Program Components | Data Source(s) |
---|---|
Staffing and Supervision | |
ā¢ Intervention team receives training targeted to learning need | Record of attendance Learning needs assessment |
ā¢ Monthly outreach meetings between the intervention team and investigators | Meeting notes |
Home visits (in-home, telephone or videoconference) | |
ā¢ Up to 3 home/telephone/videoconference visits conducted by the Registered Nurse/Registered Dietitian/Nutritionist | Home visit record |
ā¢ Screening for diabetes-related complications and comorbidities ā¢ Review of medications | Home visit record Standardized clinical assessment tools Medication record Alerts (e.g., medication, diabetes complications) |
ā¢ Assessment of self-management of diabetes and other chronic conditions and identification of clientās needs and goals ā¢ Assessment of caregiver needs (if applicable) ā¢ Motivational interviewing to foster behavioural change and encourage self-care | Home visit record My action plan Client-centred care plan Caregiver Strain Index |
Monthly Group Wellness Sessions | |
ā¢ Attend up to 6 monthly sessions led by the intervention team ā¢ Individual consultations with community program coordinator | Group wellness session record Record of individual consultations with community program coordinator |
ā¢ Provision of transportation (if needed) | Group wellness session record |
Care Coordination and System Navigation | |
ā¢ Registered Nurse helps clients access supports and services in the community as needed | Client-centred care plan |
Monthly Case Conferences | |
ā¢ Intervention team attends monthly case conferences | Case conference meeting record |
ā¢ Intervention team develops and re-evaluates a coordinated care plan for each participant | Client-centred care plan |