Putting the power back in patients’ hands:

How a new research study is empowering and educating diabetes patients at SHN

Published in SHN Foundation's biannual magazine, Our Time

When Ron Beleno watches his 82-year-old mother Ronces, a former patient at SHN’s General hospital, staying active as part of a line-dancing class, or learning about healthy eating from a nutritionist, he can see just how much of an impact it has on her.  


“As an older adult with diabetes, my mother finds joy, confidence and well-being in experiences and services that allow her to take ownership of the challenges in her life,” shares Beleno, who serves as Ronces’ parttime caregiver. “However, we’re not always sure where or how to access these services, and without the proper direction, I often find it difficult to provide my mother with the tools she needs to manage her diabetes. Her treatments are only half of the battle, but there is a gap that needs to be addressed.”


This gap is a challenge faced by many of Scarborough’s elderly patients with diabetes, where the prevalence is 30% higher than average for Toronto, and where the population over the age of 60 has nearly doubled since 2006. In the epicentre of this "diabetes hotspot" is Scarborough Health Network, host to the largest nephrology program in North America, serving more than 6,000 patients annually across three hospitals and three satellite sites, including the Yee Hong Centre for Geriatric Care.


At the helm of nephrology and chronic disease management for SHN is Director Ethel Macatangay.  


“Chronic kidney disease and diabetes are more than just illnesses – for many of these patients, particularly our most senior patients, it has become their way of life,” shares Macatangay. “While clinical treatments such as dialysis are obviously a vital part of the equation, our patients need a model of care delivery that addresses every aspect of their journey, from exercise to diet and nutrition and even socializing with other patients. By enabling greater access to community services that help educate and empower senior patients on proper self-management techniques for their chronic kidney disease, we can work together to create a healthier future for Scarborough.”


Given SHN’s recognized leadership in the area, Macatangay and her diabetes and nephrology teams were among the first to join an innovative, pan-Canadian research study out of McMaster University.  


Funded by the Canadian Institutes for Health Research (CIHR) and Diabetes Action Canada, along with funding from SHN and a generous $200,000 gift from the hospitals’ primary dialysis machine provider Baxter Canada, the research project will engage with groups of older adult patients living with diabetes and chronic kidney disease in several communities across Canada – including Scarborough. The comprehensive, multiyear study will expose them to a 6-month intervention alongside their typical clinical treatments and test the impact of integrated community services on their overall disease management and personal patient success.


The project is led by Principal Investigators Drs. Jenny Ploeg, Ruta Valaitis, Maureen Markle-Reid and Rebecca Ganann from the Aging Community Health Research Unit, Faculty of Health Sciences, McMaster University.  


“In early conversations with seniors’ groups in Guelph, Ontario, one thing was clear – the ability to selfmanage disease is something that patients are looking for, or in many cases isn’t an option they even know is available to them” said Ploeg. “With community services that inform patients about how to better manage their illness and that links them to valuable community resources that they can take advantage of themselves, this study has the potential to improve treatment outcomes and even reduce emergency visits. While we are still in early stages, we are confident that this research will open doors for a community-based model of care capable of empowering patients to not just manage their diabetes, but all chronic disease, and ultimately improving patient outcomes.”  


Valaitis remarks that the research aligns well with the provincial government’s Ontario Health Care Teams, which will involve collaboration among streamlined groupings of different care providers from different care settings, such as hospital, primary care and community. And, as one of the most diverse communities in Ontario, Scarborough and SHN are ideal settings for this study to take place.


“The Scarborough community is made up of so many different cultures and contexts, and with SHN’s alreadystrong reputation for innovation and integration with regards to diabetes care, this setting provides us with the real-world conditions necessary to properly apply this study,” shares Ganann. “SHN was also the first site to come on board and to start recruiting for the study, and they have already proven to be valuable and passionate champions in this project.”


Though previous trials were conducted in Ontario and Alberta, demonstrating improvements in self-care and mental health, the team is confident that Scarborough’s cultural and socio-economic diversity provides the optimal setting needed to more effectively test this intervention.  


To ensure that all perspectives are represented and every expertise is considered, the team has pulled together a Community Advisory Board who will consult on critical aspects of the study as it progresses. Among the members of this Board include Angie Saini, Director of Client Care at Carefirst Seniors and Community Services Association, the intervention’s community partner; Kasia Luebke, Director of System and Sub-Region Planning and Integration at the Central East LHIN; Beleno himself, serving as a voice for fellow caregivers; and, other local community organizations and patient and caregiver representatives.  


“This research is a natural extension of the work we do at CareFirst, connecting senior patients to a full array of community programs at every point of their care journey that empower them with information and greatly improve their quality of life,” remarks Saini. “By partnering with health care providers like SHN, the impact of this study can be scaled up tremendously. Patients don’t want to spend their time waiting in emergency rooms, and by giving them the credit they deserve to manage their illness on their own, Scarborough’s diabetes patients can enjoy an overall better experience.”


“Diabetes management is very complex, and is even more complicated for seniors,” adds Luebke. “However, the solution is not in a single program. It’s in an optimal model of care that is integrated within the community, and that is what this study will aim to achieve within Scarborough and across Canada. With different organizations working together to achieve the same result, we all win – our patients, our communities, and our health care systems as a whole.”


This research also contributes to the community-engagement work already taking place at SHN to continue evolving the nephrology and diabetes programs beyond the confines of the hospitals.  


“As a community hospital, it is essential that SHN looks to the integration of community-based models of care if we hope to continue our path towards industry-leading innovation in health care,” said Dr. Cathy Whiteside, former Dean of Medicine at the University of Toronto and a member of the SHN Foundation Board of Directors. “On top of this new research study, our hospitals are already taking a leading role in bringing these new models to life, as with forthcoming projects like the Bridletowne Neighbourhood Centre – a community hub for the prevention, management of chronic conditions and treatment of chronic kidney disease. And with industry partners such as Baxter Canada supporting us, not only in the latest medical equipment but also in dollars, there is no sign of our momentum slowing down.”


For Ron and Ronces Beleno, and many like them across Scarborough, this spotlight on community-based interventions for diabetes and chronic kidney disease patients is a welcome prospect.  


“I’ve seen first-hand the real possibilities that community-based services represent for seniors with diabetes, and I can’t wait to see these possibilities come to life so patients like my mother can feel empowered to take back control in their lives.”