DiaCenTRE places the situation of the patient and his entourage at the heart of care, inspired by the "Innovative Care for the Chronic Conditions" (ICCC) model.
The Centre is distinguished in particular by an interdisciplinary structuring of care, highly qualified health professionals, a unity of place and the desire to promote self-management of the disease by ensuring that it is done "with" the patient and not "for" the patient, not to mention his loved ones.
Innovative Care for the Chronic Conditions
• Care focused on the needs of the patient and his family and regular reassessment
• Taking into account the demands and needs of patients living with a chronic disease in the organization and planning of care
• Integration and coordination of care offered by health actors
• Establishment of concerted exchanges between the various health professionals taking into account the duration of care
• Promote exchanges and communication with all stakeholders in the health network (political bodies, care institutions, individual caregivers and organizations that represent patients)
• Support and promotion of patient training so that they become and remain the actors of their care
• Strengthening the resources of patients and their caregivers
• Development of preventive health actions
• Consider health costs
Services provided by the Centre
Individual and multi-professional care
Individual and multi-professional patient care
• Medical examination (individual interview) and additional assessment if necessary (target organ assessment +/- specialist opinions);
• Assessment of medical (somatic and psychological), technological and preventive needs of FRCV
• Evaluation of daily management (technique, diabetes self-management) and training needs in diabetes self-management (pedagogical approach: understanding the disease, its effects, treatments);
• Assessment of dietary needs (identification of a possible eating disorder, explanations on the role of food in the management of diabetes);
• Evaluation of fitness for physical exercise and explanation of the benefits of physical activity by a physiotherapist or sports coach.
Medium and long-term patient follow-up
Medium and long-term patient follow-up with interprofessional consultation session on the strategy and structuring of care
• Medical follow-up (specialist and attending physician)
• Technological and practical follow-up (medical-nursing)
• Dietary follow-up
• Psychological follow-up
• Annual physical fitness monitoring (physical skills assessment)
• Development of knowledge and know-how and maintenance of self-management through participation in citizen science projects (mobile application aimed at improving health litteracy and maintaining motivation to self-management of diabetes through better monitoring)
• Participation in educational activities organized by the centre
Training of the patient and relatives
Follow-up and proposal of training of the patient and his relatives in the self-management of diabetes in the medium and long term
- Individual follow-up and training during dedicated interviews and during usual visits or during structured training
- Networking with other specialists in the medical profession working in related fields (cardiologists, endocrinologists, ophthalmologists, radiologists, chiropodists, medical laboratories, etc.).
- The internal team will act on the principle of sharing knowledge and skills, transparency, coordination and collegiality of decisions.
- To promote such an exchange, the digitization of DiaCenTRE patient data and the sharing of the electronic record will be implemented in compliance with applicable legislation.
