Expanded Chronic Care Model

• Smoking abolition programs
• Community School’s Healthy Nutrition Policy – no vending machines
• Chief and Council resolution to implement Diabetes and My Nation
• Screening Band’s staff members for diabetes and hypertension
• Road safety and animal control - Dog Leash bylaw

• Hiring a part-time Diabetes Educator Nurse to ensure ongoing education, support and follow up
• Providing paid time for a staff member or members to attend the Circle of Diabetes Self-Management
• Nutrition workshops for Home Maker staff and Elder’s Coordinator resulting in weekly healthy balanced meals focusing on appropriate portion sizes, low salt and high fiber choices.
• Food security program policies for elders to be provided fish
• Prenatal national program – provides monthly financial support for prenatal and post natal breast feeding mothers up to 3 years. Similar services are provided for off reserve pre and post natal mothers through partnership with Child Development Program in Kitimat
• Mother Goose Program – pre and post natal parent group reinforcing healthy parent child relationships
• Literacy improvement group of children of elementary age to improve reading skills – Start Sept 2008
• Partnership with Northern Health Authority to provide up to date child hood immunization.
• Transportation – The Haisla First Nation has purchased a bus with Northern Health and City of Kitimat to allow community members to travel between the village and the city for medical & social needs
• Good Food Box Program providing healthy fruits and vegetables at lower cost thus reducing the need for high carbohydrate foods.
• Monthly Community Kitchen workshops for New Mother’s & Social Development clients focusing on healthy eating, balanced meals, healthy portions sizes & food preparation skills to prevent future diabetes
• Community Health Nurse provides ongoing education and supplies to raise awareness of STI’s, HIV, Hepatitis, infection control hand washing workshops, head lice assessments.
• Community Health Nurse arranges dental, hearing, vision screening in community school
• EHO partnership with staff for weekly water testing, promotion of food safe courses
• HR Manager coordinates yearly First Aide training for all Council staff
• Recreational Coordinator and staff oversee the functioning of community recreational gym and weight facility, varying operational hours to meet the needs of the community.
• Recreational Coordinator arranges ongoing physical activity classes for all ages and the local Recovery Treatment Centre
• Community Pandemic Plan – educate the community in the event of a wide spread communicable infection. Each Haisla family received a pandemic kit.

• Community groups recruited adults, youths, healthcare team members,, social work team members and school boards to participate in the design of Diabetes and My Nation activities and its implementation.
• Promoted health management through traditional activities and empowerment (through a project to build a Canoe which involved community members of different age groups.)
• Community health fair, workshops, and awareness events. The Haisla First Nation hosts an annual health fair
• Experts in diabetes management related areas participate in the Circle of Diabetes Self-Management in person and via videoconferencing utilizing Health Canada E-health system.
• Five Year Wellness Community Plan promoting a healthy mind, body and spirit – covering topics such as: generational trauma resulting from residential schools by Jane Middleton Moss, renowned author and psychologist , Women’s abuse issues, health care professional educational sessions on “Building the Strength Within us” by Rebecca Martel
• Partnership with Northwest Counseling to provide counseling services to school and all community members and staff
• Memorial Garden initiated to bring the community together recognizing community loss & celebrate the life of a loved one. A beautiful garden was established in front of the community school with a plaque honoring those who past on.
• Community fundraising events ongoing towards the building of a Community Elder’s Care Facility
• Basketball tournament to promote diabetes prevention and management
• Walk for diabetes (planned for November 2008)
• Homecare program
• Homework club for youth
• Investment club for youth

• Educational Materials - Diabetes and My Nation DVDs and website. A culturally appropriate multimedia educational program presented a holistic approach to diabetes prevention and management.

• Diabetes Awareness and Screening Gathering - a community event to share traditional food and activities, share knowledge about diabetes from healthcare professionals and community members, and provide community members an opportunity to test if they have, or at risk of developing, diabetes. Screening included random glucose. If it test was higher than (8 mmols/l) or if they have known diabetes, their A1c was tested By Point-of Care testing. Other tests included blood pressure, BMI, and lipids to complete a Metabolic Syndrome profile.

• The Circle of Diabetes Self-Management - a one year program. Each month the Circle will meet twice. At the first circle (week one), members of the circle will view one of Diabetes and My Nation DVDs (for example: Nutrition), and discuss among themselves what they have learned and what they commit to do (for example reduce their amount of carbohydrate intake). On the third week of the month, the circle will meet again to share what they have achieved and what difficulties may have prevented them from achieving their goals. These goals adhere to evidence-based practice guidelines. Home blood glucose meters will be used to document glucose status as lifestyle changes evolve. An expert on related subject matter will be invited, either in person or through video conference, to answer questions and share knowledge. Members will also participate in a physical activity program and/or cooking lessons. In addition they will check their blood pressure, BMI and give their recording blood sugar meter to the Local Health Nurse or Diabetes Nurse from the health authority to collect information about their monthly blood sugar levels and to monitor their progress. A diabetes nurse educator, diabetes specialist, and nutritionist monitor all participants and work with them to adjust their diabetes management program and with their healthcare providers to adjust medication or diet plans if required. By the end of the year, members of the circle and their family and friends will have learned what they need to know about diabetes management and prevention, combining traditional healing and modern medicine, and be able to establish ongoing community based physical activity programs that they themselves will choose. In addition, they will be able to take an active and central role in managing their health, monitor the progress of their diabetes, goal-setting, problem-solving, and build bridges with the local healthcare system.

• Evidence: The number of participants has averaged 14 at each Circle. Regular monitoring of blood sugar levels and blood pressure has been accomplished as well as noticeable changes in lifestyle, particularly in diet and physical activity (e.g. formation of the walking club and observing a reduction of A1c levels to 6.9% in six participants from significantly elevated levels documented at onset.

•  Youth Diabetes Prevention program “Our Spirit Lives” – A program for youth in the 14 – 20 age groups, promotes diabetes prevention through learning about their culture. In this case, this was accomplished by participating with the community in carving a canoe. Youth will produce a video to document the process and also customizing their “Diabetes and My Nation” DVD by including their traditional healing practices. They will learn about diabetes and how to prevent and manage it, take a pledge to avoid drugs, alcohol, and un-healthy food and drink; they will also participate in a traditional physical activity such as dancing, fishing, and/or hunting. Youth are also encouraged to join homework club if it is available at their community.

•  Evidence: The youth team participated in “Learn and Share” program to gather and prepare traditional food for their families and community elders while learning and sharing knowledge about diabetes prevention and management. They will also participate in wood cutting and distribution program to promote traditional physical activity.


• Behaviour changes and motivation: At the beginning of the project, four youth from the Haisla First Nation joined the program, today they are twelve. Changes in behaviour included the reduction (in some cases elimination) of soft drinks and “power” drinks, following a healthy diet with elimination of white flour and sugar. Members of the group joined traditional physical activities such as canoe building, dancing, and food gathering; also some of the group members joined physical activity programs at the community gym. In addition to increased physical activity and healthy diet, the group members joined a Homework club and Investment club that were established by their Nation. The main motivation is to take responsibility, to learn and apply traditional customs, and to share their knowledge with the community by producing a DVD about diabetes prevention and management.


•  Children Diabetes Prevention Education Program “Health Warriors” - An educational program was established for students in the 10-14 age groups in association with local schools. Students were invited to participate in an introductory discussion about diabetes. Each student was encouraged to learn about diabetes on their own, from elders, teachers, nurses, Internet and other sources; then share their knowledge at a community gathering in the way they prefer such as writing an essay, performing a play, drawing, singing and/or dancing, about diabetes, how it affects them and their families, and how to prevent it. Students’ presentations will be published on the Diabetes and My Nation website www.diabetesandmynation.com.

• Behaviour changes and motivation: Students were motivated by the concept of research and expressing their knowledge in their own way. At Haisla First Nation, the school eliminated un-healthy food, and started a walking program every morning.

• Diabetes and My Nation utilizes the Chronic Diseases Management (“CDM”) Tool Kit to provides access to client data for timely care, reminders, and feedback for patients and providers

• Diabetes and My Nation developed a simple database of people who were screen for diabetes and hypertension during the Diabetes Awareness and Screening Gathering to identifies relevant subpopulations for proactive care

• The local diabetes nurse shares the information with local family physicians and designated diabetes specialist to coordinate care

• The CDM Tool Kit and the database are used to monitor quality improvement efforts in practice and care systems; validate new integrated programs/services; measure broad based outcomes on health and well-being, as well as, clinical outcomes

• The diabetes nurse is working with the Ministry of Health on required modification of the CDM Tool Kit to meet the requirements of Diabetes and My Nation

• VPM key allows remote access to nurse educator’s home computer work station and northern health lab data base thus providing up to date and timely reporting of information to clients & reduces self management time

• Focus on teamwork, each team member has defined roles and tasks. The concept of canoe journey is used as a guide for project management
• Using planned interactions to support evidence based care. Most of the initiative activities are carried out applying traditional ways. For example the Circle of Diabetes Self-Management is conceptually similar to the Diabetes Talking Circle that has been successfully applied in the United States
• Ensure regular follow up by care team to ensure patients are not left on their own between visits. The diabetes nurse is visited regularly by the members of the Circle
• Provide or support case management services for complex patients. Bring the team to deal with multiple goals.
• Build relations between healthcare providers and communities / patients. Healthcare providers were invited to the Diabetes Awareness and Screening Gathering.
• Follow-up on all members of the Circle and management of their diabetes
• Training of home care team on providing foot care services to community elders
• The local diabetes nurse facilitates individual care planning
• Partnership with other healthcare providers from public and private sectors
• Integrate Diabetes and My Nation with other health programs such as the Mobile Diabetes Clinic and Northern Health Aboriginal Health Collaborative

• Integrate clinic guideline, the Canadian Diabetes Guidelines. A set of best cultural and management practices that were developed by the initiative’s team to assist in implementing the activities of the initiative ***Needs grammatical correction – no subject/verb in the sentence
• Support healthcare team by a diabetes specialist
• Share guidelines with patients, through their healthcare team, educational materials, and guest speakers; to encourage their participation
• Integrate practice guidelines into health promotion and prevention activities
• Use traditional education methods in combination with DVDs/web-based tools

• Identify required human resources and gaps.
• The Haisla First Nation hired a part-time diabetes nurse
• Training of homecare team to assist with the initiative
• Presentation to local family physicians
• Culture training for healthcare providers and Diabetes and My Nation team

Financial Resources

• Funding from FINHB for the pilot project
• Northern Health funding for A1c test cartridges
• Private funding, this include donation of A1c diagnostic system, donation of A1c test cartridges and glucose meter test strips for the Awareness and Screening event, donation of gifts and prizes by local businesses
• Initiation of efforts to have Industry support this initiative directly by provision of required but not financially supported medication including insulin where necessary