Grant: Oper Grant:eHealth Innov Partnership Program(eHIPP)-Seniors w Complex Care Needs

First Nation (FN) seniors are high risk for diabetes morbidity/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 FN seniors. 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. The Canadian Diabetes Association 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 using health technology information systems and a centralized care coordinator to strengthen FN community capacity. RADAR will establish system-wide, scalable infrastructure (an integrated diabetes registry/records system) that will support front-line community nurses in transforming care for FN seniors with diabetes. The proposed model has two major components to improve the care of FN senior diabetics: 1) Implementation of a common diabetes registry and health records system (eHIPP technology); 2) Care coordinator to support front-line providers for measurement, monitoring and streamlined, coordinated referral and follow-up with use of the technology. We hypothesize that the RADAR model will result in an overall improvement in the quality of clinical care of FN seniors living with diabetes on reserve. We also hypothesize that the RADAR model will be effective, efficient and transferable at the organizational level within these communities and will have a broader public health impact on the population of those with diabetes. Importantly, all outcomes will be assessed from the lens of the FN communities to ensure model is culturally appropriate from their perspective.