The GP, practice nurse, diabetes nurse specialist, community dietitian and podiatrist all have an important role to play in the delivery of integrated diabetes care. It is vital that these roles work effectively together in order to provide type 2 diabetes patients with the care they need. However, how this kind of integrated care is going to work in practice is not always straightforward. 

The aims and objectives of the National Diabetes Programme were laid out by GP lead Dr Velma Harkins at the Collaborative Diabetes Conference held recently in Cork. The conference, hosted by Diabetes in General Practice (DiGP), the HSE and UCC, focused on integrated diabetes care and Dr Harkins presented the main objectives of the programme (see Table 1) and explained how it will be delivered in practical terms.

“The most important thing we’re hoping to do as part of this programme is to develop all healthcare professionals’ practice so that they can be confident and competent in the management of patients with type 2 diabetes over their lifetime,” said Dr Harkins.

She explained that this will be done mainly by focusing on prevention through the provision of the following:

• Lifestyle advice, including diet and exercise, especially for high-risk patients

• By screening high-risk patients to prevent early complications

• By providing high-quality patient information appropriate to patient needs

• By regular monitoring of clinical indicators and intensive management of blood glucose, blood lipids and blood pressure

• By surveillance for early signs of complications, including retinopathy, nephropathy and neuropathy screening by developing a retinopathy screening programme for diabetes to prevent blindness, and developing a footcare screening and treatment service to prevent foot ulcerations and subsequent amputation

• By developing a National Diabetes Register.

So how will this be achieved? According to Dr Harkins, the first step of the programme is to make sure that all patients have access to integrated care by expanding the availability of primary care diabetes structured care programmes to all of Ireland.

“All patients diagnosed with type 2 diabetes should be invited to enroll in a structured integrated diabetes programme. The GP will then provide the highest proportion of care for type 2 diabetes,” said Dr Harkins.

“There should also be access to specialist hospital-based services for patients with identified clinical needs, for example at diagnosis, onset of complications or immediate support in complicated cases. Patient-care pathways need to be supported by fast-track referral systems agreed locally between primary and hospital care.”

Further to this, Dr Harkins mentioned that structured patient education programmes need to be provided to complement one-to-one patient education at GP practice and hospital level, and that all patients diagnosed with type 2 diabetes should have a structured review at primary care level at least three times per year.

“We also need to ensure that patients have up-to-date information in relation to the availability of diabetes services in their local area,” she emphasised.

National Diabetes Programme

Within the context of developing the National Diabetes Programme, a National Diabetes Working Group was established to work on how to deliver on the aims and objectives of the programme. The cost objectives for the working group were very clear: to reduce the current cost of diabetes-related complications to both the patient and the health system by reducing the number of hospital bed days used, the average length of stay in hospital and the over reliance on outpatient department services. 

“The core strategic team is led by programme lead Dr Diarmuid Smith, programme manager Mairead Gleeson, director of public health Dr Orlaith Reilly and myself (co-lead),” explained
Dr Harkins.

In addition, there’s the working group which represents all the people involved, including clinical nurse specialists, dietitians, podiatrists and representatives from the regional diabetes services implementation groups (DIGs).

Forming part of the integrated care group is also the ICT group, which is trying to develop an ICT prototype which will support integrated care. This will form an important part in the future when it comes to streamlining the care between general practices and hospitals.

The integrated care model

The integrated care model essentially means that patients with uncomplicated type 2 diabetes will be cared for in primary care, patients with type 1 diabetes will be cared for in secondary care, and patients with complicated type 2 diabetes will be cared for through a combination of primary and secondary care.

Velma Harkins pointed out that the patients in the first group amount to roughly 100,000, those in the second group to roughly 30,000 patients and those in the combined care group to a further 60,000 patients. 

“The uncomplicated type 2 patients will be seen in primary care three times per year, and one of these visits are to be an annual review,” said Dr Harkins.

“It is envisaged that the patients with complicated type 2 diabetes would be seen in primary care twice a year and have their annual review in secondary care,” she added.

This means that as many as 160,000 patients with type 2 diabetes would be seen in general practice several times every year.

Support systems

With this massive care load put on general practice, what are the supports available? According to Velma Harkins, a series of educational supports have been developed. There’s an education package for GPs and practice nurses as well as materials covering targets, guidelines on integrated care, treatment algorithms, etc.

“What we would hope is that as part of the development of the integrated care programme, we will also have regular multidisciplinary meetings,” she said.

Another vital step in supporting integrated care is the development of an IT system that links primary care with secondary care while creating a National Diabetes Register and a secure data repository for future diabetes research.

“The working group always felt that ideally, if this programme was going to work in a way that wasn’t too onerous for people participating, then it was going to have to be underpinned by some kind of an IT system that supports the clinical process, and that will also provide us with the data ultimately to evaluate the programme,” said Dr Harkins.

She also mentioned the whole issue of non-communication electronically between general practices and hospitals, and that this will have to be addressed by the development of proper IT.

Apparently, at the time of the conference a prototype of this IT system was being developed and was expected to start over the following months [meaning November/December 2012] with the view to have it completed in a further eight months.

“The software vendors on the general practice side have been able to adapt their software to communicate via Healthlink through a web portal with a secure data repository, and this data will then be able to be transferred via Healthlink to the hospital software systems, which will also need to adapt to be able to receive this information,” explained Dr Harkins.

“This secure data repository will eventually become the National Diabetes Register,” she added.

Roles within the primary care team

Role of the GP

Velma Harkins says that she sees the GP as the carrier of overall responsibility and leadership in the running of integrated diabetes care in the community.

With this comes the responsibility to ensure that practice staff members are familiarised with the agreed programme models of care, including algorithms, patient information and guidelines available, etc.

“The GP needs to ensure that all members of the team are aware of their roles and responsibilities. It’s very important, even in large practices with many GPs, that one person takes responsibility for the programme,” said Dr Harkins.

The person in charge also needs to make sure that patients are being treated in accordance with the programme protocols, and that appropriate governance is in place in order to ensure continuing improvements in quality, safety, access and cost-effectiveness.

The GP also needs to maintain an up-to-date register of all type 2 diabetes patients and ensure that regular management of the register takes place.

“However, once we have an IT solution in place, a lot of this will happen automatically,” said Dr Harkins.

“The GP also needs to be willing to adapt to new guidelines as they are made available,” she added.

Role of the practice nurse

Velma Harkins pointed out that in areas where practice nurses have been involved in diabetes care for a long time, the role of the practice nurse is familiar; however, she pointed out that for regions where integrated care is new, it is quite a change of practice for the nurse who becomes involved in the regular routine care of diabetes patients in the practice as set out in the agreed model.

“The practice nurse will maintain the practice diabetes register, set targets with patients and provide patients with education regarding diet, lifestyles and exercise,” explained Dr Harkins.

“The practice nurse will also carry out initial and annual foot assessment as per the national model, and refer patients to the community diabetes nurse specialists and for retinal screening, dietetics and podiatry as per the national model and refer agreed patients to secondary or tertiary care as required.”

Once again, the IT system will aid the practice nurse when it comes to maintaining the diabetes register.

“Those of us who were involved with Heartwatch know how onerous it was to gather that data and then manually send it off,” remarked Dr Harkins.

“So we’re hoping to bypass that step with the IT system in place,” she added.

The community diabetes nurse specialist

“These nurses are based in the community and their budget is based in primary care. They may be clinically based in hospitals, but as their budget is based in primary care they are a resource to the practice,” explained Dr Harkins.

The responsibility of the community diabetes nurse specialist is to see individuals referred to them by GPs or practice nurses and to provide training and support to the practice nurse within the GP practice to set up and deliver integrated diabetes care. 

Part of this support also extends to delivering education programmes in conjunction with the local nursing education units (eg. HETAC certificate in diabetes), along with annual multidisciplinary masterclasses.

“The community diabetes nurse will liaise with secondary care and participate in team discussions to ensure best quality care is provided for all diabetes patients,” said Dr Harkins.

“What we envisage is that the nurses will spend four days a week in the community and one day a week they will be in the local diabetes centre where they will discuss the issues that are arising, for example with complicated patients, and also look at the issues of referring complicated patients back to the community. 

“They will be going in to act as a liaison between community and secondary care.”

Finally, the community diabetes nurse specialists will also carry out research and audit, including audit data to influence the delivery of the integrated diabetes care package at practice level.

“These nurses will be highly skilled and have specialist postgraduate training in diabetes care,” she explained.

Role of the community dietitian

The community dietitian, where available, has responsibility for one-to-one dietetic interventions, delivery of structured patient group education and acts as a liaison with the multidisciplinary team to optimise patient care.

“The community dietitian is another source of liaison with acute and secondary care diabetes services,” reminded Velma Harkins.

Added to this, the community dietitian is also responsible for ongoing continuous professional development via training and resource development and commitment to ongoing audit and evaluation of the service.

Role of the community podiatrist

The community podiatrist will deliver footcare as per the national model, and identify patients as being low, moderate, high risk or having active foot disease.

“The podiatrist will see patients with moderate risk of foot disease at least annually and refer patients with high risk and active foot disease to specialist secondary care services,” explained Dr Harkins.

“The community podiatrist will also act as the liaison with foot protection teams and specialist foot services in the secondary care centre, while also supporting practice nurses in their identification, examination and management of the diabetic foot.”

Like the community diabetes nurse specialist, the community podiatrist will also commit to ongoing continuous professional development via training and resource development, and also commit to audits and evaluations.

“The roles as outlined above describe the vision of the project, or how we see it being delivered,” concluded Dr Harkins.

Practice management structure

Once a diagnosis of diabetes has been made by symptoms of diabetes being present in conjunction with one of the four tests to confirm diagnosis: a random plasma glucose concentration of >  11.1mmol/l; a fasting plasma glucose of ≥  7.0mmol/l; a two-hour glucose > 11.1mmol/l during a 75g oral glucose tolerance test; or a HbA1c ≥  48mmol/mol (the last of which is a new measure expected to be included in the updated guidelines on integrated diabetes care), the management of the patient starts with the initial assessment by a GP or practice nurse.

For a detailed view of the practice management structure, see Table 2. In the model, home blood glucose monitoring and calibration is included, but only if appropriate.

“This is because there is now convincing evidence that we are testing far too often and we’ll certainly be moving away from the current model to a model where there will be far less testing for the patient. The tendency will be away from the levels of monitoring we are doing at the moment to far less home blood glucose monitoring in the future.”

Updated guidelines

The 2012 updated diabetes integrated care guidelines will include chapters on glucose control; blood pressure control; antiplatelet therapy; smoking;  lipids; diabetic foot disease; eye disease; renal disease; painful diabetic peripheral neuropathy; and erectile dysfunction.

“What’s new in the 2012 guidelines is that there will be very specific treatment algorithms for blood pressure, glucose control, etc. They will hopefully be more helpful than the previous guidelines,” said Dr Harkins.

She presented some of the updates and mentioned that the specific treatment algorithms may, for example, provide several options for glucose control depending on what stage the patient is in, ie. if initial metformin therapy has failed to achieve target, what treatment step do you take next? 

Similar specific treatment algorithms, or options, will also be available for blood pressure control, and when it comes to foot assessment, specific management plans will be provided for the different stages or risks of foot disease.

The updated guidelines on integrated diabetes care are expected to be released early in the new year.