The Métapex project emerged from our multidisciplinary meetings aimed at continuously improving quality of care. The project marks a shift in how we follow up with patients living with type 2 diabetes. Several challenges were raised during our meetings, and we set out to find solutions.
Our family medicine group, part of CIUSSS Centre-Ouest-de-l’Île-de-Montréal, is located in a highly diverse neighbourhood with the highest prevalence of type 2 diabetes in Montreal. Managing follow-up care for patients with chronic illnesses is a complex, multifaceted task for clinicians. It requires frequent clinical evaluations, personalized patient education and ongoing coordination across professional teams.
The existing model did not fully support interdisciplinary care, and follow-up practices lacked uniformity. Our challenges included encouraging patients to take a more active role in their care, clarifying national standards to refine our internal processes and providing more personalized follow-up. In response, we set up a care trajectory within our family medicine group to ensure that each professional can fulfil their role effectively and see patients at the right time.
A single referral form was created to effectively guide patient follow-up within the family medicine group and the local community services centre. We also established documentation guidelines for patient records. Meanwhile, clinical nurses were trained in culturally sensitive nutrition and participated in workshops on pharmacotherapy and the protocols of the INESSS (National Institute for Excellence in Health and Social Services). Finally, a patient tracking tool and a purpose-built teaching folder were created to ensure easy access to essential information for managing type 2 diabetes effectively.
In summary, this project enabled us to provide more tailored, effective and accessible care while ensuring consistent follow-up that respects the cultural diversity of our community. We are proud to have developed this interdisciplinary program together.
Lead:
Jacynthe Caron, Program Manager, GMF-U Parc-Extension
