Patient Pathway

Admission to DDI is based on clear admission criteria which has been agreed upon between the health care team at DDI and the Ministry of Health. Generally, admission is based on having the intent to participate in research while at DDI and having difficulties controlling the patient’s diabetes after serious attempts to do so with the health care team at the Ministry of Health.

Patients are being admitted into DDI because they meet the criteria for admission. Patients will therefore undergo a DDI admission process to receive treatment and/or care for a period of time as determined by the health care providers at DDI. The patients journey at DDI will focus on speeding up recovery and/or control of their diabetes. In order to provide effective recovery-oriented care, it is important that the patients, their family and support systems understand and are involved in their treatment from the beginning. Patients, along with their support, have the right and responsibility to be full partners in this process.

The team at DDI understand that recovery is an individualized process and a patient may be at a different point in his/her recovery than another patient.

When patients arrive at DDI reception desk with their referral letter/report, they will be asked to complete the Patient Information Sheet and to sign the General Medical Consent form. Any questions or concerns they may have regarding the medical consent form will be answered by our staff. Once all the documents have been completed and signed, an initial appointment will be scheduled for them.

We will:

  • Perform a full assessment of the patient’s condition and devise a comprehensive care plan that is customized for him/her
  • Educate the patient and/or their family about their condition at every opportunity
  • Discuss progress toward realistic goals
  • Write down the follow-up appointment times for the patient
  • Continue to assess how well providers have explained diagnosis, condition, and discharge instructions to the patient and/or his/her family throughout their treatment
  • Start to review the reconciled medication list with the patient and/or his/her family
  • Provide patients with the phone number to contact if they have any concerns
  • Prepare the patient and family for transition to home
  • Inform the patient and/or his/her family about steps toward discharge
  • Involve the patient and/or his/her family in care practices to prepare for home/clinic/hospital care
  • Discuss who will provide long term care after discharge
For discharge to be most effective, communication between the patient, the health care provider and the patient’s family needs to happen throughout the patient’s journey at DDI.

Education and learning is a two-way path:

The patient and family will learn from health care providers about the condition and next steps, and health care providers will also make sure that patients and family members really understand the next steps in their care.

  • We will educate the patient/the family about the patient’s condition at every opportunity
  • Explain medicines to the patient/the family
  • Discuss progress toward goals
The patient may be discharged/transferred back to the Ministry of Health, health care provider if:

  • The patient’s diabetes control reaches the intended goal
  • The patient’s diabetic foot ulcer or foot-related problem has healed
  • The patient is non-compliant with the health care plan or have failed to keep their appointments as per the Appointment Policy

Once the patient’s treatment has been successfully completed the clinician will transfer the patient to their original health care provider at the Ministry of Health. Prior to discharge, a discharge planning appointment will be arranged with the patient and/or the patient’s family and a Patient Discharge Checklist of the following items will be discussed with the patient to make sure that:

  • We have reconciled the patient’s medication list and discussed, the purpose of each medicine, how much to take, how to take each medicine, and potential side effects.
  • Patients are given any individualized patient-centered discharge instructions in self-care methods that they need.
  • Patients are given a Discharge Summary Report for communicating with their health care provider at the Ministry of Health.
  • Patients are given the DDI hotline details to call us if they encounter a problem related to their diabetes or care when at DDI or if they need to ask a question.
  • The patients latest test results are explained to them and/or their family. If test results are not available at discharge, we will let the patient and/or their family know when they should hear from us about results and who to call if they have not heard back from us by a specified date.
  • Patients are given the chance to discuss all their questions and concerns about being discharged from our care at DDI.