OACCAC Conference Centralized Diabetes Intake

Cheryl LukeDave Merkley

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June 2014

Presentation Objectives

To highlight how Centralized Diabetes Intake atthe Central East CCAC enhances patient access toRegional Diabetes Services through CCAC systemnavigation and state of the art GeospacialInformation Systems.

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Ontarians with Diabetes account for:

• 32% of heart attacks• 43% of heart failure• 30% of strokes• 51% of new dialysis • 70% of amputations

Prevalence of Diabetes in the Central East LHIN

• For every 100 adults in the Central East LHIN, about 11 are living with diabetes. This prevalence (10.80 per 100) is higher than the Ontario average (9.64 per 100)

• Diabetes prevalence is highest in Scarborough (12.45 per 100)

• Durham region has a higher-than-average prevalence (10.09 per 100)

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Centralized Intake Overview

• The implementation of a centralized diabetes intake and referral process for all DEPs and CCDC in the Central East is a MOHLTC-mandated deliverable

• This process will enhance integrated access to multiple services and resources

• Provide accessibility to both Health Care providers and those living with diabetes within the Central East region

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Diabetes Education Programs

24 DEPs across the Central East region

11 adult and two pediatric DEPs are now accountableto the Central East LHIN

Provide basic-intermediate level diabetes educationservices to individuals with or at risk of diabetes

The primary role of the DEP is to educate people withdiabetes to self-manage their disease

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Centre for Complex Diabetes Care –CCDC

• 6 CCDCs across the province• Additional program in the continuum of care• Shared model of care that includes an inter-

professional team• Physicians and community-based services

are integrated as needed• Transition/discharge planning with PCP and

DEP

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Centre for Complex Diabetes Care –CCDCIn the Central East, there is one CCDC with 4 sites:

Referral and Initial Assessment• Central East Community Care Access Centre

(CCAC)

Care Delivery Sites• Lakeridge Health, Whitby• Peterborough Regional Health Centre • The Scarborough Hospital, General Campus

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Barriers to Accessing Diabetes ServicesConsumer consultations indicated that some barriers to services included:

• Provider focused vs. patient focused• Limited access in the evenings or week-ends• Limited services available in the language of the

patient• Cost of parking• Lack of understanding of value of DEP

programming

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Opportunity for Centralized Diabetes Intake and Referral Process

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• Hospital based DEPs tend to provide care for themore complex cases

• Community based DEPs tend to provide care forthe less complex cases

• Physician referral patterns tends to refer all oftheir patients to one DEP

• Supply does not match demand

Centralized Intake- Desired Outcome

• A more streamlined and integrated service

• Supports the Ontario Diabetes Strategy

• Decreased emergency department visits and hospital admissions

• People living with diabetes may self-refer

• Improved match with demand with supply

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The Model

• A common referral form based on best practices

• A single telephone call or faxed referral from a physician/provider, or a patient will initiate the intake process

• E-Referral via Health Partner Gateway allows all client referral information to be sent electronically from the Central East CCAC to the DEPs and CCDC in a secure and timely manner

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The Central East CCAC• Will support intake and patient referrals to DEPs

and CCDC

• Offer patients assistance with system navigation

• The services to be accessed include:o Diabetes Education Programmingo Centre for Complex Diabetes Careo Community Care Access Centre serviceso Community Support Serviceso Health Care Connecto The Central East Self-Management Program

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Role of the Centralized Diabetes Intake Care Coordinator• Receive referrals, assess and determine

eligibility for CCDC or DEP and provide linkages to community support services

• Provide diabetes education to patients• Collect and send appropriate documents to

CCDC or DEP• Liaise with physicians, HSP, CCDC hospital

site teams or DEPs as needed• Monitor 1-888 number and voicemail and

provide information to the public regarding Diabetes services

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The Intake Process• Patients are contacted by a the CDI Care

Coordinator who will complete a RAI assessment

• Geospacial Information Systems used by the Care Coordinator which shows the available resources to the patient

• Referral is made to the most appropriate DEP/CCDC

• Linked with CCAC and Community Support Services as needed

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The Challenge

Create a tool that would:• Juggle large volumes of data but still make the

call natural and patient driven• Explore patient requirements in the context of

geography • Explore access for home and work addresses• Make the best choices intuitive to find and easy

to explore

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The Solution

• Map based geospatial tools• Geocode an address on the fly• Select from a list of requirements• Darkest dot is most appropriate• Review more information by clicking dots• Demo

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How to Refer• Admission is completed through the Central East

Community Care Access Centre (CCAC)

• The Centralized Diabetes Intake Referral Form can be found by doing a search at: http://healthcareathome.ca/centraleast/en and faxed to 905-444-2544

OR• Call the Centralized Diabetes Intake Service at:

1-888-997-9996 to be connected with a CDI Care Coordinator to facilitate the referral

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Summary• Stats on Diabetes• Centralized Intake Overview• Barriers to Accessing Diabetes Services• Opportunities and Desired Outcome• Role of Central East CCAC• Geospatial Information System• How to Refer

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Questions?Cheryl LukeSenior Manager, Diabetes ServicesCentral East Community Care Access Centre905-430-3308 ext. 5842cheryl.luke@ce.ccac-ont.ca

David Merkley

Senior Manager, Decision Support

Central East Community Care Access Centre

905-430-3308 ext. 5433

dave.merkley@ce.ccac-ont.ca

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