Improving Diabetes Care and Outcomes: The Secondary Benefits of a Public Health–Managed Care Research Collaboration

Prenatal Nutrition in Team-Based Care: Current Practices and Opportunities for Optimization of Care

Purpose: To describe prenatal nutrition care currently delivered by Family Health Teams (FHTs) and Community Health Centres (CHCs) in Ontario, from the perspectives of health care providers, and to identify opportunities for improving care. Methods: Ten 1-hour, interdisciplinary focus groups were conducted in FHTs and CHCs, involving a total of 73 health care providers. Focus groups ranged in size from 3 to 11 team members, and at least 3 different professions participated in each group. The shared perspectives and experiences on prenatal nutrition care were collected using a semi-structured interview guide and analyzed using thematic analysis. Results: Limited time was spent on prenatal nutrition education and counselling. Two themes emerged describing gaps in care: (i) providing care in "borderline" high-risk pregnancies (i.e., impaired glucose tolerance) and (ii) providing care around gestational weight gain. Providers envisioned improving services offered by increasing preventative care, empowering providers to provide more nutrition care, facilitating patient self-care, and building a 1-stop shop "medical home". Conclusions: This study's findings can guide strategies to mobilize current nutritional knowledge into routine prenatal care, and the shared vision for improvement will inform the routes for new practice that are supported by health care professionals.

A scoping literature review of collaboration between primary care and public health

AIM

The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success.

BACKGROUND

Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone.

METHODS

The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English.

FINDINGS

The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.

Importance of effective collaboration between health professionals for the facilitation of optimal community diabetes care

Diabetes places a significant burden on the individuals concerned, their families and society as a whole. The debilitating sequelae of diabetes can be limited or prevented altogether through strict glycaemic control. Despite the seemingly uncomplicated nature of the disorder, effective management can be elusive, as the impact of having to deal with diabetes on a daily basis can be profound and appropriate professional support is not always readily available. As the roles of general practitioners (GPs) and allied health professionals have evolved, a major issue now facing all is that of developing and maintaining effective collaborative relationships for the facilitation of optimal community diabetes care. Using a simple survey methodology, the present exploratory study investigated the referral patterns of GPs to diabetic educators (DEs) working for a community health service in an Australian town, and reasons for referral and non-referral in order to identify factors that contribute to a sound and sustainable collaborative relationship. The results provide some evidence that GPs and DEs in this town do work collaboratively towards achieving client-centred goals and highlight the need to inform GPs who are new to communities, such as this one, of the available DE services. Most importantly, the study identified that there are many opportunities to strengthen collaboration so as to facilitate optimal community diabetes care. This information is valuable, because there is limited empirical evidence either nationally or internationally about the process of collaboration between health professionals in the management of chronic diseases, such as diabetes.

Personalizing nutrigenomics research through community based participatory research and omics technologies

Personal and public health information are often obtained from studies of large population groups. Risk factors for nutrients, toxins, genetic variation, and more recently, nutrient-gene interactions are statistical estimates of the percentage reduction in disease in the population if the risk were to be avoided or the gene variant were not present. Because individuals differ in genetic makeup, lifestyle, and dietary patterns than those individuals in the study population, these risk factors are valuable guidelines, but may not apply to individuals. Intervention studies are likewise limited by small sample sizes, short time frames to assess physiological changes, and variable experimental designs that often preclude comparative or consensus analyses. A fundamental challenge for nutrigenomics will be to develop a means to sort individuals into metabolic groups, and eventually, develop risk factors for individuals. To reach the goal of personalizing medicine and nutrition, new experimental strategies are needed for human study designs. A promising approach for more complete analyses of the interaction of genetic makeups and environment relies on community-based participatory research (CBPR) methodologies. CBPR's central focus is developing a partnership among researchers and individuals in a community that allows for more in depth lifestyle analyses but also translational research that simultaneously helps improve the health of individuals and communities. The USDA-ARS Delta Nutrition Intervention Research program exemplifies CBPR providing a foundation for expanded personalized nutrition and medicine research for communities and individuals.

Developing a community health promotion agenda for a managed care organization

Coordination and collaboration between organizations interested in promoting the health of the populations they serve can potentially help to ensure that key services are provided as well as augment the efforts beyond that which could be accomplished by each organization alone. Understanding the perspectives of each organization can facilitate development of health promotion initiatives that will be of mutual benefit. In Maryland, when a Medicaid managed care program was initiated, Memoranda of Understanding were signed between each managed care organization (MCO) and each of the 24 local health departments; many stipulated that the parties will coordinate on community health issues. This report describes a telephone survey of the health departments that was performed by one MCO to better understand the interests and expectations of the health departments and discusses a process for developing a community health promotion agenda for an MCO.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings

OBJECTIVE

To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics.

RESEARCH DESIGN AND METHODS

Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention.

RESULTS

All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35).

CONCLUSIONS

This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.