Taking charge

An innovative First Nations health program is helping residents living with diabetes in First Nations communities better manage their condition

Caroline Chartrand, Executive Director of DIP, holds an educational tool meant to represent what a vial of blood looks like when it is being tested for blood sugar levels as Dr. Barry Lavallee (far right) and nurses Belinda Beardy (far left) and Sharon Flett look on
Caroline Chartrand, Executive Director of DIP, holds an educational tool meant to represent what a vial of blood looks like when it is being tested for blood sugar levels as Dr. Barry Lavallee (far right) and nurses Belinda Beardy (far left) and Sharon Flett look on.
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Learn more about the Diabetes Integration Project

Winnipeg Health Region
Wave, January / February 2015

Rhonda Louise Spence pulls out half a dozen blue pill bottles from her purse and lines them up on the table in front of nurse Belinda Beardy.

The Sandy Bay First Nation resident explains that each bottle contains a different type of medication, and that she takes all of them to help control her Type 2 diabetes.

"I've had diabetes since 2009, and I take my pills every day," Spence tells Beardy, who is in this community of 3,685 people on the western shore of Lake Manitoba as part of a three-day diabetes clinic. "I make sure my husband takes his pills, too."

The nurse is clearly pleased with her patient. Medications to control diabetes do many different things - such as lowering blood sugar levels, making the body more sensitive to insulin, helping the pancreas produce more insulin, and slowing the breakdown of long-chain sugars in the blood - and the nurse needs to know which ones her patient is taking.

Once the information is gathered, Beardy then obtains blood and urine samples from Spence and places them into a trio of portable machines that she has brought along on the trip from Winnipeg. The machines are testing for albumin-creatinine ratios, estimated glomerular filtration rates, and the average blood glucose levels over the past three months.

While the machines do their work, Beardy gets Spence onto a scale to measure her weight and waistline, and follows this up with a look at her blood pressure.

Ten minutes later, the machines spit out the results. Spence is pleased to see her blood sugar levels haven't changed that much since her last visit to the diabetes clinic six months ago. Nonetheless, Beardy wants Spence to see her regular doctor to check up on a couple of things. Spence agrees and soon heads out the door.

To the casual observer, this exchange between patient and health-care provider might not seem all that unusual. But the fact is this three-day clinic in Sandy Bay represents a major shift in the way health care is delivered to First Nations residents like Spence living in rural communities, one that promises to change the very nature of the way care is provided to Aboriginal people throughout the province and the rest of Canada.

That's because it is part of an innovative program launched in 2007 known as the Diabetes Integration Project (DIP). Led by Executive Director Caroline Chartrand, the mobile diabetes screening program operates in 19 First Nations communities, with mobile screening teams based in Winnipeg, Dauphin and Thompson.

The fact that these mobile clinics exist and travel to rural communities to deliver specialized care is noteworthy in and of itself. But the thing that truly separates DIP from other health-care initiatives of this kind, says Chartrand, is the model of care.

As she explains, First Nations people may sometimes feel stereotyped when seeking health care in some settings and under certain circumstances. DIP operates on a non-deficit model of care, meaning health-care providers do not blame the patient for failing to comply with medical instructions. Chartrand says the DIP model is rooted in a strength-building approach that helps avoid the potential for stereotyping and advances the therapeutic relationship between patient and health-care provider.

"Our model of care interrupts (stereotyping) at the grass roots; our community members know this and experience an encounter where their needs are addressed, acknowledged and validated," she says. "This is the most unique feature of DIP."

The impetus for DIP can be traced as far back as the late 1990s and a decision made by the Assembly of Manitoba Chiefs (AMC). At the time, First Nations leadership was growing increasingly concerned about rising rates of diabetes among people living in their communities.

Type 2 diabetes occurs when the body does not produce enough insulin and does not respond effectively to the insulin it does produce. As a result, glucose levels in the blood can increase unchecked, leading to complications such as blindness, numbness in limbs, amputation and heart disease. Diabetes is also a major cause of kidney disease, which may lead to kidney failure and leave a person living on dialysis for the rest of their life.

The risk of Type 2 diabetes among First Nations community residents is three to five times higher than the general population. Some First Nations people, most notably people living in northeastern Manitoba and northwestern Ontario, have a genetic predisposition toward the disease, which can see children as young as 10 showing symptoms.

In response to the diabetes epidemic, the AMC struck a committee in 1999 to come up with solutions. The committee identified five areas for action, including: care and support; prevention and promotion; gestational diabetes; research, surveillance and evaluation; and policy and infrastructure.

In time, the committee's work led to the development of an integrated diabetes health-care service delivery model. But it would take several years before funding could be secured to launch the project. Eventually, the Diabetes Integration Project was launched in 2007 with funding from First Nations and Inuit Health Branch, Manitoba Region, Health Canada, through the Aboriginal Diabetes Initiative.

Headquartered in Winnipeg, Chartrand says DIP represents a major milestone in the delivery of care to First Nations residents. Prior to the program, most people had to travel to seek health care, often making several trips to have different aspects of their disease monitored, such as having retinal screening on one trip, and foot care on another. DIP turned that process on its head.

"This is bringing care to the people," Chartrand says of the mobile clinics.

Under the program, mobile teams of nurses, dietitians and other health-care workers are based in Winnipeg, Dauphin and Thompson. These teams make the trip to rural First Nations communities, getting in by road or airplane, to monitor the health of a population of approximately 8,000 people per team.

As Chartrand explains, the program's mandate is to provide secondary prevention and education, with a focus on adults who have already been diagnosed with Type 2 diabetes. Nursing care in the communities is often overwhelmed by the sheer number of patients they see, she adds, so diabetes screening often isn't a priority.

"The teams are a one-stop-shop approach," she says. As part of the onsite consultation, nurses will do a foot inspection and a footwear review. They also ask how the patients are sleeping and if they are experiencing sexual dysfunction. In addition, the information gathered by the screening teams during clinic visits is uploaded into the DIP database. That information in turn is then collected by DIP as part of an effort to keep tabs on the health of the individuals in question.

Team members co-ordinate consultations with specialists such as nephrologists working in the Manitoba Renal Program and write letters of recommendation for further testing to be done by each patient's physician. They also connect patients to medical transportation, as many of the patients have to travel to Winnipeg for specialized care.

The health-care system in the province can seem like a giant spider web at times, says Chartrand. "Our job is to make it all work together."

A key part of the DIP difference in the delivery of care is the attention to culture.

For example, although DIP teams use the Canadian Diabetes Association Clinical Practice Guidelines as their basis for health care, they also integrate cultural awareness into everything they do.

"Our nurses are the bridge between traditional medicine and western medicine," says Chartrand. "The nurses speak the language of the people they're treating. That way, there's no misinterpretation. Having a nurse who speaks Cree or Ojibway helps the patients open up and talk about their health. It's all about developing relationships."

Dr. Barry Lavallee, Medical Consultant for DIP, and Director of the University of Manitoba's Centre for Aboriginal Health Education, agrees that the non-deficit approach used by the program is the key to its success. "Non-compliance is a term that you'll hear when a person doesn't follow the instructions their doctor gave them," says Lavallee.

But, as he explains, the health problems of First Nations residents are often rooted in geographical barriers, a lack of economic opportunities, poor housing and living conditions, and other social and political problems that have their roots in more than 200 years of colonialism, racism and oppression. In Manitoba, people living in remote communities often lack fresh food, clean drinking water and quality housing, which can affect their efforts to keep diabetes and other health problems under control.

The DIP teams take such matters into account when working with patients. "We try to understand the reasons why a person might not be able to follow through on those instructions about taking their pills or diet or exercise," says Lavallee.

"We know people in our communities want to get better. Our job is to support that journey, to understand the obstacles people face, such as poverty and living in isolated communities. So we see not only the patient, but the system, and their family situation. People want to get well, and our job is to put them in the driver's seat of their own health," says Lavallee, who is also a practicing family physician with an interest in trans-generational trauma as it causes challenges for First Nations and M├ętis in health and healing.

Chartrand says a big part of understanding First Nations patients is developing relationships with them and being respectful. "We understand that it's hard to eat healthy on a social services budget," she says. "We also recognize that being physically active doesn't mean doing 150 minutes of exercise a week. Berry picking, going canoeing, or taking a walk in the bush with your grandchildren are all examples of physical activity that are culturally relevant for First Nations people."

Lorraine McLeod, the Provincial Coordinator of Training with DIP, says the screening teams are trained to recognize the importance of family when talking to patients. "You have to learn about a person's social network. A First Nations family will often have three generations living in their house. Grandparents are bringing up their grandchildren. So we build on that strength. For example, instead of throwing a package of food into the microwave, why not teach your grandchildren how to cook a healthy meal?"

DIP is making a difference in the health of its patients, says Lavallee.

"We've discovered that the average sugar count per patient has decreased one to three per cent after seeing a DIP nurse more than two times. People are able to reduce the sugar in their diet, reduce their weight and reduce their blood sugars. It's an affirmation that what we're doing is working. To see a person go from a blood sugar level of 13 down to 7 or less is incredible."

An evaluation of DIP noted the mobile clinics provided the following benefits:

  • Access to diabetes screening and care services.
  • Measurable improvements in the conditions of clients with diabetes in glycemic (Alc), blood pressure and cholesterol.
  • Improvements in indicators were sustained over a number of years.
  • Shorter average time since the last visit than the clients of other programs.

"DIP is the top performer with respect to weight loss, glycemic control and blood pressure control," the evaluation read in part.

Left unmonitored and untreated, Type 2 diabetes can go on to cause kidney disease, heart complications, blindness and amputations. Having to go on dialysis after kidney failure alone costs the health-care system an estimated $60,000 per year.

"We theorize that if we can help 10 people keep their blood sugar at a safe level, they won't go on to need dialysis or amputation or have heart failure," says Lavallee. "That's a savings of $10 million health-care dollars for those 10 people alone."

With an eye on the future of diabetes care, Chartrand is working to have the DIP teams hooked up to the provincial eChart system, which would allow the nurses to view all medications prescribed to each patient, and the results of any tests they've undergone.

"Our nurses ask everyone to bring in their medications, but people forget, and it can be a nightmare tracking what medications they're using, for everything from lowering cholesterol to protecting their kidneys," she says.

At the Sandy Bay Health Centre, Beardy ran into that uncertainty with one patient, who couldn't remember when she had last taken her medications or how much she had left. The woman said she felt sick when she took some of the medications, so she stopped taking them, and was uncertain about her schedule for the other medications.

"I talked to her about going back to see her doctor in Portage la Prairie, and also wrote a letter to her doctor," says Beardy. "This is why we ask everyone to bring in their pills, because they can't remember the names of the medicines."

Eventually, Chartrand would like to see the DIP screening teams expanded so that all 64 First Nations in the province would receive care, rather than just the 19 currently served.

Another wish is to see the DIP model of mobile screening teams being used for other health-care concerns, such as cancer and heart health. She adds there's also a need to work better with regional health authorities in the province, and other interested health-care institutions. "Some are taking up our model," she says. For example, the Winnipeg Health Region's Manitoba Renal Program has teamed up with DIP to create the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project (FINISHED). Using the DIP model and funded through Health Canada, it operates a mobile kidney screening clinic in 11 First Nations communities.

Indeed, the DIP model of mobile care has proven so successful that it was recognized nationally in 2011, when it was presented to the executive committee of First Nations and Inuit Health Branch, Manitoba Region, Health Canada.

"People feel better after our teams visit, better able to take care of themselves," says Chartrand. "Our job is to support them, and teach them using small steps. Our people are human, they're sick, and that makes each one of them important to us."

Susie Strachan is a communications advisor with the Winnipeg Health Region.

Wave: January / February 2015

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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