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INITIATIVES TO SUPPORT THIS PRIORITY

What needs to be done in the next three years?

To improve the prevention, management and treatment of diabetes and reduce complications from other conditions, the Toronto Central LHIN has prioritized the following initiatives over the next three years.

Initiative #1
Expand outreach and screening programs, starting with high-needs neighbourhoods.

Actions that will drive this initiative

  • Ensure ongoing screening and outreach in high-needs neighbourhoods.
  • Enhance existing diabetes programs by including outreach workers and partnerships with screening programs.

Initiative #2
Increase access to primary care teams -- which include family physicians, nurse practitioners and dieticians -- starting with high-needs neighbourhoods and high-risk groups.

Actions that will drive this initiative

  • Continued expansion of Diabetes Education Program in high-needs neighbourhoods in the northwest and northeast areas of the LHIN,
  • Implement a primary care engagement strategy focusing on high-risk neighbourhoods.
  • Build awareness of diabetes programs and services in the LHIN through communications strategies that include information tailored to the needs of primary care physicians and teams, outreach through community groups, media and interactive web-based tools that direct clients to local services.

Initiative #3
Improve the quality, consistency and comprehensiveness of diabetes services in the primary care or physician clinic setting.

Actions that will drive this initiative

  • To ensure higher quality and more culturally appropriate care, establish a Regional Diabetes Coordinating Centre to support the dissemination of best practices and innovations, and centralize client referrals and coordination of care.
  • Identify a baseline diabetes dataset -- based on the number of people with diabetes and physician adherence to four evidence-based tests over the past 12 months -- and establish system performance targets.
  • Convene providers to agree on initial priorities for evidence-based diabetes prevention and management care pathways e.g. retinal exams to screen for glaucoma.
  • Start collecting diabetes management data “dynamically” with regular updates, making the data more timely and beneficial for clinicians and system managers.
  • Make the diabetes registry available to primary care physicians and other health professionals in a way that supports Toronto Central LHIN’s proposed diabetes care model.

Together these activities will promote stronger interaction and collaboration among primary care physicians, specialists and other health professionals.