The Model

Diabetes and My Nation initiative is a community based health management program to achieve evidence based outcomes for the prevention and management of diabetes (Type 2 diabetes Mellitus – T2DM) in First Nations communities. It applies culturally appropriate and holistic methods, and includes all age groups including youths but not infants in the community.

The program has evolved through the contribution of a First Nation leader, a strategy developer, (both of whom have Type 2 diabetes) and a diabetes specialist, with extensive consultation with community members, First Nations healthcare professionals, and healthcare professionals from both federal and provincial programs with actual experience working with First Nations communities.

The program consists of six integrated components: Awareness and Motivation, Education, Management and Monitoring, Treatment, Prevention, and Diabetes Management Software. Diabetes Nurse Educators play an integral part in the implementation of the program as the main point of contact for monitoring patients and coordinating treatment activities. This provides intimate motivational access to healthcare which permits alternative and cost effective approaches to all aspects of diabetes management.

Since each First Nation is different from other Nations in term of level or readiness, resources, and relations with the healthcare system, the implementation of the various components of the initiative has a degree of flexibility to allow adjustments in each community. The goal and objectives, however, are the same for all communities.

Diabetes and My Nation model could be a catalyst to assist in the implementation of the Expanded Chronic Care Model.

The main objectives of Diabetes and My Nation are:

• Raise awareness of diabetes, its risk factors, and the value of healthy lifestyle practices.
• Promote screening for metabolic diseases at the community level.
• Support the development of a culturally appropriate approach to care and treatment, diabetes prevention and health promotion programs, and lifestyle support programs.
• Build capacity, linkages and infrastructure for long-term sustainability of the initiative.
• Promote effective self-management of diabetes.
• Build bridges between the community and the healthcare system.
• Coordinate with other federal, provincial, and community-based programs.
• Promote public/private partnership.
• Identify gaps in the delivery of healthcare to First Nations communities.

A pilot project was carried out at the Haisla First Nation, British Columbia; it has demonstrated that a successful program that integrates all aspects that affect the person with diabetes, from motivation to social support with constant monitoring by the health care professionals, can achieve considerable reduction in diabetes clinical parameters (A1c, Lipids, BP, etc.) which would be predicted to result in major reductions in renal impairment, cardiovascular disease, other disabilities, and hospitalization costs.

The striking finding was the improvement in the same parameters in the community as a whole in those who did not participate in the intense program, demonstrating the spill-over effect of such a program in the community as a whole. Over the same time period, this program advanced the care of First Nations people significantly compared to the care of people in the adjacent community of non-First Nations people. The entire community now demonstrates a remarkable understanding and awareness of the risks of this disease and of methods to reduce this risk.