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Chronic diseases are the leading cause of mortality in industrialized countries and diabetes is one of the most important systemic chronic diseases. The consequences of diabetes on physical and mental health, and the economic impact on Quebec’s healthcare systems, are well documented. The organization of care by disease trajectory is a tool for optimizing the use of care and services in our healthcare system. However, the organization of care by disease trajectory does not always seem to correspond to people's needs and to the improvement of their health throughout their life course. Moreover, primary care and the community have a major role to play in the care of people with diabetes, as together they have the potential to better take into account the determinants of these people's health to optimize their follow-up. Indeed, living with a chronic disease is complex and requires a good understanding of the person's living environment. That's why collaboration between the healthcare sector and the community is a promising way of supporting people throughout their lives. The INMED-COMMUNITY trajectory has been developed and implemented since 2018 in a region near Montreal, Quebec, integrating a vision of care with the life course trajectory. This trajectory is promising and promotes an innovative approach to supporting people living with chronic diseases, described at the end of this chapter.

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How Can We Better Take Person-Centered Needs into Account? The Integrated Care Trajectory Approach and Intersectoral Collaboration in Primary Care to Support People Living with Diabetes

  • 会议论文

  • 出版模式：

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  • 发表日期：

    2026年

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  • Geraldine Layani

摘要

Chronic diseases are the leading cause of mortality in industrialized countries and diabetes is one of the most important systemic chronic diseases. The consequences of diabetes on physical and mental health, and the economic impact on Quebec’s healthcare systems, are well documented. The organization of care by disease trajectory is a tool for optimizing the use of care and services in our healthcare system. However, the organization of care by disease trajectory does not always seem to correspond to people's needs and to the improvement of their health throughout their life course. Moreover, primary care and the community have a major role to play in the care of people with diabetes, as together they have the potential to better take into account the determinants of these people's health to optimize their follow-up. Indeed, living with a chronic disease is complex and requires a good understanding of the person's living environment. That's why collaboration between the healthcare sector and the community is a promising way of supporting people throughout their lives. The INMED-COMMUNITY trajectory has been developed and implemented since 2018 in a region near Montreal, Quebec, integrating a vision of care with the life course trajectory. This trajectory is promising and promotes an innovative approach to supporting people living with chronic diseases, described at the end of this chapter.