The Centre for Complex Diabetes Care (CCDC) is a regional care delivery program established to assess and support patients with diabetes who have complex needs that require intensive shorter-term care management and a single point of access to a specialized interprofessional team. The CCDC is another program that augments the continuum of care currently provided by primary care providers, Diabetes Education Programs, diabetes specialists and other diabetes programs.
In the Central East region, the CCDC has been established in three care delivery sites located at The Scarborough Hospital, Peterborough Regional Health Centre and Lakeridge Health. The CCDC team provides the following:
- Supports patients through assessment, education, treatment, and transition/discharge, using an intensive care management approach and regular follow-up.
- Collaborates with the patient and primary care provider to develop an individualized care plan to address the patient’s unique needs.
- Aids in the navigation of the health care system as identified in the care plan.
- Supports all providers involved in the patients’ care, including specialties, primary care providers, CCAC, etc.
- Communicates regularly with all providers regarding patient care plans.
- Transitions/discharges the client back to their primary care provider and/or Diabetes Education Program, as appropriate.
Services are free of charge.
The CCDC assesses and supports patients with diabetes who have complex needs, such as co-morbid health conditions that require intensive case management. Patients who attend the CCDC are typically those who need more contact, more resources and more follow-up across health care and social services systems.
For patients with less complex needs, referral to the Diabetes Education Program (DEP) remains the best option. To be referred to the CCDC, patients must be 18 years of age or older and have Type 1 or Type 2 diabetes along with one or more of the following:
- Multiple episodes of inadequate glycemic control and/or significant co-morbidities impacting glycemic control
- Serious mental health issues, barriers in accessing health care, frail elderly, mobility issues, and other determinants of health that are lacking
- Recurrent emergency department visits or hospitalizations
- Would benefit from an interprofessional team who coordinates the care the patient is receiving from multiple healthcare providers
Once patients are stabilized, they are discharged back to their primary care provider and/or appropriate Diabetes Education Program for follow-up when their condition has stabilized.