Changing the landscape for delivery of type 2 diabetes care

An overview of the innovative approach of the Midland Diabetes Structured Care Programme

Diabetes has been described by the International Diabetes Federation as one of the greatest challenges of the 21st century. The rising number of people with diabetes, the chronic nature of the condition and associated complications places a burden on health systems. Internationally there has been a drive to move away from reactive, episodic management of type 2 diabetes in the acute setting to greater primary care-led structured disease management with the aim of delivering better quality care closer to home for patients. Efforts to optimise care across Europe have seen the establishment of disease management programmes which better organise management in primary care and aim to improve the co-ordination of care between different settings: the community, outpatient/ambulatory and in-patient settings. 

Given that primary care provides first-contact, continuous, comprehensive and coordinated care, it is a good place to start in terms of improving care. In Ireland, primary care management of diabetes is not standardised. Care delivery can vary regionally, from ad hoc and opportunistic management in primary care in some areas, to largely hospital-led management in others. Efforts to better organise care delivery have included a number of national reforms, including the establishment of the HSE National Clinical Programme for Diabetes, the Diabetes Cycle of Care, and publication of guidelines including A Practical Guide to Integrated Type 2 Diabetes Care (2016), which set out roles and responsibilities for the key professionals involved (GPs, diabetes nurse specialists, practice nurses) and targets for management; HbA1c, lipids, and blood pressure  (Table 1).

Development

A local need for improvements in the quality of care has driven a ‘ground up’ response, namely the development of primary care-based diabetes initiatives that better organise diabetes management in the community. In operation since 1997/1998, the HSE Midland Diabetes Structured Care Programme is the longest established such programme, led by Dr Velma Harkins, a GP Unit doctor, who was looking to utilise small funds from drug savings.  She was inspired by the 1989 international St Vincent Declaration on Diabetes to use these funds to improve care of patients with diabetes in the area.  In collaboration with Dr Davida de la Harpe, Specialist in Public Health, Dr Harkins conducted an audit of the care received by patients with diabetes in her own practice. A pilot of the structured programme was carried out in 1997 in the practice before extending to ten practices locally who had GPs with an interest in diabetes, enabling them to develop a partnership with the Department of Public Health and Planning in the then Midland Health Board. The programme was linked to the Cardiovascular Strategy in 2001 through the HSE Midland Area Primary Care Working Group and in 2002 the programme was integrated into the national cardiovascular disease secondary prevention programme in general practice: Heartwatch.

The programme is dedicated to improving the quality of care for patients with diabetes in the counties of Longford, Westmeath, Laois and Offaly, and comprises of several strategies to improve diabetes management, including the use of evidence-based clinical guidelines, patient register and recall and protected time for review visits, ongoing organisation and coordination of care by practice nurses, structured multidisciplinary support and professional and patient education. 

The programme comprises regular structured patient visits per year.

The initial assessment after diagnosis (first patient visit) includes the following elements:

Diagnostic details such as patient name and address, type of diabetes, medical history, family history.

Medical examination – weight, blood pressure, foot examination.

Investigation – full blood count, liver function tests, ferritin, HbA1c.

Referral of patient to various services such as dietitian, podiatry, retinal screening.

Addition of the patient to the practice register and given a follow-up appointment.

Regular review visits are arranged for the prevention, early detection and management of complications associated with type 2 diabetes.  These regular review visits include the following elements:

Review of medications, hypoglycaemia/hyperglycaemia, dietary habits, physical activity.

Medical examination – weight, blood pressure, foot examination.

Investigations – HbA1c, urinary analysis.

Referral follow-up.

Along with all of the areas monitored at regular reviews, surveillance of the following should also be carried out annually:

Symptoms: ischaemic heart disease, peripheral vascular disease – neuropathy, erectile dysfunction. All patients with symptoms that might reflect vascular disease, particularly ischaemic heart disease, should be investigated.

Feet: footwear, deformity/joint rigidity, poor skin condition, ischaemia, ulceration, absent pulses, sensory impairment.

Eyes: visual acuity and retinal review by ophthalmologist/retinal screening programme.

Kidney: renal damage, albumin excretion, serum creatinine and calculate eGF.

Arterial risk: blood glucose, blood pressure, blood lipids, and smoking status, ECG.

Attendances: podiatry/dietitian/other as indicated.

The initial aims of the programme were to develop a model of care for people with diabetes suitable for the Irish healthcare environment based on the St Vincent Declaration and on best evidence, specifically:

Raise the overall standard of care for people with diabetes in the region.

Document the barriers to implementing the model of care.

Develop methods to evaluate the effect of changed processes on health outcomes for people with diabetes.

Expansion

Beginning with just 10 practices, the programme has continued to expand; now 30 practices participate in the programme and there are almost 4,000 patients enrolled (mid 2019). Over time, the programme has contributed to the evidence base for structured primary care-led diabetes management in Ireland, serving as an example of what can be achieved through this approach to care delivery. The programme has brought structure and organisation to a previously ad hoc approach in primary care. As one participating GP reflected; “Before I joined the Midland Diabetic Structured Care Programme in 1999, the care that my patients with type 2 diabetes received was very disjointed and disorganised.  As there was no consultant endocrinologist in the Midlands, the patients with type 2 diabetes were being seen in the medical clinics in the hospital often only once a year”. Since taking part in the programme practices have seen improvements, particularly in terms of the training and education facilitated through the programme: “Once the programme was initiated, my practice nurse and myself received specialist training in diabetes care. There were also guidelines written and we got access to a diabetes nurse specialist, specialist foot care and dietetics in the practice. Having access to the training and guidelines and feeling supported by the availability of the diabetes nurse specialist, gave me and my practice nurse the confidence to provide all the high-quality care these patients required in the practice.”

Recognition

A recent analysis of the programme demonstrated the sustainability of this model of care, with significant improvements in processes of care delivered to enrolled patients since first initiated in 1999.

The programme underpins the model of care developed by the HSE National Diabetes Clinical Programme, whereby management of patients with uncomplicated type 2 takes place in primary care. The programme is committed to ongoing monitoring and the outcomes from the programme have been communicated widely, through publicly available audit reports; the most recent of which was launched by the Minister for Health and received national media coverage. In October 2018, the work of the Midlands programme was recognised as part of Quality in Care (QiC) Diabetes, an awards programme for the UK and Ireland that recognises good practice in patient care. The Midlands programme was a finalist for the Judge’s Special Award and received the certificate for highly commended.

We were delighted to be chosen for this award. It has been a very exciting project from the start. It was a great privilege to be able to develop a model of care based in general practice and it has been very gratifying to see such excellent results achieved over the past 20 years. Its success is due to the excellent care provided by the practice nurse, CNS, dieticians,  foot care specialists and by the support of local HSE Primary Care. Patients themselves have engaged with the programme with great enthusiasm, appreciating the ease of access to doctor appointments and the equity of care.

The project clearly demonstrates how a chronic disease can be managed in primary care when the appropriate resources are made available. We are looking forward to continuing to improve our care, and to continue to be involved with other research partners to help to best map outcomes and processes for this condition.