The challenge of promoting integration: conceptualization, implementation, and assessment of a pilot care delivery model for patients with type 2 diabetes

Fam Med. 2004 Jan;36(1):40-5.


Background: The Côte-des-Neiges diabetes pilot project strove to conceptualize, implement, and assess an integrated health care system for Type 2 diabetes. Using a disease management and population-based approach, a multidisciplinary team sought to (1). organize health care in an integrative framework, (2). promote behavior changes in patients to foster self-care, (3). introduce tools to allow family physicians to modify their practices, and (4). encourage local community action to support patients and providers.

Methods: Information from a needs assessment helped guide the development of the care model, which was implemented over a 1-year period. A preliminary assessment was undertaken using qualitative methods. Data were collected through in-depth interviews, focus groups, participant observation, and document analysis.

Results: (1). Physicians and patients appreciated having access to a multidisciplinary team and related services, and personalized communication was preferred to computerized links. (2). Patients also perceived the benefit of individualized assessment and self-care educational sessions allowing them to participate in their illness management. (3). A diabetes care flow sheet altered the management strategies of physicians. (4). Limited time prevented full development of networking efforts to promote community mobilization.

Conclusions: Approaches to chronic diseases such as diabetes require integrative health care strategies to support patients and providers in their community. In spite of time constraints, patients perceived the value of education with increasing involvement in their illness, physicians reported changes in their practice, and steps were initiated to mobilize community resources.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Community Health Services / organization & administration
  • Delivery of Health Care, Integrated / methods*
  • Diabetes Mellitus, Type 2 / therapy*
  • Disease Management*
  • Education, Medical, Continuing
  • Family Practice / organization & administration
  • Female
  • Focus Groups
  • Hospitals
  • Humans
  • Interviews as Topic
  • Male
  • Middle Aged
  • Models, Organizational
  • Needs Assessment
  • Patient Education as Topic
  • Pilot Projects
  • Process Assessment, Health Care
  • Quebec