FINISHED Project for Health-Care Providers and Stakeholders

What is FINISHED?

  • FINISHED is a three-year project that will provide mobile kidney disease screening through a proven model of delivery in First Nations communities in the West Region and Island Lake Tribal Council areas.
  • The project is funded through Health Canada’s Health Services Integration Fund and led by the Diabetes Integration Project (DIP), Manitoba Renal Program (MRP) and the Winnipeg Regional Health Authority.\
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    Project Goals

    The goals are immediate kidney disease prevention and early detection for individuals, demonstration of a sustainable platform for comprehensive kidney care unique to First Nations people and ultimately reducing the burden of kidney failure requiring dialysis in Manitoba.

     

    Project Components

    Partnership

    DIP and MRP will work alongside federal, provincial and community stakeholders to ensure an integrated approach to developing and implementing the FINISHED project.

    Screening

    A qualified mobile team will provide culturally safe screening and education to First Nations people right in their home community.

    Early Detection

    Screening results will be analyzed at the point of care and in real time to predict a patient’s risk of kidney disease and direct them to appropriate follow up care including access to traditional healing.  This model will not rely on existing RHA infrastructure to perform the testing.

    Data Collection

    Data collected through this project will be applied to Manitoba Renal Program’s risk prediction formulae to create more accurate early detection methods for First Nations peoples in Manitoba and Canada while adhering to First Nations Principles of OCAP.

    Risk Prediction and Treatment Based on Risk

    All patients screened will receive a treatment plan based on their level of risk of kidney failure. They will received detailed counseling on their level of risk, and be referred to an appropriate treatment platform consisting of everything from exercise and dietary information for patient with no current risk, to immediate referral to an interprofessional nephrology prevention clinic for those at the highest risk.

     

    Screening Timelines

    The project will target 11 communities in the Island Lake and West Regional Tribal Councils between 2013 & 2015.

    YEAR 1:  September 2012 – March 2013

    • Project initiated and deployment planning begins
    • Recruitment and Training of Staff
    • Stakeholder Communications, Primary Advertising and Community Engagement
    • Pilot Screening
    • Evaluations and Analysis
    • Preparation for Year 2

    YEAR 2: April 2013 – March 2014

    • Screening in Island Lake & West Region areas
    • Evaluations

    YEAR 3: April 2014 – March 2015

    • Screening in remaining Island Lake &West Region communities
    • Evaluations
    • Analysis
    • Dissemination of Results
    • Stakeholder Consult for Interpretation
    • Abstract, Manuscript and Report Writing

     

    Community Engagement

    The FINISHED team meets with community leadership to present information on the project and plan a community meeting for all residents. At the community meeting information about the screening project is presented and feedback is gathered on how to best deliver screening within the community.

     

    What does screening involve?

    A qualified mobile team will set up within a community facility, either a hall, school or health centre/nursing station. Teams will consist of two nurses, each screening individuals or families. All adults and children older than ten years of age are eligible for the 30 minute, low intensity screening. Before consenting, participants are encouraged to watch a video about kidney disease and about the screening process. Screening involves registration, a finger-prick blood sample, urine sample and questionnaire.

    Blood and urine test information will be utilized in an equation that will predict a participant’s five year risk of kidney failure. Results are instant and direct feedback to screened individuals will be provided, creating a personalized risk profile.

    SCREENING PROCESS


     

    Kidney Failure Risk Assessment

    All patients screened will receive a treatment plan based on their level of risk of kidney failure. They will receive detailed counseling on their level of risk, and be referred to appropriate treatment options consisting of everything from exercise and dietary information for patients with no current risk, to immediate referrals to an inter-professional nephrology prevention clinic for those at the highest risk


     

    Video explaining Pediatric Low Risk Treatment Guidelines for Primary Care Providers

    SUPPLEMENTAL INFORMATION FROM THE VIDEO:

    Click here for Pediatric Low Risk Treatment Guidelines for Primary Care Physicians

    A Pocket Guide to Blood Pressure Measurement in Children

    The Fourth Report on Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents (In particular see pages 10 – 13)

    Contact Info: Dr. Allison Dart, Pediatric Nephrologist, Health Sciences Centre, 204.787.4947, email

     

    Follow-Up

    All results will be entered into the computer based Electronic Kidney Health Record (eKHR) database so their kidney health can be tracked, and the appropriate follow-up completed. The new system will centralize key information collected as patients receive kidney care in the province. The goal of the system is to allow for more efficient access to patient information which will result in better care

     

    Enhanced Screening Subset & Biobanking

    A more detailed screening in a subset of the population is a common feature of many mass screening initiatives across multiple countries and chronic disease disciplines. The FINISHED team will seek to include approximately 10 percent of our clinic participants in a more detailed screening process. The purpose of this more detailed screen is to identify new risk factors, (currently unknown) that may affect-progression of kidney disease, specifically in First Nation populations. This will involve more detailed documentation of risk factors, more laboratory testing and banking of serum and urine samples.  These samples will be tagged using unique identifiers and stored in secure freezers within the Manitoba Centre for Systems Biology at the U of Manitoba.

     

    We will use this information over time to improve the performance of our risk prediction tool and appropriate treatment, specifically for Manitoba First Nations people. This will ensure that our model remains valid in the future, as new markers for disease and diagnosis become available.

     

    Project Partners

    Diabetes Integration Project (DIP) is an Integrated Diabetes Health Care Service Delivery Model that was developed to begin to address the needs for First Nations people who have been diagnosed with diabetes. The project will overcome barriers to access to a comprehensive, coordinated and integrated diabetes care and treatment service for limb, eye, cardiovascular and kidney complications. The DIP will utilize Mobile Diabetes Health Care Service Delivery Teams to provide diabetes care and treatment services in First Nation communities throughout Manitoba.

    Manitoba Renal Program (MRP) is a clinical program of the Winnipeg Regional Health Authority that provides education and care for people at risk of developing kidney disease and people with chronic kidney disease. Primary services offered by the Manitoba Renal Program include kidney health care, hemodialysis care, peritoneal dialysis care, and renal health outreach. Hemodialysis is offered in Winnipeg, Brandon, and 16 rural locations throughout the province.

     

    How do I find out more?

    Call Diabetes Integration Project at 204-956-7174 or 1-855-333-9320 or call Project Manager Audrey Gordon at 204-926-7840.

    www.diabetesintegrationproject.ca