Grant: Project Grant

First Nations (FN) people are at very high risk of diabetes morbidity and mortality and this is compounded by suboptimal care in isolated FN communities. Limited community nursing capacity and a lack of electronic registries/records leads to a reactive, disorganized approach to care. This situation is directly responsible for the poor diabetes-related outcomes observed in FNs. Health Canada's 2010-2015 Aboriginal Diabetes Initiative calls for innovative, culturally relevant approaches aimed at increasing community wellness and reducing the burden of diabetes through the use of local knowledge. Diabetes Canada specifically mentions the importance of using systems to identify diabetics and have a systematic follow-up process. The RADAR study fits exactly with these priorities by the use of new health information systems and a centralized care coordinator to strengthen FN community capacity. RADAR aims to expand our support system for front-line community nurses to transform care for FN diabetes patients. The proposed model has two major components to improve the care of FN diabetics: 1) Implementation of a common diabetes registry and health records system 2) Professional care coordinator to support front-line service providers for measurement, monitoring and streamlined, coordinated referral and follow-up of care with the use of the technology. We hypothesize that the RADAR model will result in an overall improvement in the quality of clinical care of FN living with diabetes. Moreover, we aim to expand RADAR to continue support for our existing 7 communities for an additional 2 years, as well as to add 5 communities) and to measure the potential impact that RADAR has had on patients to reduce their need for hospitalizations and/or emergency department visits over time. Importantly, all outcomes will be assessed through the lens of the FN communities to ensure the model is culturally appropriate from their perspective.