Diane's story: Chronic care

What can primary health care teams offer to people with long-term health conditions? Let's look at a hypothetical story set in a place where primary health care is well developed and operating efficiently.

Diane* is 56 years old and has had type 2 diabetes since she was 47. Type 2 diabetes can lead to complications such as heart attacks, strokes, kidney damage, nerve damage, blindness, and foot infections (which can become severe enough to require amputation). Fortunately, Diane has a much better chance of avoiding these complications, thanks to the care she receives in her community.

Many people in Diane's community, including Diane herself, are of Indigenous heritage. Because Indigenous people are at a higher risk of diabetes, Diane's community has developed excellent diabetes care services. Diane uses the services of the team of health professionals at a local diabetes clinic to help her manage her disease. Diane is an important member of her health care team, helping to make decisions about her own care and treatment. Being involved in the decision-making gives Diane more control over her health and her treatment, which in turn helps motivate her to keep track of her blood sugar, take her medications, and stick to her diet and exercise plan.

This is how several members of the community primary health care team helped Diane to better manage her diabetes.

The doctor and nurse practitioner:
Since doctors are scarce in Diane's community, a nurse practitioner works with the doctor at the clinic to regularly monitor her blood sugar results, blood pressure, weight, kidney function, cholesterol, and nerve function to make sure the diabetes is under control and there are no signs of any complications associated with the disease. Diane's doctor, her nurse practitioner, and a physiotherapist who consults with the team helped her develop an exercise routine she could stick to.

The pharmacist:
When she was first diagnosed, Diane's pharmacist showed her how to use the blood glucose monitor and taught her about her new medications. After she started medications, Diane's pharmacist helped her monitor her blood sugar levels, and called Diane's doctor to suggest changes to her medications to help keep Diane's blood sugar within a healthy range. Since then, Diane has been able to control her blood sugar quite well, but she still visits her pharmacist regularly for medication refills and checks her blood pressure in the pharmacy's blood pressure machine.

The dietitian:
The dietitian at the clinic helps Diane with meal planning and gives free talks at the local high school to help other people with diabetes in the community. She has worked with Diane and others in the community to develop an online database of healthy recipes and alternatives.

The optometrist and podiatrist:
Diane has a yearly eye exam to check for eye damage. She also regularly sees the podiatrist (foot doctor) at the clinic, who checks her feet and gives her advice on how to care for her feet and check them daily for damage. This helps reduce her risk of foot infections.

The team:
All of these health professionals are in regular contact with one another as part of the primary health care team in Diane's community. Most of them work together in the diabetes clinic and regularly get together to share information and consult with each other. They communicate with each other through regular discussions and refer to Diane's electronic health record to make sure that all members are aware of any changes in Diane's condition. If Diane has any questions, she can access a nurse whenever she needs to through the telephone health advice line.

Diane's primary health care team, with her as the central member, helps her manage her diabetes and live life to the fullest. It all adds up to better health and fewer diabetes complications for Diane.

* Note: The stories of Mitchell, Diane, and Alex are hypothetical stories based on the goals and vision of primary health care.

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