into account. With increasing numbers of individuals
with type 2 diabetes living with other comorbidities, integrating services for a variety of chronic
diseases has the potential to reduce this burden (Boehmer et al., 2018; Canadian Academy of
Health Sciences, 2017; Pryke, 2019).
This project resulted in evidence-based recommendations unique to the context of Home
Health in Squamish to optimize diabetes care and create a plan for future action. Developing a
community plan to improve diabetes care is as individualized as the individual’s plan for
managing the disease; therefore, collaborating with community members and key stakeholders is
the next step in validating and prioritizing results from this project to create the foundation for
future action. This project was focused on the Home Health program in Squamish; therefore,
limitations to this project include the missing perspectives of primary care providers and
community members with diabetes. Whichever recommendations become the focus for quality
improvement work, it is essential the concepts of person-centered, evidence-based and integrated
care underpin the work as they lead to healthier people, communities and better care (World
Health Organization, 2016a, 2002). By having a better understanding of how diabetes care is
organized, it is possible to imagine creative solutions to the challenge of providing effective
diabetes care within the constraints of competing resources and funding in rural community in
BC.

65
These next steps are an opportunity to engage the community for participatory planning.
Recommendations for future work are noted in the next section based on the findings of the
literature review and gap analysis.
Recommendations
The recommendations are based on the results of the narrative literature review and gap
analysis. The Chronic Care Model is a useful framework to organize the recommendations and to
focus future quality improvement efforts (see table 3). A plan for future action includes hosting a
focus group for individuals with type 2 diabetes and a key stakeholder meeting including primary
care providers to address the limitation noted in the conclusion. The recommendations listed
below will be reviewed in the focus group and stakeholder meetings to validate results, to add
new recommendations based on clients’ and providers’ perspectives and to prioritize future work
based on the agreed upon recommendations. These recommendations may not all be attainable
with a finite number of resources; however, it provides a list of suggestions to prioritize based on
the outcomes of the focus group and stakeholder meeting. All interventions and changes to the
current Home Health program for diabetes management must include a plan for evaluation.
Table 3
Recommendations and Evidence
Recommendations
Self-Management
• Add group self-management education and
support either by creating group classes in
Squamish or, referring clients to group classes
at the Diabetes Education Center in West
Vancouver
• Create a systematic process for scheduling
ongoing follow up
• Integrating chronic disease services to reduce
treatment burden for clients with multimorbidity

Evidence
Improved outcomes associated with
self- management education and
support when delivered by a
combination of individual and group
diabetes management with greater than
10 hours of contact time (Chrvala et
al., 2016) and follow-up at least 4
times a year (Sherifali et al., 2018).
Multimorbidity increases the treatment
burden (Boehmer et al., 2018; Pryke,
2019).

66
Delivery System Design
• Integrating additional disciplines from Home
Health into diabetes care and management to
create team-based care until PCNs are
developed in the community
• Adding case management care by allocating
additional time for the dietitian to case manage
clients or adding a nurse case manager

Multidisciplinary team-based care
result in improved outcomes for
diabetes care (Barrett et al., 2007;
Clement et al., 2018; Siminerio et al.,
2005; Wagner et al., 2001).
Case management results in improved
glycemic control and cardiovascular
risk factors (Clement et al., 2018;
Wagner et al., 2001).

Decision Support
• Integrate diabetes guidelines into routine
practice by using flowsheets and decision
support tools from Diabetes Canada or BC
Guidelines until the clinical information system
allows for guidelines to be embedded in the
EMR
• Integrating telemedicine to support care with
specialized services and self-management
resources such as Self-Management BC

Integrating decision support tools into
practice result in better adherence to
clinical practice guidelines, improved
glycemic control and cholesterol
markers (Baptista et al., 2016;
Stellefson et al., 2013).
Telemedicine strategies improve
glycemic control and cardiovascular
risk factors (Clement et al., 2018; Riazi
et al., 2015).

Clinical Information Systems
• Investigating the potential for improvements to
the current clinical information system and/or
advocating for a change of clinical information
system to allow for patient registries, diabetes
trend tacking, benchmarking and evaluating
quality improvement work

Clinical information system
technologies are associated with
reduced HbA1C levels (Riazi et al.,
2015).

Community Resources
• Create partnerships with community resources
to bridge gaps in service
• Create partnerships with local community
groups and to create culturally sensitive peer
supports such as with the Squamish Nation and
community religious groups.
• Groups interested in creating diabetes or
chronic disease supports should be involved in
future planning.

Creating community partnerships
addresses barriers to care and creates
opportunities to address gaps in service
(Clement et al., 2018; Ricci-Cabello et
al., 2013; Stellefson et al., 2013)

Health System Organization
• Advocate for health system policy that supports
diabetes services at a local level.

For health services to succeed in
reorganizing or optimizing diabetes
care and services, it must be included
in organizational goals or policy
(World Health Organization, 2016a).

67

Evaluation is necessary to assess the quality and effectiveness of the recommendations
and interventions (McKenzie et al., 2013). Evaluations include formative evaluations that occur
during the process of planning and implementation to assess the overall quality or elements of
the process, and summative evaluation which occurs at the end to assess the effectiveness of the
interventions (McKenzie et al., 2013). Formative or process evaluations include validating the
results of the narrative review and gap analysis with community members and key stakeholders.
Other example of formative evaluation includes evaluation strategies to assess whether quality
improvement interventions are having the desired effect. These would be specific to the
interventions. For example, if the intervention is to create group self-management sessions,
formative evaluation could include a client satisfaction survey to assess if the sessions addressed
self-management topics; whereas summative evaluation would assess if behavior change
occurred or improvement in glycemic control or reduction of cardiovascular events occurred.
Summative evaluation can be more challenging to complete as it often requires more time and
resources (McKenzie et al., 2013).
Evaluation methods will be included in the planning of the quality improvement
initiatives as it is important to determine achievement of the intended goals, to provide
accountability for actions and interventions to the community and key stakeholders, and to
increase support for future improvements (McKenzie et al., 2013). Additional evaluation tools
specific to evaluating the effectiveness of person-centered implementation strategies in
accordance with the Chronic Care Model include the Patient Assessment of Care for Chronic
Conditions (PACIC) (Improving Chronic Illness Care, 2021). The PACIC is an assessment tool
used to measure actions and qualities of care for chronic diseases as experienced by patients

68
(Improving Chronic Illness Care, 2021). This Patient-Reported Experience Measure (PREMs) is
an evaluation tool that can be used to assess and benchmark quality improvement projects as it
assesses a person-centered approach to care and can be applied regardless of the objective of the
specific intervention. Patient-Reported Outcome Measures (PROMs) is another person-centered
tool to measure the impact on outcomes and can be tailored to the intervention (Santana et al.,
2018). The outcome measure would be selected based on what goals are being assessed as part of
the quality improvement work.
Focus Group
Recommendations include hosting a focus group for individuals in the community living
with type 2 diabetes. This person-centered care approach incorporates the clients’ perspective
regarding the services they currently access and creates an opportunity to identify gaps in care.
Focus groups are a useful participatory qualitative method to obtain preliminary insights or
confirm information on a particular issue from a specific group of people (McKenzie et al.,
2013). A quality leader from the Quality, Patient Safety and Infection Control team would be
involved in the planning of the session to ensure it conforms to ethical standards. An invitation to
five to eight individuals currently receiving care from the Home Health program would be sent
three weeks prior to the session. The session would be held over two hours at the health unit or
virtually due to restrictions from the COVID 19 pandemic and include a set of semi-structured
interview questions to guide the conversation (see appendix C). Answers will be recorded on flip
chart to allow for a summary of the responses to be validated prior to closing the session. The
focus group is essential to the integrity of the process in order to identify gaps in service not yet
identified in the project and validate the recommendations. A limitation to the process includes
the findings of the focus group may not be generalizable to the population of individuals with

69
type 2 diabetes in Squamish because the focus group will only include the perspective of a
limited number of participants (McKenzie et al., 2013).
Stakeholder Meeting
The key stakeholder meeting is fundamental to the process of optimizing diabetes care
because primary care providers are central to the care for individuals with type 2 diabetes and
their voice has not yet been added this project. At present, despite a voiced interest in improving
current diabetes services by the manager of Home Health and the primary care physicians in the
community, the response to the COVID 19 pandemic has taken priority over other initiatives
such as chronic disease management (C. Moberg, personal communication, November 12, 2020).
It is essential for future work that key stakeholders from the community validate results
and recommendations and are involved in future planning. Participants of the key stakeholder
meeting include members of the Home Health program: the manager, the team lead, the intake
nurse, the dietitian, a member from the rehab team, a social worker, the community pharmacist,
and primary care provider representatives from each of the three family physician practices in
Squamish. For community priorities to be successful, key stakeholders must be the ones to
establish priorities and set goals (McKenzie et al., 2013).
The purpose of the stakeholder meeting includes three main objectives: 1) disseminate a
summary of the findings of the literature review and gap analysis, 2) identify current services
offered to people living in the community with type 2 diabetes and identify what services the key
stakeholders felt are missing, and 3) review and revise recommendations to generate a plan for
future work. An agenda outlines the elements of the session (see table 3).

70
Table 4
Agenda for Stakeholder Meeting
Time
0900-0915

Agenda Items
Meet and greet for participants
Share role and what they are hoping to learn or accomplish in the
meeting

0915-0930

Presentation of the summary of finding from the narrative literature review and
gap analysis

1030-1045

Coffee break

1045-1115

Group discussion based on semi-structured questions (see Appendix C).

1115-1145

Group discussion to identify key priorities and make plan for future work

1145-1200

Conclude meeting with summary and plan for next steps

A set of semi-structured interview questions guide the group discussion (see appendix C).
The answers will be recorded on a white board or flip chart and will be summarized in a table
and shared with the participants via email within 2 weeks of the meeting. Responses will be
organized under the six elements of the Chronic Care Model. Future work will include a plan to
evaluate any recommendations implemented as described in the Recommendations section. A
timeline for the work required to prepare for the stakeholder meeting is included in appendix D
and a sample email invitation to send to participants in appendix E.

71
CHAPTER 7
Reflection
The idea for this project was sparked by a perceived gap in services for people living with
type 2 diabetes in Squamish. I started by wondering what diabetes care should look like in the
community setting, but I had no idea where to begin. A broad literature search was initiated to
assess different ways to optimize and organize diabetes health services. Some of the major
themes that emerged regardless of the theory, model or framework being used to examine type 2
diabetes management included integrated care, person-centered care, self-management, teambased or multidisciplinary care, evidence-based care, and care pathways. Organizing all the
findings from a broad literature review was challenging. When I looked at the major themes I
identified in the literature, many of them were the same as the elements of the Chronic Care
Model which then became my framework to organize all the information.
Having a framework to evaluate the literature and to focus the gap analysis was essential
in reducing my bias towards certain aspects of diabetes care such as self-management education
and support as well as team-based care. Those elements of diabetes care were of greater interest
to me and I was less inclined to be interested in the benefits of clinical information systems
supporting the delivery of diabetes care. The Chronic Care Model provided an unbiased structure
to the elements with evidence to support improved diabetes outcomes. The process evolved over
the course of a year and has resulted in clear recommendation that I am extremely hopeful may
become action. Integrating clients and primary care providers from the community is the next
step towards prioritizing quality improvement work. Together, we build capacity to make
change, and we will be able to improve care for individuals with type 2 diabetes in Squamish.

72
References
Alharbi, N. S., Alsubki, N., Jones, S., Khunti, K., Munro, N., & de Lusignan, S. (2016). Impact
of information technology-based interventions for type 2 diabetes mellitus on glycemic
control: A systematic review and meta-analysis. Journal of Medical Internet Research,
18(11), e310. https://doi.org/10.2196/jmir.5778
Baptista, D. R., Wiens, A., Pontarolo, R., Regis, L., Reis, W. C. T., & Correr, C. J. (2016). The
chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic
Syndrome, 8(1), 7. https://doi.org/10.1186/s13098-015-0119-z
Barr, V., Robinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., & Salivaras, S.
(2003). The expanded Chronic Care Model: An integration of concepts and strategies
from population health promotion and the Chronic Care Model. Healthcare Quarterly,
7(1), 73–82. https://doi.org/10.12927/hcq.2003.16763
Barrett, J., Curran, V., Glynn, L., & Godwin, M. (2007). CHSRF synthesis: Interprofessional
collaboration and quality primary healthcare. Canadian Health Services Research
Foundation. https://docplayer.net/18393911-Chsrf-synthesis-interprofessionalcollaboration-and-quality-primary-healthcare.html
BC Centre for Disease Control. (2020). Chronic disease dashboard. http://www.bccdc.ca/healthprofessionals/data-reports/chronic-disease-dashboard
BC Freedom of Information and Privacy Association. (2011). Other ministry of health
databases. Health Information Privacy in British Columbia.
http://www.healthinfoprivacybc.ca/other-health-information-programs/other-ministry-ofhealth-databases

73
BC Ministry of Health. (2014). Setting priorities for the B.C. health system.
https://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BCHealth-Feb14.pdf
BC Ministry of Health. (2015a). Diabetes care: BC guidelines. Province of British Columbia.
https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bcguidelines/diabetes
BC Ministry of Health. (2015b). Diabetes patient care flow sheet.
https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bcguidelines/dc_flow_sheet.pdf
BC Ministry of Health. (2015c). The British Columbia patient-centered care framework.
https://www.health.gov.bc.ca/library/publications/year/2015_a/pt-centred-careframework.pdf
BC Ministry of Health. (2018). North Shore-Coast Garibaldi.
https://www2.gov.bc.ca/assets/gov/data/geographic/land-use/administrativeboundaries/health-boundaries/33_north_shore-coast_garibaldi.pdf
BC Ministry of Health. (2020). Ministry of Health 2020/21—2022/23 service plan.
https://www2.gov.bc.ca/assets/gov/government/ministriesorganizations/ministries/health/hlth_sp_2020.pdf
BC Ministry of Health. (2021). Home and community care policy manual. Province of British
Columbia. https://www2.gov.bc.ca/gov/content/health/accessing-health-care/homecommunity-care/accountability/policy-and-standards/home-and-community-care-policymanual
BC Self-Management. (2020). Self-Management BC. https://www.selfmanagementbc.ca/home

74
BC Stats. (2019). 2019 sub-provincial population estimates highlights.
https://www2.gov.bc.ca/assets/gov/data/statistics/people-populationcommunity/population/pop_sub-provincial_population_highlights.pdf
BCDiabetes. (2020). BCDiabetes—British Columbia diabetes care, research, and education.
BCDiabetes. https://www.bcdiabetes.ca/
Boehmer, K. R., Abu Dabrh, A. M., Gionfriddo, M. R., Erwin, P., & Montori, V. M. (2018).
Does the chronic care model meet the emerging needs of people living with
multimorbidity? A systematic review and thematic synthesis. PloS One, 13(2), e0190852.
https://doi.org/10.1371/journal.pone.0190852
Bongaerts, B. W. C., Müssig, K., Wens, J., Lang, C., Schwarz, P., Roden, M., & Rathmann, W.
(2017). Effectiveness of chronic care models for the management of type 2 diabetes
mellitus in Europe: A systematic review and meta-analysis. BMJ Open, 7(3), e013076.
https://doi.org/10.1136/bmjopen-2016-013076
Braga, M. F., Casanova, A., Teoh, H., Dawson, K. G., Gerstein, H. C., Fitchett, D. H., Harris, S.
B., Honos, G., McFarlane, P. A., Steele, A., Ur, E., Yale, J.-F., Langer, A., Goodman, S.
G., & Leiter, L. A. (2010). Treatment gaps in the management of cardiovascular risk
factors in patients with type 2 diabetes in Canada. The Canadian Journal of Cardiology,
26(6), 297–302.
Busetto, L., Luijkx, K. G., Elissen, A. M. J., & Vrijhoef, H. J. M. (2016). Context, mechanisms
and outcomes of integrated care for diabetes mellitus type 2: A systematic review. BMC
Health Services Research, 16(16). https://doi.org/10.1186/s12913-015-1231-3

75
Canadian Academy of Health Sciences. (2017). Review of chronic care. https://www.cahsacss.ca/wp-content/uploads/2017/09/Review-of-Chronic-Care_Veterans-AffairsCanada.pdf
Canadian Diabetes Association. (2018). Diabetes patient care flow sheet for adults. Canadian
Journal of Diabetes, 42, S309–S310. https://doi.org/10.1016/j.jcjd.2017.10.042
Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for
adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic
control. Patient Education and Counseling, 99(6), 926–943.
https://doi.org/10.1016/j.pec.2015.11.003
Clement, M., Filteau, P., Harvey, B., Jin, S., Laubscher, T., Mukerji, G., & Sherifali, D. (2018).
Organization of diabetes care. Canadian Journal of Diabetes, 42, S27–S35.
https://doi.org/10.1016/j.jcjd.2017.10.005
Desmedt, M., Vertriest, S., Hellings, J., Bergs, J., Dessers, E., Vankrunkelsven, P., Vrijhoef, H.,
Annemans, L., Verhaeghe, N., Petrovic, M., & Vandijck, D. (2016). Economic impact of
integrated care models for patients with chronic diseases: A systematic review. Value in
Health, 19(6), 892–902. https://doi.org/10.1016/j.jval.2016.05.001
Diabetes Canada. (2018). Managing my diabetes: My action plan.
https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-MyDiabetes/Tools%20and%20Resources/managing-my-diabetes-my-actionplan.pdf?ext=.pdf
Diabetes Canada. (2019). 2020 pre-budget consultation submission.
https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-

76
Policy/Submissions%20to%20Government/Provincial/2020-BC-Pre-BudgetSubmission_Final.pdf
Diabetes Canada Clinical Practice Guidelines Expert Committee. (2018). Diabetes Canada 2018
clinical practice guidelines. Candian Journal of Diabetes, 42(S1), S1–S325.
Dinca-Panaitescu, M., Dinca-Panaitescu, S., Raphael, D., Bryant, T., Pilkington, B., & Daiski, I.
(2012). The dynamics of the relationship between diabetes incidence and low income:
Longitudinal results from Canada’s National Population Health Survey. Maturitas, 72(3),
229–235. https://doi.org/10.1016/j.maturitas.2012.03.017
District of Squamish. (2015). Community profile. https://squamish.ca/assets/EconomicDevelopment/40a0b58e88/Community-Profile-October-2015.pdf
Dorsey, E. R., & Topol, E. J. (2016). State of telehealth. New England Journal of Medicine,
375(2), 154–161. https://doi.org/10.1056/NEJMra1601705
Doyle, A. (2020). Best diabetes apps of 2020. Healthline.
https://www.healthline.com/health/diabetes/top-iphone-android-apps
Elissen, A. M. J., Steuten, L. M. G., Lemmens, L. C., Drewes, H. W., Lemmens, K. M. M.,
Meeuwissen, J. A. C., Baan, C. A., & Vrijhoef, H. J. M. (2013a). Meta-analysis of the
effectiveness of chronic care management for diabetes: Investigating heterogeneity in
outcomes. Journal of Evaluation in Clinical Practice, 19(5), 753–762.
https://doi.org/10.1111/j.1365-2753.2012.01817.x
Elissen, A. M. J., Steuten, L. M. G., Lemmens, L. C., Drewes, H. W., Lemmens, K. M. M.,
Meeuwissen, J. A. C., Baan, C. A., & Vrijhoef, H. J. M. (2013b). Meta-analysis of the
effectiveness of chronic care management for diabetes: Investigating heterogeneity in

77
outcomes. Journal of Evaluation in Clinical Practice, 19(5), 753–762.
https://doi.org/10.1111/j.1365-2753.2012.01817.x
Epstein, R. M., & Street, R. L. (2011). The values and value of patient-centered care. Annals of
Family Medicine, 9(2), 100–103. https://doi.org/10.1370/afm.1239
Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24, 230–235.
https://doi.org/10.1179/2047480615Z.000000000329
Forbes, A., While, A., Griffiths, P., Ismail, K., & Heller, S. (2011). Organizing and delivering
diabetes education and self-care support: Findings of scoping project. Journal of Health
Services Research & Policy, 16(s1), 42–49. https://doi.org/10.1258/jhsrp.2010.010102
General Practice Service Committee. (2020). Primary care networks. https://gpscbc.ca/what-wedo/system-change/primary-care-networks
General Practice Service Committee. (2020). Team-based care. https://gpscbc.ca/what-wedo/system-change/team-based-care
Goodwin, N., Smith, J., Davies, A., Perry, C., Rosen, R., Dixon, J., & Ham, C. (2012). Integrated
care for patients and populations: Improving outcomes by working together. A Report to
the Department of Health and the NHS Future Forums.
Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101–117.
https://doi.org/10.1016/S0899-3467(07)60142-6
Greenhalgh, T. (2019). How to read a paper: The basics of evidence-based medicine and
healthcare (Sixth edition). John Wiley & Sons Ltd.

78
Grover, A., & Joshi, A. (2015). An overview of chronic disease models: A systematic literature
review. Global Journal of Health Science, 7(2), 210–227.
https://doi.org/10.5539/gjhs.v7n2p210
Gucciardi, E., Espin, S., Morganti, A., & Dorado, L. (2015). Implementing specialized diabetes
teams in primary care in southern Ontario. Canadian Journal of Diabetes, 39(6), 467–
477. https://doi.org/10.1016/j.jcjd.2015.07.006
Gucciardi, E., Espin, S., Morganti, A., & Dorado, L. (2016). Exploring interprofessional
collaboration during the integration of diabetes teams into primary care. BMC Family
Practice, 17(11). https://doi.org/10.1186/s12875-016-0407-1
Hou, C., Carter, B., Hewitt, J., Francisa, T., & Mayor, S. (2016). Do mobile phone applications
improve glycemic control (HbA1c) in the self-management of diabetes? A systematic
review, meta-analysis, and GRADE of 14 randomized trials. Diabetes Care, 39(11),
2089–2095. https://doi.org/10.2337/dc16-0346
Houlden, R. L. (2018). Introduction. Canadian Journal of Diabetes, 42, S1–S5.
https://doi.org/10.1016/j.jcjd.2017.10.001
Improving Chronic Illness Care. (2021). PACIC survey: Improving Chronic Illness Care.
http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36
Improving Chronic Illness Care (ICIC). (2020). The Chronic Care Model: Model elements.
http://www.improvingchroniccare.org/index.php?p=Model_Elements&s=18
International Diabetes Federation. (2009). IDF diabetes atlas: 4th edition.
International Diabetes Federation. (2019). IDF diabetes atlas: 9th edition.
https://www.diabetesatlas.org/upload/resources/material/20200302_133351_IDFATLAS
9e-final-web.pdf#page=38&zoom=auto

79
Lim, L. L., Lau, E. S. H., Kong, A. P. S., Davies, M. J., Levitt, N. S., Eliasson, B., AguilarSalinas, C. A., Ning, G., Seino, Y., So, W. Y., McGill, M., Ogle, G. D., Orchard, T. J.,
Clarke, P., Holman, R. R., Gregg, E. W., Gagliardino, J. J., & Chan, J. C. N. (2018).
Aspects of multicomponent integrated care promote sustained improvement in surrogate
clinical outcomes: A systematic review and meta-analysis. Diabetes Care, 41(6), 1312–
1320. https://doi.org/10.2337/dc17-2010
LMC Healthcare. (2020). Diabetes prevention. https://www.lmc.ca/diabetes-prevention/
Locke, S. R., Dix, G., Te Hiwi, B., Oelke, N. D., Rush, K. L., Berg, S., Dinwoodie, M., Jung, M.
E., & Martin Ginis, K. A. (2020). Improving diabetes care in the British Columbia
Southern Interior: Developing community‒university initiatives to address service gaps.
Canadian Journal of Diabetes. https://doi.org/10.1016/j.jcjd.2020.04.003
Manns, B. J., Tonelli, M., Zhang, J., Campbell, D. J. T., Sargious, P., Ayyalasomayajula, B.,
Clement, F., Johnson, J. A., Laupacis, A., Lewanczuk, R., McBrien, K., & Hemmelgarn,
B. R. (2012). Enrolment in primary care networks: Impact on outcomes and processes of
care for patients with diabetes. Canadian Medical Association Journal, 184(2), E144–
E152. https://doi.org/10.1503/cmaj.110755
McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2013). Planning, implementing and evaluating
health promotion programs: A primer (6th ed.). Pearson Education, Inc.
https://www.vitalsource.com/en-ca/products/planning-implementing-amp-evaluatinghealth-james-f-mckenzie-v9780134394060
Mignerat, M., Lapointe, L., & Vedel, I. (2014). Using telecare for diabetic patients: A mixed
systematic review. Health Policy and Technology, 3(2), 90–112.
https://doi.org/10.1016/j.hlpt.2014.01.004

80
Morgan, S., & Yoder, L. H. (2012). A concept analysis of person-centered care. Journal of
Holistic Nursing, 30(1), 6–15. https://doi.org/10.1177/0898010111412189
O’Brien, S. V., & Hardy, K. J. (2003). Developing and implementing diabetes care pathways.
7(2), 4.
Olesen, K., Hempler, N. F., Drejer, S., Baumgarten, S. V., & Stenov, V. (2020). Impact of
patient-centred diabetes self-management education targeting people with type 2
diabetes: An integrative review. Diabetic Medicine, 37(6), 909–923.
https://doi.org/10.1111/dme.14284
Penn, M. L., Kennedy, A. P., Vassilev, I. I., Chew-Graham, C. A., Protheroe, J., Rogers, A., &
Monks, T. (2015). Modelling self-management pathways for people with diabetes in
primary care. BMC Family Practice, 16(1), 112. https://doi.org/10.1186/s12875-0150325-7
PHSA. (2019). BC community health profile: Squamish.
http://communityhealth.phsa.ca/HealthProfiles/PdfGenerator/Squamish
Pryke, R. (2019). The challenges of multimorbidity: Building bridges between diabetes and
comorbidities. Diabetes & Primary Care, 21(3), 79–83.
Public Health Agency of Canada. (2016). Health status of canadians 2016.
https://healthycanadians.gc.ca/publications/department-ministere/state-public-healthstatus-2016-etat-sante-publique-statut/alt/pdf-eng.pdf
Pulvirenti, M., McMillan, J., & Lawn, S. (2014). Empowerment, patient centred care and self‐
management. Health Expectations : An International Journal of Public Participation in
Health Care and Health Policy, 17(3), 303–310. https://doi.org/10.1111/j.13697625.2011.00757.x

81
Reichert, S. M., Harris, S., & Harvey, B. (2014). An innovative model of diabetes care and
delivery: The St. Joseph’s Primary Care Diabetes Support Program (SJHC PCDSP).
Canadian Journal of Diabetes, 38(3), 212–215.
https://doi.org/10.1016/j.jcjd.2014.03.008
Reynolds, R., Dennis, S., Hasan, I., Slewa, J., Chen, W., Tian, D., Bobba, S., & Zwar, N. (2018).
A systematic review of chronic disease management interventions in primary care. BMC
Family Practice, 19(1), 11. https://doi.org/10.1186/s12875-017-0692-3
Riazi, H., Larijani, B., Langarizadeh, M., & Shahmoradi, L. (2015). Managing diabetes mellitus
using information technology: A systematic review. Journal of Diabetes and Metabolic
Disorders, 14. https://doi.org/10.1186/s40200-015-0174-x
Ricci-Cabello, I., Ruiz-Perez, I., Rojas-García, A., Pastor, G., & Gonçalves, D. C. (2013).
Improving diabetes care in rural areas: A systematic review and meta-analysis of quality
improvement interventions in OECD countries. PLoS ONE, 8(12), e84464.
https://doi.org/10.1371/journal.pone.0084464
Romanow, R. (2002). Building on values: The future of health care in Canada—Final Report.
National Library of Canada.
Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2018). How to
practice person‐centred care: A conceptual framework. Health Expectations : An
International Journal of Public Participation in Health Care and Health Policy, 21(2),
429–440. https://doi.org/10.1111/hex.12640
Sherifali, D., Berard, L. D., Gucciardi, E., MacDonald, B., & MacNeill, G. (2018). Selfmanagement education and support. Canadian Journal of Diabetes, 42, S36–S41.
https://doi.org/10.1016/j.jcjd.2017.10.006

82
Siminerio, Piatt, G., & Zgibor, J. C. (2005). Implementing the chronic care model for
improvements in diabetes care and education in a rural primary care practice. The
Diabetes Educator, 31(2), 225–235.
Siminerio, Ruppert, K., Huber, K., & Toledo, F. G. S. (2014). Telemedicine for Reach,
Education, Access, and Treatment (TREAT): Linking telemedicine with diabetes selfmanagement education to improve care in rural communities. The Diabetes Educator,
40(6), 797–805. https://doi.org/10.1177/0145721714551993
Statistics Canada. (2017). Census Profile, 2016 Census—North Shore/Coast Garibaldi Health
Service Delivery Area. https://www12.statcan.gc.ca/census-recensement/2016/dppd/prof/details/page.cfm?Lang=E&Geo1=HR&Code1=5933&Geo2=PR&Code2=59&Se
archText=North%20Shore/Coast%20Garibaldi%20Health%20Service%20Delivery%20A
rea&SearchType=Begins&SearchPR=01&B1=All&GeoLevel=PR&GeoCode=5933&TA
BID=1&type=0
Statistics Canada. (2017). Census Profile, 2016 Census—Squamish, British Columbia.
https://www12.statcan.gc.ca/census-recensement/2016/dppd/prof/details/page.cfm?Lang=E&Geo1=POPC&Code1=0781&Geo2=PR&Code2=59&
Data=Count&SearchText=Squamish&SearchType=Begins&SearchPR=01&B1=All
Statistics Canada. (2018). Aboriginal population profile, 2016 Census—Squamish, district
municipality. https://www12.statcan.gc.ca/census-recensement/2016/dppd/abpopprof/details/page.cfm?Lang=E&Geo1=CSD&Code1=5931006&Data=Count&S
earchText=squamish&SearchType=Begins&B1=All&SEX_ID=1&AGE_ID=1&RESGE
O_ID=1

83
Statistics Canada. (2018b). Diabetes, 2017. https://www150.statcan.gc.ca/n1/pub/82-625x/2018001/article/54982-eng.htm
Statistics Canada. (2018a). Table 13-10-0096-07 Diabetes, by age group.
https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009607
Statistics Canada. (2019). Overweight and obese adults, 2018.
Stellefson, M., Dipnarine, K., & Stopka, C. (2013). The chronic care model and diabetes
management in US primary care settings: A systematic review. Preventing Chronic
Disease, 10, E26. https://doi.org/10.5888/pcd10.120180
Strauss, K., MacLean, C., Troy, A., & Littenberg, B. (2006). Driving distance as a barrier to
glycemic control in diabetes. Journal of General Internal Medicine, 21(4), 378–380.
https://doi.org/10.1111/j.1525-1497.2006.00386.x
Szafran, O., Kennett, S. L., Bell, N. R., & Torti, J. M. I. (2019). Interprofessional collaboration
in diabetes care: Perceptions of family physicians practicing in or not in a primary health
care team. BMC Family Practice, 20(1), NA-NA. https://doi.org/10.1186/s12875-0190932-9
Vancouver Coastal Health. (2012). Sea to Sky Healthy Heart Program.
https://happyheartsvancouver.files.wordpress.com/2013/03/pamphlet-sea-to-skysquamish.pdf
Vancouver Coastal Health. (2015). Aboriginal cultural practices: A guide for physicians and
allied health care professionals. http://www.vch.ca/Documents/AH-cultural-practices.pdf
Vancouver Coastal Health. (2019). Service plan 2019/20-2021/22.
http://www.vch.ca/Documents/Service-Plan-2019.pdf

84
Vancouver Coastal Health. (2020a). Diabetes clinic: Gordon and Leslie Diamond Health Care
Centre. http://www.vch.ca/Locations-Services/result?res_id=708
Vancouver Coastal Health. (2020b). Diabetes education centre: North Shore chronic disease
services. http://www.vch.ca/Locations-Services/result?res_id=637
Vancouver Coastal Health. (2020c). Healthy living program: Vancouver community.
http://www.vch.ca/Locations-Services/result?res_id=1347
Vancouver Coastal Health. (2021). DASH: Data Analytics Solution for Health.
http://vchphcdash.healthbc.org/Pages/DASH.aspx
Wagner, Davis, C., Schaefer, J, Von Korff, M, & Austin, B. (1999). A survey of leading chronic
disease management programs: Are they consistent with the literature? Managed Care
Quarterly, 7(3), 56–66.
Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001).
Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6),
64–78. https://doi.org/10.1377/hlthaff.20.6.64
Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic
illness. The Milbank Quarterly, 74(4), 511–544. JSTOR. https://doi.org/10.2307/3350391
Wagner, E. H., Davis C, Schaefer J, Von Korff M, & Austin B. (2002). A survey of leading
chronic disease management programs: Are they consistent with the literature? Journal of
Nursing Care Quality, 16(2), 67–80. https://doi.org/10.1097/00001786-200201000-00008
World Health Organization. (2016a). Framework on integrated, people-centred health services.
https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1

85
World Health Organization. (2016b). Integrated care models: An overview.
https://www.euro.who.int/ data/assets/pdf_file/0005/322475/Integrated-care-modelsoverview.pdf
World Health Organization. (2002). Innovative care for chronic conditions: Building blocks for
action.
https://apps.who.int/iris/bitstream/handle/10665/42500/WHO_NMC_CCH_02.01.pdf
World Health Organization. (2020). Diabetes. https://www.who.int/news-room/factsheets/detail/diabetes
Zgibor, J. C., Gieraltowski, L. B., Talbott, E. O., Fabio, A., Sharma, R. K., & Karimi, H. (2011).
The association between driving distance and glycemic control in rural areas. Journal of
Diabetes Science and Technology, 5(3), 494–500.
https://doi.org/10.1177/193229681100500304

Topic/focus/question

To assess the impact of
information technology
on changes in the levels
of HbA1C using the
CCM

Review of randomized
controlled trials to
evaluate different
elements of the Chronic
Care Model (CCM) in
patients with type 2
diabetes mellitus
(T2DM) and to assess
the influence of the
CCM on different
clinical outcomes.

Review of European
Chronic Care programs
that include

Author/Date

(Alharbi et al.,
2016)

(Baptista et al.,
2016)

(Bongaerts et
al., 2017)

CCM and
T2DM

Chronic Care
Model
(CCM) and
Type 2
Diabetes
(T2DM)

Information
technology;
Chronic Care
Model

Concept/Th
eoretical
Model

Systematic
Review of 12

Systematic review
of12 RCTs
USA and Hong
Kong

Systematic review
and meta-analysis
of 32 clinical
studies, mainly
from the US

Context/Setting/
Sample/Method

Multifaceted diabetes care resulted in
small improvements of outcomes,
there is a lack of studies looking at

Greater benefit obtained through
combing all 6 elements of CCM.
Article review findings organized
under each of the 6 CCM categories.

Studies focusing on electronic selfmanagement systems demonstrated
the largest reduction in HbA1C,
followed by those with electronic
medical records, an electronic
decision support system, and a
diabetes registry. In addition, the
more CCM-incorporated the
information technology–based
interventions were, the more
improvements there were in HbA1C
levels.

Findings

Narrative Literature Review Matrix

Appendix A

Meta-analysis of
all reported
outcomes was

Studies
reviewed
included
limitations such
included short
follow-up period
and a low
number of
patients.
Research
including all 6
elements would
be of benefit.

Further
investigation
required to
understand how,
why, and when
information
technology can
improve the care
of patients with
T2DM. This
includes a costbenefit analysis.

Future
Research/limit
ations

Challenging to
evaluate outcomes
due to

Prevention and
early intervention
with integrated
management –
isolated
components of the
CCM are not
enough, but
combining
elements is better.

The results align
with other reviews
that changes must
be made in
multiple areas of
the CCM in order
to considerably
improve the
outcomes of
diabetes care

Conclusion/Notes

86

To answer two research
questions: First, what
are the context,
mechanisms and
outcomes of integrated
care for people with
type 2 diabetes?
Second, what are the
relationships between
context, mechanisms
and outcomes of
integrated care for
people with type 2
diabetes?

The report aims to
present current best
practices and emerging
trends in chronic
disease management.

(Busetto et al.,
2016)

(Canadian
Academy of
Health
Sciences,
2017)

multifaceted diabetes
care interventions for
T2DM compared with
usual diabetes care.

CCM; selfmanagement;
patientcentered care

Chronic Care
Model,
integrated
care, Context
mechanism
outcome
model
(CMO)

Summary report
based on
comprehensive
review of care for
people with
chronic health
conditions

Systematic review
of 32
Qualitative and
quantitative
studies

studies and Metaanalysis

Five key areas: 1) high prevalence of
chronic conditions in Canada; 2)
Patient-centered care is required for
effective CDM; 3) critical elements
of patient-centered care include
interdisciplinary team and selfmanagement support; 4) Clinicians
require decision making tools that

Due to the low number of articles
reporting comparable quantitative
outcome measures or in-depth
qualitative information, it was not
possible to make statements about
the relationship between context,
mechanisms and outcomes. Barriers
at an innovation level include
difficulties relating to the database or
electronic medical record used for
the innovation. At the individual
professional level, reluctance to
discharge patients or share care as
well as general low provider
engagement were often mentioned.

all 6 components. Difficult to
compare because of variety of
components addressed and differing
outcome measures. Most benefit
found for newly diagnosed T2DM
compared to people with prevalent
diabetes.

Does not
explain review
process

Future research
should be
conducted with
the CMO model
incorporated
into study
designs to gain
insights into the
relationships
between the
context,
mechanisms and
outcomes of
integrated care.

not possible
because of the
heterogeneity of
study
populations,
duration of the
interventions –
this is found
with other
reviews

Patient-centered
care from
multidisciplinary y
teams focused on
providing selfmanagement
support is key to
effective

Efficient resource
allocation should
increase
investments at the
organisational
context level
where most
barriers are
expected to occur.

heterogeneity of
interventions and
outcome measures.

87

To understand the effect Chronic Care
of heterogeneity in
Model
outcomes when
evaluating the Chronic
Care Model

(Elissen et al.,
2013b)

Chronic Care
Model; Selfmanagement

Chapter on
Organization of Care
from the
Diabetes Canada 2018
Practice Guideline.

(Clement et al.,
2018)

Selfmanagement
education
and selfmanagement
support

Assess the effect of
diabetes selfmanagement education
and support methods
such as providers,
duration, and contact
time on glycemic
control in adults with
T2DM.

(Chrvala et al.,
2016)

Systematic review
of 61 studies and
15 systematic
review evaluating
diabetes programs

Clinical practice
guideline for
Diabetes Canada

Systematic review
of 118
randomized
controlled trials in
adults with T2DM

HbA1C, systolic BP and guideline
adherence were the most frequently
evaluated outcomes with
improvements in all for the
intervention/CCM group. 3-4
components attained stronger results

Person with diabetes needs to be an
active participant in care and care is
organized within the context of the
expanded chronic care model.
Facilitated by an interprofessional
team trained in diabetes care
involving the primary care provider
and case management and supported
by clinical information and decision
support system.

A combination of group and
individual engagement results in the
largest decreases in A1C (0.88).
Contact hours ≥10 was associated
with a greater proportion of
interventions with a significant
reduction in A1C (70.3%). In
patients with persistently elevated
glycemic values (A1C>9), a greater
proportion of studies reported
statistically significant reduction in
A1C (83.9%).

consider the overall burden of
disease to effectively manage people
with multimorbidity; 5) the CCM is
the most promising model for CDM.

Despite
including the
CCM as a
framework to
guide the
organization of
diabetes care,
there is no
standardized
approach in
Canada.
Further
investigations of
heterogeneity to
ensure evidencebased

Some studies
did not include a
detailed
description of
the intervention
and
characteristics
of the study
population
which limits
generalizability
of their results.

Overall CCM
results in positive
outcomes,
especially when
including more

The chapter
reflects the value
of using the CCM
for QI work

management of
chronic diseases.
The CCM can be
used to guide
health care
improvements.
Robust data
demonstrated
diabetes selfmanagement
education results
in a statistically
significant
decrease in A1C
levels.

88

Goal to outline an
overview of the
organization and
delivery of diabetes
education and self-care
support.

The goal was to
systematically review
and evaluate various
existing chronic disease
models, their elements
and
their role in the
management of
diabetes, Chronic
Obstructive Pulmonary
Disease (COPD), and
Cardiovascular diseases
(CVD).

(Forbes et al.,
2011)

(Grover &
Joshi, 2015)

CCM,
Improving
Chronic
Illness Care
(ICIC),
Innovative
Care for
Chronic
Conditions
(ICCC),
Stanford
Model (SM),
and
Community
based

Selfmanagement
education
and support

Systematic
literature review
of 23 studies.
Majority in USA

Scoping review
including 4
methods to collect
data: literature
review (211
papers), patient
participation
event (38 people),
online survey
(495 patients and
423 professionals
complete the
survey) and
conference (20
participants).
CCM was the most studied model.
Elements of the various models
studied include delivery system
design and
self-management support (87%),
clinical information system and
decision support (57%) and health
system
organization (52%), care centered on
the patient and family (13%), patient
safety (4%), community policies
(4%), built integrated health care
(4%) and remote patient monitoring
(4%).

A variety of themes were identified
to in the organization and delivery of
self-care – there was little
consistency between the approaches
and rarely embedded in a
comprehensive framework for care
delivery. 4 models were developed in
an effort to shape self-care: a
diabetes education pathway;
integrating self-care and clinicalcare; choice as a method of
optimizing care; and an integrated
framework for delivering for diabetes
self-care.

– changes made in multiple areas to
considerably improve the quality and
outcomes of diabetes care.

Future studies
should include
racially and
ethnically
representative
patients.
Limitations
include the
inclusion of
only studies that
specifically
mention a
particular
chronic disease
model. There
are individual

Further research
to identify the
approaches that
would be most
successful in
creating long
term behavior
change and
benefit.

The variety of
models makes the
study of effective
CDM challenging.
A comparison of
the models and all
the elements is
complex and
therefore difficult
to come to
conclusions on the
most effective
frameworks to
optimize care.

The lack of
structure or
consistency in
approaches
strengthens the
case for the use of
the CCM to guide
change or another
unified
implementation
strategy.

improvements in than 2 elements of
care
CCM

89

This study explores the
implementation
processes of integrating
specialized diabetes
teams, specifically
nurse and dietitian
diabetes educators into
primary care sites.

Website for CCM

(Gucciardi et
al., 2015)

(Improving
Chronic Illness
Care (ICIC),
2020)

Improving
Chronic
Illness Care
and CCM

CCM,
Selfmanagement
and teambased care.

Transition
Model
(CBTM).

Qualitative
interviews with
patients (23),
educators (20)
and primary care
physicians (16).
Ontario, Canada

The Chronic Care Model (CCM)
originated from a synthesis of
scientific literature undertaken
by The MacColl Institute for
Healthcare Innovation in the early
1990’s. The website provides
resources available through the
Improving Chronic Illness Care

The analysis revealed 3 themes:
Right time, right place, right service;
creating partnerships; operational
complexities and strategies. The
benefits to implementing specialized
diabetes teams were explored as well
as the barriers to implementation

Implemented in
city settings;
therefore
potentially lacks
generalizability
to rural setting.

elements of
these chronic
disease models
that have been
widely studied
in literature but
have not
referred to a
model.
Effective
implementation
requires an
understanding of
the benefits (for
buy in), proper
introductory
support, genuine
invested support
from management
and organization,
and the ability of
team to
communicate
effectively and
solve problems to
offset challenges
as they arise.

90

To examine sustained
effectiveness of
multicomponent
integrated care in type 2
diabetes.

The purpose of the
study was to identify
diabetes services in the
region and to codevelop communityuniversity research
project to address
service barriers and
gaps.

(Lim et al.,
2018)

(Locke et al.,
2020)

Communityengagement
approach;
culturally
sensitive care

Chronic Care
Model;
Integrated
care

Web based
search,
environmental
scan and a
meeting with
researchers and
community
members.
Southern interior
of BC, Canada

Systematic review
and meta-analysis
of 181 RCT
evaluating 13
quality
improvement
strategies

78 diabetes related services were
identified, and the meeting produced
plans for 2 collaborative projects: the
development of a diabetes patient
journey map and the development of
a diabetes service hub with patient
navigators.

Multicomponent integrated care
lasting at least 12 months reduced
HbA1C, SBP, DBP, and LDL levels.
Due to their phenotypic
heterogeneity, patients require
individualized biomedical, cognitive,
psychosocial, and behavioral
interventions.
The QI strategies: team change,
patient education, patient selfmanagement, electronic registry, and
using relay to promote patientprovider communication had the
largest independent effect.

program on the CCM and other
related resources from improving
chronic illness care such as the
Patient-Centered Medical Home.

Future research
should include
patients with
diabetes to
provide a more
comprehensive
perspective of
diabetes services

Lack of access
to patient-level
data limited the
robustness of
our subgroup
analyses. Here,
socioeconomic,
education status,
sex, ethnicity,
disease duration,
health care
system (e.g.,
public, private,
subsidized), and
access to drugs
can all influence
the effectiveness
of integrated
care.

Research that
partners with
members of the
community at the
outset has
increased potential
to create
meaningful and
sustained change.

Team-based care
and improved
information flow
may improve
patient-provider
communication
and selfmanagement.

91

To determine outcomes
for patients with T2DM
enrolled in primary care
networks.

Experience of
developing care
pathways for NSF in
UK.

To synthesize primary
research results on
person-centered selfmanagement education
and supports for T2DM
to identify effective
interventions.

(Manns et al.,
2012)

(O’Brien &
Hardy, 2003)

(Olesen et al.,
2020)

Selfmanagement
education

Care
pathways

Primary Care
Networks –
multidiscipli
nary teams
and T2DM

Integrative review
of 22 studies (mix
of quantitative
and qualitative)

Started in
outpatient clinics
with measured
success and
developed for
inpatient and
primary care
settings.

Primary Care
Networks in
Alberta, BC,
Canada

Majority of interventions were
successful in improving HbA1C and
quality of life. Limited benefit in
lowering cholesterol, weight and
long-term behavior changes. Many
studies with positive outcomes were
group programs where personal
sharing and group interactions (peer
support) improve self-management

Developed care pathways because
clients were not receiving consistent
medical management and there was
no formal patient education program.
Implemented and evaluated over 4
years. Care pathways equaled an
important tool to deliver high quality,
evidence-based care.

The care received by patients with
diabetes in the primary care networks
was associated with more use of
guideline-recommended screening
and (for patients with prevalent
diabetes) a lower rate of admissions
to hospital or visits to emergency
departments for diabetes- specific
ambulatory care sensitive conditions.
However, the absolute changes were
small, and unable to establish
causality. (Ontario implemented
similar model = Ontario family
health teams and patient centered
medical homes in the US – they all
seek to improve access to and
coordination of care)

The ability of
the authors to
compare
specific
interventions
and specific
approaches was
limited because
of the lack of

Future studies
should aim to
determine how
primary care
networks can
best implement
evidence-based
programs for the
management of
diabetes. This
study was not
randomized

The application of
person-centered
approaches is more
successful than
traditional didactic
self-management
education.
Provider training
may have an

Authors encourage
pathway to be used
and adapted to fit
other diabetic
services.

Primary Care
Networks
interventions and
programs varied as
there is no guiding
framework on how
to best implement
CDM programs;
therefore,
challenging to
accurately
compare and
evaluate.

92

Goal was to model
pathways in primary
care to explore
processes and points
where people struggle
to find selfmanagement support.
Then collated into a
combined pathway to
create a model to
promote selfmanagement.

Detailed description of
the services unique
model of care: The St.
Joseph's Primary Care
Diabetes Support
Program (SJHC
PCDSP). It incorporates
team-based care to
provide patient
education and selfmanagement with

(Penn et al.,
2015)

(Reichert et al.,
2014)

Integrated
care; Patient
Medical
Home; Selfmanagement;
team-based
care;
Diabetes
Canada
Guidelines

Process
mapping (but
they called it
creating
maps to
represent the
experience of
patient’s
progress
through the
system).

Model of diabetes
care serving 3000
patients in
London, Ontario.

Operational
research and
modelling
21 NHS general
practices in UK

Combination of medical care and
diabetes education. Team-based care
includes a social worker to address
the social determinants of health. It is
supported by an EMR. Include
remote support to all patients. Social
worker facilitates behaviour
modification group – “Craving
Change” and weekly exercise plan.

Appointment frequencies are
orientated to bio-medical monitoring
rather than increasing the ability to
undertake self-management
activities. The model provided a
visual picture of the complexities in
achieving self-management support.
It illuminated the lack of integration
with community resources or other
social support networks.

by maintaining motivation and
sustaining change.

Limitations of
the paper is that
is only
descriptive, does
not include
outcome
measures of
success.

Future
modelling to
take into
account
resources
beyond the
health system

This is an example
of comprehensive
diabetes services
in Canada and
includes many
features of the
CCM but does not
mention it in the
article .

Self-management
is quickly hidden
from view in a
system orientated
to treatment
delivery rather
than to enhancing
patient selfmanagement. Care
pathways provide
a alternative to the
CCM when
organize selfmanagement care.

detail and
important role in
limited reporting achieving positive
in the studies.
outcomes.
Diverse
interventions
and measures
made it
challenging to
synthesize.

93

Aim to evaluate the
pattern of health
outcomes in chronic
disease management
interventions for adults
in primary or
community settings.

Review to assess the
effectiveness of QI
strategies designed to
improve diabetes care
in rural areas – the
authors wanted to look
at how QI was
specifically applied in
rural areas to see if they
had the same impact as
the general population

Chapter on Selfmanagement education
and support
Diabetes Canada 2018
Practice Guideline.

(Reynolds et
al., 2018)

(Ricci-Cabello
et al., 2013)

(Sherifali et al.,
2018)

active medical support
at each clinic
encounter.

Chronic Care
Model; Selfmanagement;
Patientcentered

QI initiatives
and T2DM

Chronic Care
Model and
variety of
Chronic
Diseases
interventions

; Patient
centered care

Clinical practice
guideline for
Diabetes Canada

Systematic review
& meta-analysis
of 26 studies from
the USA, Canada
and Japan.

Systematic review
of 165 studies
(majority RCTs)
Majority of
studies in USA

Education AND support required for
best outcomes. Evidence support
self-management education reduces
risk of complications.
Technology can support selfmanagement education.

Successful QI interventions include
interventions with multiple strategies
aimed at clinicians and/or health
systems rather than traditional
patient-oriented interventions. When
case management was employed as a
strategy, care being delivered in the
community instead of a clinic, and
not requiring patients to commute to
receive the intervention all decreased
HbA1c more effectively.

Self-management support
interventions were the most
frequently implemented and resulted
in statistically significant
improvements in patient-level
outcomes. Few studies included
Health Care organization or
Community Resources as the primary
intervention.

Integration of diabetes self-care and
management with the Patient’s
Medical Home.

No standard
framework for
ease of
implementation
of selfmanagement
education and
support. It is up

The
considerable
differences in
the studies
meant only
glycemic control
was used as an
outcome. This
limits the results
as it is only one
of several
important
outcomes.

There is a need
for more
research to
address Health
Care
Organization
and Community
Resources as
interventions.

QI have to move
beyond only
patient education
but on
organizational
structures to have
impact on health
outcomes. The
majority of
interventions were
focused on patient
education, but
these seem to be
least effective.
Self-management
education should
be provided to
everyone with
diabetes. Selfmanagement
support sustains
the short-term

Self-management
is an integral part
of high-quality
CDM

94

To examine diabetesrelated behavioral and
psychosocial outcomes
as well as patient
satisfaction with
telemedicine services
provided by an
endocrinologist at an
urban area in
partnership with a
diabetes educator in a
rural area, working
together with patients
and primary care
providers.

Goal to describe how
researchers have
applied CCM in the US
primary care settings &
outcomes of CCM
implementation for
T2DM.

Describes survey and
site visit results of the

(Siminerio et
al., 2014)

(Stellefson et
al., 2013)

(Wagner et al.,
1999)

CCM

Chronic Care
Model;
T2DM

Analysis of
survey and site

Systematic
review; of 16
studies; Primary
Care setting in
USA

Telemedicine Pre- and post; team-based measures with 29
care; T2DM
participants.
Primary care in
rural USA

Testing of the chronic illness model
developed by a process of literature

CCM is effective in improving health
of people with diabetes. Most benefit
from incorporating multiple
components, each site can select a
combination of components to
achieve optimal results. Selfmanagement is highlighted to
improve psychosocial and clinical
outcomes. Other models need
additional research – such as the
Innovative Care for Chronic
Conditions by WHO or Expanded
Chronic Care Model by Barr et al.

There was significant improvement
in empowerment, self-care
(adherence to diet and monitoring),
and reduction in diabetes distress.
Patients reported high levels of
satisfaction.

Future work: the
CCM is “like an

Limitations
includes the
variability of
study design did
not allow
authors to pool
data.

Limitations
include small
sample size and
did not contain a
control group.

to the
provider/health
organization.

“Despite the recent
flurry of activity

Future research to
determine if group
or individual selfmanagement
education is best,
more on culturally
tailored programs,
training to support
use of technologies

The TREAT
model may be a
viable option for
rural communities
that suffer from a
shortage of teambased diabetes
specialist and selfmanagement
support services.

benefits of selfmanagement
education.

95

(Wagner et al.,
2001)

The goal of the paper is
to describe the CCM
and how it has been
applied to quality
improvement activities.

chronic disease
management activities
of programs nominated
as being innovative and
effective and analyzised
using the model for
effective chronic illness
care – later to be know
the Chronic Care
Model.

CCM

Description of the
model and 6
components.

visits 72
innovative
chronic illness
programs

Summary of evidence supporting the
adoption of each of the 6 elements of
the model to guide quality
improvement. Useful guide
demonstrating the intent of the 6
elements in improving chronic illness
care.

synthesis and expert review resulted
in an effective method to describe the
characteristic consistently shared by
successful programs. One of the
barriers identified was the reliance of
programs on traditional didactic
patient education models instead of
self-management support.

As new
evidence
surfaces, the
CCM continues
to be refined and
improved. One
of the
challenges as
the model
evolves is other
models also
emerge so
which model is
to followed for
guidance?

evidence-based
guideline” that
can evolve as
additional
evidence arises

Ultimately Chronic
disease
management
requires: 1.
Evidence- based
medical
management, and
2. Competent selfmanagement. The
CCM model helps
health care
organizations
organize care to
reach these goals.

around improving
chronic illness care
in organized health
systems, our
review of the ‘best
practices’’
identified
relatively few
organizations that
have made the
comprehensive
system changes
associated with
demonstrably
better patient and
system
outcomes”(p.79).

96

(World Health
Organization,
2016a)

Outlines a framework
with the ultimate goal
to integrate peoplecentered health
services.

Integrated
care; peoplecentered care

The framework includes five
interdependent strategies: 1)
Empowering and engaging people
and communities; 2) strengthening
governance and accountability; 3)
reorienting the model of care; 4)
coordinating services withing and
across sector; and 5) creating an
enabling environment. They
cumulatively build more effective
health services and lack of progress
in one area, undermines the other
strategies. Policy options and
interventions are provided for each
strategy.

Future work will
require Core
Health
Indicators to
include
measures of
integration and
people-centered
health services
(which are
critical but less
frequently
measured
domains) in
order to track
progress.

The reorientation
of health services
will take a long
approach and
countries will need
to define their own
goals and
strategies to
implement the
change towards an
integrated and
people-centered
systems specific to
the contexts they
serve.

97

Goal of Program

Tertiary teambased care facility
dedicated to the
treatment of
diabetes to help
individuals in BC
live healthier lives
and minimize the
impact of
diabetes.

A 12-month,
digital coaching
program that
empowers
individuals with
diabetes to lead a
healthier life and
reduce your risk

Name of Program

BC Diabetes
(BCDiabetes,
2020)
www.bcdiabetes.
ca

Canadian
Diabetes
Prevention
Program
(LMC
Healthcare, 2020)
https://www.lmc.
ca/diabetesprevention/

Pilot project.
12-month program consists of
regular telephonic interactions
with a personal Health
Coach, online education
modules and health tracking to
help you make small,
incremental changes to improve
your health and reduce your risk
of developing Type 2 Diabetes.

Services include clinical care,
med management, counseling
and pharmacy services. Team
includes Diabetes specialist,
physician and nurse case
managers, dietician and access to
an onsite pharmacist. Virtual
care is available for clients.
Research and clinical trials are
important parts of the service.

Description (Including type of
facilitator)

Via telephone and
online resources.
First 3 months,
weekly telephonic
sessions. From
months 4 to 12,
monthly
telephonic
sessions. Plus,
monthly
workshops

Location, method
of delivery and
duration or
frequency
N/A

Environmental Scan Results: Community Resources

Appendix B

Covered by
MSP.

Organized
by

Only available in
Diabetes
these cities in BC
Canada
Greater Vancouver
Vancouver Island
Abbotsford
Kamloops
Prince George
Dawson Creek
Nelson
(Location limited
because participants
must have access to
LifeLabs for
bloodwork)

Must be referred by
physician (although
website includes selfreferral- the
receptionist stated a
physician referral is
required).

Referral criteria

Funding or

98

Goal of Program

Goal to provide
education, support
and treatment to
individuals with
complex diabetes
management
issues

Group diabetes
and prediabetes
self-management
education.
Also offers foot
care, individual
counselling

Name of Program

Diabetes Clinic:
Gordon and
Leslie Diamond
Health Care
Centre at VGH
(Vancouver
Coastal Health,
2020a)
http://www.vch.c
a/LocationsServices/result?re
s_id=708

Diabetes
Education Centre
– North Shore
Chronic Disease
Services
(Vancouver
Coastal Health,
2020b)
http://www.vch.c
a/LocationsServices/result?re
s_id=637

Registered Nurses and Dietitians
with specialized training in
diabetes care
Offered in English and Farsi.
Interpreter services for nonEnglish speaking clients
available, usually by telephone.
outline of class schedules for
group education.
Prediabetes Group Education Class Outline

Tertiary care
Education and training on
advanced carbohydrate counting,
intensive insulin therapy and
continuous glucose monitoring
as well as endocrinology
referral.
Multidisciplinary team consists
of nurses, dietitians,
endocrinologists, geriatrician,
psychiatrist, clerks, social
worker, pharmacist and
podiatrist.

Description (Including type of
facilitator)

Three 3 hr
sessions held one
month apart
Previously held in
person in West
Vancouver and
since COVID
virtually via zoom
or phone

Location, method
of delivery and
duration or
frequency
N/A
VCH

Funding or
Organized
by

North Shore residents VCH
diagnosed with Type 1
or Type 2 diabetes,
prediabetes (impaired
fasting glucose or
glucose intolerance),
diabetes in pregnancy
and insulin resistance.
North
Shore Chronic
Disease
Services Referral
Form

A physician referral is
needed. Click to
download the form
Eligible for
individuals with
complex management
issues, including
insulin therapy and
presence of chronic or
acute diabetic
complications.
Individuals on insulin
or with chronic or
acute diabetic
complications

Referral criteria

99

Goal of Program

Community-based
lifestyle
intervention
program designed
to support
individuals who
are at risk for
chronic disease,
such as type 2
diabetes, high
blood pressure
and heart disease.

Health programs
for adults of all
ages living with
one or multiple
ongoing health
conditions,
offered
throughout British
Columbia online,
by telephone, or
by mail. Included
workshops
specific to
diabetes.

Name of Program

Healthy Living
Program
(Vancouver
Coastal Health,
2020c)
http://www.vch.c
a/LocationsServices/result?re
s_id=1347

Self-Management
BC
(BC SelfManagement,
2020)
https://www.self
managementbc.ca
/

NEW online, phone and mail
based programs. This service
was not available prior to
November 2020. Previously
programs were run in person in
select cities across the province.
1. Tool Kit for Active living plus
Calls is a free program that
includes a one-time mailing of
resources and a small-group
teleconference with a Program
Leader and with other
participants to review the topics
in the booklet via zoom or
phone.

The Healthy Living Program is a
health promotion and chronic
disease prevention and
management program for adults
living in Vancouver who have or
who are at risk for developing
chronic diseases.
Interdisciplinary team includes:
Registered Nurses, Registered
Dietitians, Certified Exercise
Physiologists
Free

Description (Including type of
facilitator)

connect with
participants by

2. Coaches

for Active Living
- Diabetes + Calls
Program is a free,
six-session
weekly program.
Each week a
Program Leader
conducts a 30–45minute
teleconference
call.

1. The Tool Kit

Location, method
of delivery and
duration or
frequency
The program
consists of 3
sessions in
Vancouver: two
hours each for
three consecutive
weeks. Sessions
are in group
settings to
promote sharing
and learning.
Self-referral by email
or phone.

Self-referral or by
Physician
Vancouver
Community Diabetes
Education Program Referral Form

Referral criteria

Sponsored
by SelfManagemen
t BC is
supported
by the
Province of
BC,
University
of Victoria
and Institute
on Aging
and
Lifelong
Health

VCH

Funding or
Organized
by

100

Goal of Program

The Sea to Sky
Healthy Heart
Program is a
rehabilitation
program for
people with
chronic diseases
such as
cardiovascular
disease, diabetes,
COPD, asthma or
anyone requiring
risk factor
modification.

Name of Program

Sea to Sky
Healthy Heart
Program
(Vancouver
Coastal Health,
2012)
https://happyheart
svancouver.files.
wordpress.com/2
013/03/pamphletsea-to-skysquamish.pdf

Exercise and education program
led by a Physiotherapist who
will provide a personalized
exercise evaluation plan and a
Registered Nurse who will
facilitate group education
sessions and self-management
counseling

2. The Self-Management Health
Coach Program is a free,
telephone-based coaching
program to support people living
with chronic conditions to
become better self-managers and
support participants to choose
goals, initiate and maintain
health behaviour change.

Description (Including type of
facilitator)

12-week program
with weekly 2 hr
sessions (1 hour
exercise and 1
hour education)

Location, method
of delivery and
duration or
frequency
telephone, once a
week for 30
minutes, for a
period of three
months

Referral from
physician

Referral criteria

Funded by
VCH – plus
a charge
when inperson
classes are
running to
access the
recreation
facilities
($60 for the
program)

Funding or
Organized
by

101

102
Appendix C
Semi-Structured Interview Questions

The goal of the semi-structured interview questions is to obtain the participants (clients or
providers) knowledge of the state of diabetes services in Squamish, BC. The questions include:
1. What is your understanding of the services available for individuals with type 2 diabetes
in Squamish, BC?
2. Which of these services have you accessed (or referred clients to access if you are a
providers)?
3. Are there any services outside Squamish you have accessed (or referred clients to access
if you are a provider)?
4. What are the barriers to accessing services?
5. What are the benefits or strengths of the services?
6. Are there any gaps in services? If yes, describe?

103
Appendix D
Preparation Timeline for the Key Stakeholder Meeting

Time until Meeting
6 Weeks Prior

Task
•
•
•
•

4 Weeks Prior

•
•
•

Send out email invitation to meeting to primary care providers
requesting representatives from each practice
Book room at health unit with audiovisual equipment to project
presentation from computer and/or create zoom meeting invite
Update local data if it has been greater than 1 year since data was
collected.
Identify coworkers interested in co-facilitating workshop and
documenting discussion key points
Confirm primary care provider and send welcome letter with agenda
for the day
Send invitation to other participants including: Home Health
manager, Home Health team lead, dietitian, rehab team member,
social work, community pharmacist
Support co-facilitator in familiarizing themselves with the content of
the findings, the goals of the stakeholder meeting and the semistructure questions to guide the conversation with participants.

1 Week Prior

•

Send reminder to all participants

3 Days Prior

•

Book coffee and treats if meeting to be held in person

104
APPENDIX E
Sample Email Invitation
Subject line: Key Stakeholder Meeting for Type 2 Diabetes Care and Services
Hello,
You are invited to participate in a key stakeholder meeting on
from 0900-1200 regarding
the optimization of care and services for type 2 diabetes in Squamish, BC.
Key stakeholders from the Home Health program and primary care providers from the
community are being invited to participate in a planning meeting to review recommendations
and identify priorities for type 2 diabetes care in our community.
Please reply to this email by

if you are interested in attending.

Coffee and treats will be served.
Your expertise and opinion are greatly valued, and we hope you will be able to attend.
If you have any questions, please feel free to contact Jennifer Shaw at Jennifer.Shaw@vch.ca or
604-848-9351
Thank you,
Insert email signature