PRP160: Structuring and Organizing Interprofessional Healthcare in Partnership with Diabetic Patients: The INMED care pathway

Geraldine Layani, MD, MSc, Clinical Assistant Professor; Brigitte Vachon, PhD; Arnaud Duhoux, PhD; Marie Therese Lussier, MD, BSc, FCFP, MSc


Background: Diabetes is one of the health emergencies of the 21st century. The Chronic Care Model (CCM) provides an integrated approach to continuous improvement for this disease. Recent advances in primary care in Quebec are conducive to implementing the CCM and optimizing current practices in Family Medecine Groups (FMGs).

Objective: Document the implementation of an integrated care trajectory (CT) combining the components of the Chronic Care Model (CCM) in order to develop an implementation guide for this CT.

Type of study: Based on the Model for Improvement integrating reflective practice and Plan-Do-Study-Act (PDSA) cycles.

Location: Two FMG-Us in Quebec

Participants : FMG-U professionals, their diabetic clientele, and partner patients.

Intervention/instrument: 1) continuing education for professionals and patient partners, 2) extraction of data from the electronic medical record, 3) use of a feedback intervention in the form of a report, 4) project governance by a local continuous quality improvement committee, 5) a steering committee including FMG leaders to ensure that the CT is scaled up.

Parameters under study: Effectiveness will be evaluated using the INESSS quality indicators defined for diabetes, levels of self-management and diabetes-related distress, and costs associated with emergency room visits, hospitalizations, and physician visits.The changes implemented during the implementation of CT will be evaluated by the data from the electronic medical record. Adoption will be evaluated through online interviews and surveys of participants. The implementation process will be documented through the use of monitoring tools and detailed descriptions of PDSA cycles.

Conclusion: This project will propose an innovative, personalized, multidisciplinary approach to planning adapted follow-up for people with diabetes in FMGs.

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