champlain drcc newsletter vol.2, no. 6, november 2012 ch… · strategy and best practice training...

Vol.2, No. 6, November 2012

This issue of the DRCC newsletter highlights some of our new activities and community initiatives, from the Champlain chiropodist expansion and the upcoming screening events to engage the high risk communities in Ottawa, to the expansion of our own DRCC team. This newsletter includes upcoming education events and our Champlain Community Client Champions’ insights, as well as the expansive conversation about the Conversation Maps and an information for clients to join a new research study on the influence of the mind over the pain of neuropathy. November is Diabetes month with November 14th 2012 marking International Diabetes Day. It is more and more evident that in order to manage diabetes well the client requires a multidisciplinary team, with the client/patient at the centre of care. It is the goal of the Champlain DRCC to continue to provide valuable education sessions and resources through our DRCC roadshows, our website, newsletter and factsabout.

In the new year, we will continue to collaborate with many community partners to develop, promote and sustain new initiatives, such as the Self-Management Community of Practice, high risk foot care assessment training for all healthcare providers in our region, Long Term Care diabetes education and the collaboration between our regional diabetes education programs and primary care practices.

Champlain DRCC Newsletter

Introduction

INSIDE THIS ISSUE*The effects of an Interdisciplinary Program Including Mindfulness Based Stress Reduction on

Psychosocial Function, Pain and Metabolism in Patients with Painful Diabetic Peripheral Neuropathy*Regional Chiropody Update

*Invitation to participate in the Champlain Diabetes Foot Ulcer and Amputation reduction strategy and Best Practice Training Initiative in 2013

*Self-Management Support Community of Practice*New member to the Champlain DRCC

*From the Diabetes Educators Sector*From our Champlain Community Client Champions

*The Mystique of Blood Sugar Control for Type 2 Diabetes*Champlain Diabetes SCREEN Project screening events

*Conversation Maps: the conversation continues*Tools and Resources

Champlain DRCC Newsletter - November 20122

The Effect of an Interdisciplinary Program Including Mindfulness Based Stress Reduction on Psychosocial Function, Pain and Metabolism in Patients with Painful Diabetic Peripheral Neuropathy.Principle Investigator: Howard J. Nathan, MD. Ottawa Hospital Pain Clinic, Professor, Department of Anesthesiology, University of Ottawa.Co-Investigators: Ian Gilron, MD, Anesthesiologist, Queens University; John Kowal, PhD. Psychologist, Ottawa; Heather Lochnan, MD, Endocrinologist, Ottawa; Patricia Poulin PhD, Psychologist, Ottawa; Alex Sorisky, Endocrinologist, Ottawa; Stan Van Uum, Endocrinologist, University of Western Ontario

The readers of This newsleTTer are well aware of the difficulties of living with diabetic peripheral

neuropathy. In addition to the challenge of adhering to their medical management and foot care program, many patients often also have chronic pain. Chronic pain has negative effects on activity, concentration and mood and can diminish enjoyment of life. Despite the use of various classes of drug to alleviate pain it is rare to achieve more than a 50% reduction in pain intensity through pharmacological treatment alone. Patients therefore must find ways to cope and continue to enjoy life in the presence of residual pain and disability. We are a team of health researchers at the Ottawa Hospital Research Institute who have recently been awarded funding from the Canadian Diabetes Association to test a new approach to the care of those suffering from painful diabetic peripheral neuropathy (PDPN). We will be testing the effect of Mindfulness Based Stress Reduction on physical and social functioning, mood, pain, and metabolism in patients with PDPN.

Our current understanding is that pain is a unique individual experience influenced by the interaction of biological, psychological and social factors. An inter-professional model of care addressing both the biological and psychological needs of patients is key to improving outcomes. Psychosocial interventions such as cognitive behavioural therapy (CBT) have been shown to have a significant positive impact when integrated into chronic pain treatment programs. More recently there is great interest in the efficacy of a psychosocial intervention known as Mindfulness Based Stress Reduction (MBSR), originally developed for refractory chronic health problems. This method utilizes a combination of cognitive behavioural therapy, education, meditation and gentle yoga. It is delivered in a group setting and generally consists of 8 weekly 2.5 hour sessions focused

on teaching participants various mindfulness skills as well as providing psycho-education about stress, pain, and coping skills.

With the availability of functional magnetic resonance imaging there is an emerging literature documenting the effect of mindfulness meditation and MBSR training in decreasing activation of brain centers involved in the neuroendocrine response to stress. Thus, MBSR may be particularly appropriate for diabetic patients with chronic pain in that it not only addresses pain and psychosocial issues but has the potential to improve glycemic control through improved adherence to medical management as well as through improved metabolism by reducing the activation of the hypothalamic-pituitary-adrenal axis that is part of the stress response. There is preliminary evidence for all these effects.

We are interested in the added value of MBSR to patients receiving optimal care from an inter-disciplinary team. Eligible and consenting patients will first be seen by a chronic pain specialist at the Ottawa Hospital Pain clinic where their pain medications will be optimized according to national guidelines. They will then be randomized to attending the MBSR group sessions or waiting. Pain, psychosocial and functional outcomes as well as HbA1c and cortisol levels will be measured on entry to the study, after medication optimization, 2 weeks after the MBSR course and 3 months after the course. After the 3 month measures, the patients who were waiting will also receive the course. Our primary hypothesis is that, compared to patients who are waiting, those who have had the course will have significantly improved social and physical functioning.

continues on page 3

3Champlain DRCC Newsletter - November 2012

The effects of an interdiscipinary program... (continued)

Eligible patients would be 18 years or older and have a diagnosis of diabetic peripheral neuropathy causing foot pain for at least 6 months. They must be willing to attend the group sessions and be open to gentle yoga as well as meditation. They must be able to fill out questionnaires in English or French. All materials will be available in both languages but the group sessions will be held in English. At a later date, after research ethics board approval, the Champlain DRCC will email with the information you need to refer patients to our study. If you have any questions you may contact Brittany Warren at 613-761-4486 or email [email protected]

what is new in champlain

Regional Chiropody UpdateWe are pleased to announce that the Champlain Community Chiropody Program for people living with diabetes is expanding to Kemptville and Hawkesbury in November 2012. We will also be using the Ontario Telehealth Network (OTN), which will enable us to provide foot screening session remotely.

We would like to welcome Lauren Clow, our new chiropodist, who has completed her orientation and will be running clinics on her own in November.

If you have any questions, please contact Barbara Neuwelt at [email protected] or 613-233-4443 x 2183. I am the new director at the Community Diabetes Education Program - Ottawa, the host program for the LHIN-wide chiropody program. I look forward to meeting all of you in the future.

Invitation to participate in the Champlain Diabetes Foot Ulcer and Amputation reduction strategy and Best Practice Training Initiative in 2013Foot ulcer and lower extremity amputation risk reduction has been identified as a priority focus by the Champlain Regional Diabetes Advisory Committee. As a result, the Champlain Diabetes Foot Care Expert Committee was established to develop a best practice “tool box”, training module, and evaluation strategy to support the uptake of best practices for reducing foot ulcers and amputations for people living with diabetes across the Champlain region. The foot care tool box reflects many elements of the RNAO Best Practice Guidelines and includes documents and resources for health care providers and patients such as, an evidence based Foot Ulcer Risk Assessment Protocol, Patient Foot Ulcer Risk Profile Report, Patient Foot Care Tips, and Champlain Regional Diabetes Foot Care Teaching Record.

Our goal is to have all health care providers of diabetes care in the Champlain region uptake the standardized best practices within their practices.

We are inviting you and your team to participate in this regional effort to standardize common core elements of foot ulcer risk assessment, risk stratification, and self-management education.

Champlain DRCC Newsletter - November 20124

A 2 1/2 hour on-site training program, facilitated by foot care experts and Champlain Diabetes Regional Coordination Centre staff, has been developed to help participants:• Perform a quick, standardized foot risk assessment• Stratify clients/patients according to their ulcer risk• Provide brief, evidence-based self-management education to reduce ulcer risk• Identify and refer to foot care resources within their community • Be aware of and evaluate established foot care performance metrics

Please contact Olga Nikolajev if you would like to take part in this important initiative. Olga Nikolajev, Champlain DRCC Outreach [email protected] 613-894-9356

Self-Management Support Community of Practice in the Champlain region:Launch Date - January 2013

Living Healthy Champlain and the Champlain Diabetes Regional Coordination Centre (DRCC) have partnered to host, develop and sustain the Self-Management Support (SMS) Community of Practice (CoP) so that providers can practice, integrate and support their peers.

The Self-Management Support (SMS) Community of Practice (CoP) brings together professionals, leaders, and healthcare providers to advance their Self-Management skills and techniques. Our shared goal is to increase/improve/integrate Self-Management skills and techniques through knowledge exchange, skill development and integration of Self-

Management Support within healthcare practices, with the goal to best assist clients living with chronic illness to Self-Manage with confidence and knowledge. The Self-Management Support (SMS) Community of Practice (CoP) works collaboratively to address the needs of our regional healthcare providers, to deliver best practice knowledge dissemination and implementation. We envision that the Self-Management Support (SMS) Community of Practice (CoP) as a web-based platform which would house SM training videos, training notices, resources and discussion boards. In addition, the Self-Management Support (SMS) Community of Practice (CoP) would engage in hosting and facilitating in-person case studies and Self-Management skills and techniques follow-up or practice sessions. In order for us to be better able to develop an effective, engaging and interactive Self-Management Support (SMS) Community of Practice (CoP) please fill out the following survey. www.surveymonkey.com/s/SMSCoPAssessment

Your input is vital to our success!

If you have any additional questions, please contact your Diabetes Regional Coordination Centre, Outreach Coordinator: Olga Nikolajev at [email protected]


New member to the Champlain DRCCIt is with great pleasure that we have the opportunity to introduce to you Renee Lebovitz Pelletier as our newest member to the Champlain Diabetes Regional Coordination Centre. Renee is well known in the diabetes community and comes to us from the Canadian Diabetes Association where she has been actively involved within the diabetes community, building capacity within the programs and services for the past ten years. Some of the highlights of Renee’s involvement in the community include providing leadership to the Annual Diabetes Expo committee; organizing multiple community education symposia; providing basic diabetes education to the community through the volunteer Speakers’ Bureau and community health fairs; mobilizing high risk diverse

populations; developing Physician and Pharmacy Outreach programs; managing Camp Banting - a residential camp for children living with type 1 diabetes for 8 years.

Renee is a team player and has developed many community partnerships to address the needs of people living with diabetes and their families while engaging health care providers to provide the necessary resources to achieve this goal.

Renee has joined Olga Nikolajev in the role of diabetes outreach coordinator but will have a different role and portfolio. She started on October 9th in her new role and has already been very busy.

Please join us in welcoming Renee to the Champlain DRCC [email protected] 613-808-1808

Working with Different Cultures A patient-centered culturally sensitive health care

provider training workshop

Monday, December 10, 2012 Registration/Refreshments 12:30 pm

Workshop 1:00 – 3:30 pm Ben Franklin Place - 101 Centrepointe drive

Ottawa, Ontario

Online registration: http://bit.ly/SxiFNM

613-238-3722

You will learn how people of diverse cultures and belief systems perceive health and illness differently which can impact how they respond to various symptoms, diseases, and treatments.

You will gain a cultural understanding of your patients while increasing cross-cultural competence and effectiveness.

You will develop strategies to improve cross-cultural diabetes care.

Supported by: The Champlain Diabetes Regional Coordination Centre

Partners: Canadian Diabetes Association, Catholic Immigration Centre of Ottawa, Ottawa Local Immigration Partnership and Ottawa Public Health

Sponsored by: Refreshments provided by Lilly and Boehringer-Ingelheim

Speakers

Free workshop

Immigrants, Diabetes and Culturally-Responsive Health Care Dr. Sylvia Reitmanova, MD, PhD Vision 2020 Postdoctoral Fellow, University of Ottawa

Cultural Barriers to Optimal Diabetes Management Dr. Hasina Visram, MD, MSc Fellow in endocrinology and metabolism, University of Ottawa

Case Study Dr. Shajia Khan, MD, FRCPC The Ottawa Hospital, Division of Endocrinology & Metabolism Learn from patients sharing stories about their challenges with diabetes management and lifestyle behavior changes from the Latin American, Nepalese, Punjabi and Somali communities.

Workshop Objectives An opportunity to explore the impact of culture on diabetes management and

develop a culturally-responsive practice to improve patient outcomes

Supported by: The Champlain Diabetes Regional Coordination Centre and the Ottawa-

based community Diabetes Education Programs

Partners: Canadian Diabetes Association, Catholic Immigration Centre of Ottawa, Ottawa Local Immigration Partnership and Ottawa Public Health


From our Champlain Community Client Champions

The Champlain Community Client Champions met in early October to provide insight and reflection on the Champlain DRCC website, Foot Care client tools, self-referral process to community diabetes education programs and regional priorities. We thank them all for their continued commitment to provide feedback on new initiatives and their willingness to share their stories. Reta Desmarais shares her story in this issue of our newsletter. Look for more stories from our Champlain Community Client Champions in our future newsletters.

The Mystique of Blood Sugar Control for Type 2 Diabetes

People with type 2 diabetes are always told about the importance of exercise to enhance the action of insulin produced in the body or given as a supplemental medication. The assumption, then, is that ‘the more exercise, the better it is’. This is not necessary the case.

In cases of extreme exercise e.g. walking or running a marathon, the body is put to an added physical stress and the natural response is to mobilize sugars into the blood to provide the required energy. However, we know that you must have insulin to accompany the sugar through the cell wall and into the cell to provide the energy. Some people are surprised when they check their blood sugars and find they have increased rather than decreased. Therefore the person using insulin must take some additional units for all the sugars to work and their blood sugar level to decrease.

A personal experience with this phenomenon occurred for me when I was hiking in the Nyungwe National Park in Rwanda. We were already at 2365 meters altitude and our trek through the jungle lead us 300 meters down to a small but lovely waterfall. During the hike I kept close tabs on my blood sugars and even though it was expected that the strenuous exercise would lower the levels, it was a surprise to learn by testing that the blood sugar levels were rising. It became apparent that the body was mobilizing sugars to be used in this demanding situation but the insulin was not available to carry it into the cells to be used. A few units of insulin taken on the trail in the middle of the jungle soon put me back into prime operating mode to enjoy and complete the hike.

From: The Fuchsia Umbrella – Traveling Well with Diabetes by John and Reta Desmarais


Ottawa DES Chapter UpdateThe Physical Activity Workshop held in late September showcasing the new CDA Physical Activity Manual presented by developer Dr. Christopher Shields from Acadia University was well attended and well received according to the evaluations. This was an exceptional day to network with colleagues from across our LHIN and the SE LHIN. Thank you to our corporate sponsors Animas, Lifescan and NovoNordisk for their support. These manuals and accompanying patient resources are available on online at www.diabetes.ca under Professional Resources. Some binders still may be available at a reduced price of $ 55.

Contact [email protected] for more information.

REMINDER - Professional Membership with DES expired as of Aug 31/12. Please renew now online at www.diabetes.ca in order to continue to receive world class journals such as the Canadian Journal of Diabetes (CJD) and continue to be connected to 1000’s of diabetes educators.

Local DES Executive Activities Helene Charlebois, Dominique Gendron and I (Kim Twyman) continue to represent diabetes educators locally. We will be meeting with the Champlain DRCC (including their additional outreach coordinator Renee Lebovitz-Pelletier, well known to us from the Regional CDA office) to discuss plans on how we can move forward to provide valued education to our membership and people living with diabetes. The following are sessions in the works...

November: Diabetes and Heart Disease, Dr Roland Sabbagh, sponsored by Lilly

December: National Conference Learning’s shared by DES Members, Wine and Cheese, sponsored by Sanofi Aventis

January: Diabetes Team Approach to Management of Diabetes and Exercise

February: Research update

April: Obesity (for health care providers and clients)

May /June: Pharmacist’s role on the Diabetes Team

CDA Future Conferences2013 National Conference will be held in Montreal and will be a joint conference with our Vascular Counterparts such as Heart and Stroke and the Cardiovascular Network. Watch for more details as it unfolds. Winnipeg is in negotiations for the 2014 Conference and IDF is back in Canada for 2015.

from the diabetes educators sector (des)By Kim Twyman

8 Champlain DRCC Newsletter - November 2012

from the champlain diabetes screen project:

Screening Events in the CommunityThe Champlain Diabetes SCREEN project team is happy to announce two or more screening events for the high risk immigrant population before the Holiday Season. Our two first events were held on October 20 for the Latin American community and on November 10th for the Somali Community.

• Wednesday, November 28th – Punjabi Community – Gurdwara Punjabi School, 4 pm – 7 pm• Saturday, December 8th – Nepalese Community – Ben Franklin Place, 1:30 pm – 4:30 pm

The events will involve screening activities for community members at high risk for type 2 diabetes from the different communities mentioned above. The screening sessions will include screening for risk of type 2 diabetes, education sessions, referrals and hand-outs for the high risk immigrant populations. The objective of these events is to create awareness among the high risk populations of their risk factors, to build capacity within the high risk populations about their risk factors, to connect the high risk populations to the diabetes services available in the community and to build a network of partners to help reduce the risk of diabetes in the long term among high risk immigrant populations.

New diabetes guidelines for the High Risk Immigrant Populationshttp://www.cmaj.ca/content/184/15/1687.full

Champlain Diabetes SCREEN project announces Cultural Sensitivity training for Health Care Providers:Rate of diabetes among the Somali, Nepalese, Latin American and Punjabi communities are 2-4 times the rate of diabetes among the general population in Ottawa. Immigrant population was 24 % of the general population in Ottawa 2009 and is expected to reach 28% by 2017, with 58 % of the immigrant population being of a visible minority.

Different studies including phase one of this project has revealed that there are cultural barriers between the high risk immigrant population and their health care providers which, in turn, affect the high risk population engagement in their treatment, prevention and the continuity of care; this is one of the important factors why these communities (Somali, Nepalese, Latin American, Punjabis) have higher risk of type 2 diabetes than the general population. Several needs have been identified by past research such as the need for cultural health interpretation and bilingual services in primary health care settings; need for recognition and respect of the prominent role of spirituality in many culturally diverse populations; and a need for delivery of culturally competent primary health care.

It is our hope that the patient-centered culturally sensitive health care training Working with Different Cultures will have a positive impact on the care for these high risk immigrant populations. There are several challenges that immigrant populations face such as problems accessing and navigating the health care services in Ottawa; problems sustaining an on-going relation with a health care provider or accessing different health care services available to manage their diabetes. Health care providers may not know the cultural background of the immigrant populations, and may be unaware of culturally-specific eating habits, barriers to physical activity or may not be aware of the presence of culturally-specific expectations towards the health care providers. All these factors have an impact on the rate of type 2 diabetes among the high risk population.


A patient-centered culturally sensitive health care training Working with Different Cultures will be held on December 10th at Ben Franklin Place from 1-3:30 pm.

The overall objective of this workshop is to break the cultural barriers between the high risk immigrant population and their health care providers, so that the health care providers may: • Understand the values of cultural and ethnic differences • Be able to clearly understand and communicate effectively across cultures• Be able to make culturally informed diagnoses, assessments, and treatment plans• Provide culturally sensitive management and improve outcome of high risk immigrant living with diabetes• Increase engagement and retention in services, satisfaction with services, and positive clinical outcomes

For further information and registration, please contact Hesham Abdalla, Champlain Diabetes SCREEN Project Coordinator [email protected] 613-608-5991

Visit the SCREEN project page, which includes an outline of the project, team members, FAQ and a schedule of events: http://www.champlaindrcc.ca/SCREEN.html

Screening: Identify people at high risk of diabetes or with

diabetes

Capacity Building: Build knowledge among high risk communities and providers

of diabetes services

Risk Management: Improve the ability of people at risk

of diabetes or with diabetes from high risk ethnic

communities to manage their risk factors and

diabetes

Education : Increase access to diabetes education

programs and link people to appropriate resources,

programs and follow up including primary care and

diabetes services

Evaluation: Assess the results of this program (process and impact)

Networking : Work in partnership with

communities, health service providers and organizations and primary care providers


innovations in diabetes care

In our March 2012 Newsletter we highlighted the use of Conversation Maps by diabetes educators, how they were developed, what they are and their impact on providing a facilitated education session to people living with diabetes. http://www.champlaindrcc.ca/downloads/newsletters/Newsletter%20Champlain%20DRCC%20March%202012.pdf

An excerpt from the August 2012 Canadian Journal of Diabetes: Conversation Maps: Should the Conversation Continue? By Gail MacNeill BNSC, RN, Med, CDE

Are They A Match?As diabetes educators, we are seeking to engage our patients in a collaborative partnership. By working with the components of knowledge, attitudes, confidence, conviction and problem solving, we aim to facilitate the patient’s development of their own action plan. Through tailoring and follow-up of this patient-generated action plan, the ensuing behaviour change is anticipated to improve the diabetes related outcomes. A wishful process, but, nevertheless, one we are all participating in. A tool that has shown promise in helping us facilitate this process is the Conversation Maps. In clinical practice they generally have been enthusiastically received both by the healthcare professional and the patients for use in a variety of situations. However, the most rigorous randomized control trial to date has shown them to be less effective than individual education. What can account for this discrepancy?

One issue is the comparison of individual to group interventions and the outcomes being studied. These different modalities are used for different purposes yielding different results. As Gonzales and Handley suggest, group programs offer the opportunity to “harness social norms and peer counselling to promote greater behaviour change.” The use of the Conversation Maps and current literature strongly supports the use of peers, yet the value of this strategy to behaviour change cannot be measured in individual education. Further research in this area should compare traditional groups to Conversation Map sessions and measure specific relevant outcomes to the group process of education and behaviour change. Consideration should be given to identifying the effect of the duration of diabetes, the type of diabetes and the cultural aspects of the learning process to give us evidence as to which audience is best suited to the use of the Conversation Maps. Because the experience of the facilitator has been shown to affect the results the suggestion is to use the same facilitators in the comparative groups eliminating this variable. Other variables such as the length of time the educator is with the participants, size of the groups and curriculums used should be well-documented and standardized to allow for valid comparisons. Further research is also warranted to examine the role of this tool in healthcare provider training to identify what type of trainers, at what stage may most benefit from the use of this tool.

The Conversation Maps have filled a gap in the “how to” of patient education. Theoretically and intuitively they “feel right,” however, some convincing scientific evidence to date does not support our perspective. Further research using more indicative markers with variables accounted for mat yield different results. Until then, the high level of patient and healthcare professional satisfaction with the use of the maps will ensure that the conversation continues.

To view the full article: http://www.canadianjournalofdiabetes.com/


tools and resources

For Healthcare Providers:Management of Hyperglycemia in Type 2 Diabetes: a Patient-Centred Approach; June 2012http://care.diabetesjournals.org/content/35/6/1364.full.pdf+html

For People Living with Diabetes:Diabetes GPS: The Canadian Diabetes Association provides information, support and resources to people with diabetes in ways that are meaningful to them—anywhere in Canada, anywhere there is a phone, an address, or a computer. Our resources are widely available and easily accessible through our offices, at 1-800-BANTING or on-line at http://www.diabetesgps.ca/ Our resources are available in several languages with culturally-relevant references, like food choices, providing meaningful help to our populations at greatest risk for the development of diabetes.

Champlain Diabetes Regional Coordination Centre420 Cooper St, Ottawa K2P 2N6Website: www.champlaindrcc.ca | Twitter: ChamplainDRCC

Newsletter publication dates: January, March, May, September, and November. Submissions must be received by the 15th of the previ-ous month and sent to [email protected]

The content and opinions expressed within the DRCC Newsletter articles are those of the authors and are not necessarily endorsed by the Champlain DRCC.

Contact information:

champlain drcc newsletter vol.2, no. 6, november 2012 ch… · strategy and best practice training...

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