System of Integrated Services for Type 2 Diabetes Patients in Côte-des-Neiges Territory: Analysis of Effects

by Andre-Pierre Contandriopoulos | Dec 01, 2003

Key Implications for Decision Makers

  • Type 2 diabetes can be controlled with an integrated intervention. Most people with type 2 diabetes (even if they are economically and socially underprivileged) can control their disease when they have access to a personalized program of education, basic services (diet, foot care, blood glucose monitoring), and medical services delivered by an integrated multidisciplinary team.
  • As easy as it is to increase the volume and range of services available, it is equally difficult to create the necessary conditions for developing genuine co-operation among various professionals working in different settings. Co-operation requires more than goodwill; it must be encouraged by a system of incentives. In tangible terms, compensation of the professionals involved must reflect the time devoted to co-operation; activities performed in organizations other than their own must be recognized and valued; and information systems must be developed that are truly useful for and usable by all team members.
  • The program's success depends on participation and training of people with diabetes. The personalized service plan, drawn up jointly by the multidisciplinary project team and each participant, is the core component of the intervention.
  • The pilot project concept must be rethought. Introducing a new intervention with short-term funding seriously limits the tendency of professionals to become involved in activities that alter their practice and might leave them and their patients in a difficult situation at the end of the project. They might even be reluctant to participate in other new initiatives later on.

Executive Summary

The project for which the findings are reported here is designed to assess the effects of an integrated system for intake of type 2 diabetes patients, known as SIDi, one year after introduction in the Côte-des-Neiges CLSC in Montreal. The integrated services model assessed is based on the concept that services for diabetic patients must be under an integrated group of family physicians, patients, and a multidisciplinary team. The multidisciplinary team is centred on a contact nurse, who acts as a liaison between the family physician, the team, the diabetic patient, and his/her next of kin.

Implications for Decision Makers

The study shows that control of moderate or severe type 2 diabetes can be improved by the introduction of integrated programs that capitalize on patient education, make basic services accessible, and forge closer links between the expertise of family physicians and that of nurses. The personalized services plan is the core component of the intervention. It supports co-ordination of team members' activities and gives patients a guide for adopting the behaviour necessary to control diabetes. The more it leads to tangible action, the more it leads to changes in behaviour.

The main difficulty in implementing an integrated program for diabetes is to develop genuine co-operation between family physicians and other professionals. The active participation of physicians might be encouraged by compensation for time devoted to these activities, greater physical proximity between the multidisciplinary team and family physicians, as well as assured stability of the project, if the results prove satisfactory.

To be sustainable, integration of care requires that an explicit governance system be established, so co-ordination of activities is encouraged through adequate financial incentives, learning about team work, and access to necessary information for co-ordinating the duties of each team member.


This is a single case study with embedded levels of analysis. This approach is designed to verify whether all the anticipated results are observed; in other words, whether the theory of intervention withstands the test of practice and whether the various players involved agree on the program's effects. Many sources of data were used: 1) SIDi administrative files (patient records, education, medication, medical follow-up); 2) interviews with patients participating in the project; 3) interviews with family physicians participating in the project; and 4) interviews with nurses participating in the project.


One year after implementation of SIDi, patients and physicians believe the program fostered better control of diabetes. Patients have a better knowledge of the disease and its treatment, and they believe the program has helped them change their life habits. The key component of the program is definitely patient education by nurses. The positive benefits of this approach were assessed by patients as well as attending physicians.

Adoption by nurses of a model for changing behaviour in stages not only fostered adaptation of services to each patient's specific and particular needs but also allowed nurses to play a new role within a multidisciplinary team.

The lack of agreement on the intervention philosophy made genuine co-operation between family physicians and nurses difficult. Physicians considered themselves responsible for all care, delivery of which they delegated to the multidisciplinary team, whereas members of the multidisciplinary team, especially nurses, saw themselves as the hub of the program.

The SIDi project supported the establishment and mobilization of a multidisciplinary team centred on the nurse. Physicians, who remained outside this team, did quickly acknowledge the importance of services delivered by the multidisciplinary team, and especially liked the role played by nurses in defining the personalized services and patient follow-up. The project also demonstrated that professionals from different organizations can all work together on a specific problem. Improved access to second- and third-tier services also helped bolster interest in the project among family physicians.

For members of the multidisciplinary team, especially nurses, the SIDi project enhanced the appreciation of their role with a client group dealing with a chronic disease. The personalized services plan is the core of the transformation in nursing practices. It also provides a tool for co-ordinating use of the services of the multidisciplinary team and for implementing the educational approach taken by nurses.

Participating physicians preferred to continue working with their paper files and communicating by telephone or fax, despite the establishment of a computer network.

More detailed research

Three factors characterize our research:

  • the duration and timing of our assessment cannot capture the program's long-term effects;
  • our assessment of the program's effects, based on participants' perceptions, would benefit from validation through objective measurements, especially for control of diabetes; and
  • the addition of services that accompanied initiatives to integrate services could not make a distinction between the effects specific to the two intervention factors.