Implementing the Diabetes Cycle of Care
Katie Murphy, Diabetes Nurse Facilitator in General Practice, discusses the practical steps to implement the Diabetes Cycle of Care in your practice. Topics covered include patient registration, coding in patient notes, diabetes prevalence insights, current recommendations and guidelines, and the aim of diabetes care.
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Presentation Transcript
IMPLEMENTING THE DIABETES CYCLE OF CARE IN YOUR PRACTICE Katie Murphy Diabetes Nurse Facillitator Diabetes In General Practice (DiGP)
WHERE TO START! Register- How many patients require care Quantifying the time required- 2 -3 visits per year Ensuring you have the Knowledge and skills to deliver Diabetes Care Organising how you will organise delivering the care: Protected Time Who is on the team Referrals
REGISTER CODE DX IN PATIENTS NOTES T89/E10 = Type 1 Diabetes Caution Metformin being used for Cardiovascular protection in Type 1 Diabetes T90/E11= Type 2 Diabetes Note exclude patients on Metformin for PCOS and Pre-Diabetes Patients who start on insulin Still Type 2 Other Types: Slow onset Type 1 also called Type 1.5! MODY- Mature Onset Diabetes in Youth LADA-Latent Auto-immune Disease in Adults
PREVALENCE OF DIABETES 5.6% of total Population (>200,000 Irish people, and rising!) CODEIRE Study: Making Diabetes Count: Some studies suggest as much as 10% in the >50 age group Type 2 Diabetes accounts for >85% of all Diabetes in Europe Diabetes is a Common Condition- SEEK and you SHALL FIND!- e.g. Findrisk Screening Tool in Waiting room Ave. Time from onset to Diagnosis is 7 years as initially asymptomatic, frequently Dx. when they present with a complication eg MI
CURRENT RECOMMENDATIONS/GUIDELINES ON DIABETES A Practical Guide to Integrated Type 2 Diabetes Care- ICGP 2016 Diabetes Cycle of Care Dataset Oct 2015 Awaiting Publication of HSE Model of Integrated Diabetes Care International Guidelines ADA (USA), SIGN (Scotland) NICE (UK) HSE Expert Advisory Group on Diabetes- First Report with recommendations 2008 Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Postnatal period- July 2010 National Diabetes Programme 2010 Aims: Save Lives, Eyes and Limbs of patients with Diabetes. Everyone with Diabetes should have access to a structure programme of care which covers all aspects of their Diabetic care. http://www.hse.ie
AIM OF DIABETES CARE To Enable People with Diabetes to have similar life expectancy and quality of life to that of the general population by reducing the complications of Diabetes Structured Diabetes Care can be delivered in primary care, provided it is Organised, Agreed, Fully supported and run by interested trained professionals.
NATIONAL DIABETES CLINICAL CARE PROGRAMME 2010 Reduction in mortality by 10%. Reduction in morbidity Reduce; Blindness by 40%, Amputations by 40%, Cardiovascular events by 20%. Priority in 2011 Reduce Blindness and Amputations Retinopathy Screening Program-30% of Patients invited in 2013, 70% in 2014 and from 2015 onwards 100% - But uptake is just over 50% 2011 Model of Care Diabetic Foot -Foot screening and treatment service- 13 of 16 planned Podiatry posts in 2014, further 8 in 2015 2012- Requested 25m for HSE Model of integ care but got 2m 2013/2014 Recruited 17 CNS (Diabetes Integrated Care) Integrated Care Programme- HSE Service plan 2014 KPI Align 10 initiatives to HSE model of care 2016- 9 Podiatrists, 18 Dietitians and 9 Community CNS (Diabetes)
NATIONAL PLAN FOR DIABETES CARE Hospital Only (Specialist) Care Patients with: Type 1 Diabetes, <30 years at dxDiabetes in Pregnancy, Genetic Diabetes (LADA, MODY)(approx.30,000 Patients) Shared Care: Early diagnosis of Complications with prompt review in Secondary Care once stable 2 visits to the GP/PN and 1 Hosp visit per annum (approx. 60,000 patients) Integrated Diabetes Care in General Practice: Screening for Diabetes. Early detection with Patient education and comprehensive Regular reviews with GP/ Practice Nurse. Access to Community CNS (Diabetes Integrated Care)/Dietitian/Podiatrist (100,000 patients) Prevention of Diabetes: Screening the at Risk Pop. and offering lifestyle interventions will reduce the progression of approx. 60% of patients from ever developing Type 2 Diabeteswith GP/ Practice Nurse/Dietitian
DIABETES CYCLE OF CARE Oct 2015 Diabetes cycle of care for adult patients with type 2 diabetes who hold a medical card or GP visit card- 2 visits per year (at least 4 months apart) one to be an annual review visit To date, over 88,000 patients with diabetes have been registered for the service First patients registered Sept/Oct 2015 should be called for first visit before end May to have 2 visits >4mths apart in the 12 months Data to be returned within 3 months of 12 month period since registration- GP Software providers working with GPIT and PCRS and HSE looking at data protection issues around the HSE getting patients consent to get clinical data from their GP. Feb 2016 Revised ICGP Guidelines for Type 2 Diabetes published
CYCLE OF CARE FIRST VISIT Review Blood Test Results: HbA1c, Lipids, Creatinine & ACR, Preventative lifestyle factors: smoking, alcohol, exercise, weight control and provide brief intervention and referral if appropriate Medication Foot status and referral if appropriate Participation in eye prevention programme & referral if appropriate Record BP and manage as appropriate BMI and manage as appropriate Immunisation status (flu and pneumococcal) Provide Diabetes patient education and refer to Patient Education Service if newly diagnosed Recall Schedule next review
CYCLE OF CARE SECOND VISIT Review and Record HbA1c and Lipids Preventative lifestyle factors: smoking, alcohol, exercise and weight control BMI and refer on if appropriate Blood pressure GP to Carry out review of medication. Data to be submitted annually to PCRS on registered patients who have consented to data return
WHAT IS NEEDED FOR INTEGRATED CARE TO SUCCEED? Expand Cycle of Care to include all patients with Type 2 Diabetes Empower Patients- Access to Structured Patient education Invest in HCP Education- NB Scope of Practice Agreed Referral Pathways HSE to align the existing initiatives to the Integrated Care Model as per KPI in HSE 2014 Service Plan, and then expand that all patients have 3 visits per year. GP contract to include Diabetes Care Build MDT- GP/PN/DNS/Endocrinologist/ Podiatrist/Dietician/ Health Promotion Officer/ Psychological Support/Social Worker
EDUCATION IS KEY TO PROGRESSING DIABETES MANAGEMENT IN PRIMARY CARE Practice Nurses :5 day Diabetes Module in MUH/DCU/ Midlands HETAC accredited Module and 3 Day course in Mater Dublin (5 credits level 8) GP s/PN/Dietitian/Podiatrists Diabetes Module UCC/NUIG- Blended learning format Online and 2 study day (10 credits level 9) Conferences Annual Diabetes Conferences: Diabetes in Primary Care (Cork 20th Sept 2017) Primary Care Diabetes Society Dublin April/ May 2017 Diabetes Ireland Croke Park March 2017 CROI Integrated Diabetes Care Conference Limerick 7th/8th Oct. 2016 HCP Module on Retinopathy Screening http://www.learningesource.ie/course/view.php?id=29 eLearning course Promoting Physical Activity in Primary care www.hseland.ie Foot Assessment- ICGP eLearning https://www.icgp- education.ie/mod/page/view.php?id=3489 Follow on practical session Required Contact Marie Courtney PDC Practice Nursing Cork/Kerry Patricia McQuillan PDC Practice Nursing South east
DIABETES IN GENERAL PRACTICE GROUP Commenced in 2001 with 10 practices Diabetes Nurse Facilitator appointed in July 2007, HSE funding Based in Dept.General Practice UCC 69 practices enrolled comprising approx. 7,600 patients- 20 further practices waiting to join. 2011 Employed Diabetes Nurse Specialist Angie O Connor Providing clinics in 30 Practices. Audit 2010 Nurse Facilitator Manually extracted Data from patient files into Access database 2013- Irish Primary Care Research Network (IPCRN) Automated data extraction. Individual practice report and collated DiGP Audit Report. 3 Educational meeting s per year in Cork/Kerry/Waterford (Mar/May/Sept) Annual Diabetes Conference in Sept.
COMMUNITY DIABETES NURSE SPECIALISTS DiGP: DNS Angie O Connor Employed by DiGP since Nov 2011. Initiative Funded by grants from Sanofi/NovoNordisk/MSD/Astra Zeneca 20% in SIVUH/ 80% in Community providing specialist clinic in 30 DiGP Practices. 2014 HSE Community DNS Integrated Care Posts: Cork Ann Wall (80% Community 20% CUH) Kerry Angela O Riordan (80% Community 20% TGH) South Tipp-Dorothy Moore (80% Community 20% STGH) Wexford- Helen Foley (80% Community 20% Wexford General Hospital) Referral Criteria- patients with Type 2 Diabetes with poor glycaemic control (HbAic >58/7.5% for >3months) Patients with Type 1 diabetes are also reviewed with the aim of re-engagement with secondary care services
TAKE HOME MESSAGES General Practice Ideally placed for primary prevention in children and adults as we have ongoing regular contact with people who trust us- Healthy Eating/Physical Activity Targeted Case finding in General Practice =Early Detection Clearly document dx Diabetes in patient file- If not involved in delivering diabetes care,opportunistically check patient is receiving care in OPD Diabetes Cycle of Care will result in increased reviews in General Practice= prevention and early detection of complications If delivering Diabetes Care- Register, Review, Recall NB Lifestyle Factors: Healthy Eating/Physical Activity Refer for Retinopathy Screening Refer Podiatry :Mod/High Risk and active foot dis. Refer for Structured Patient Education
RESOURCES AVAILABLE Diabetes Nurse Facilitator-086 0566077 katie.murphy@ucc.ie- Diabetes In General Practice (www.digp.ie) PN Prof Dev co-ordinator- Cork/Kerry Marie Courtney (Marie.courtney@hse.ie) South East -Patricia McQuillan (Patricia.McQuillan@hse.ie) Community Dietician HSE Community Dietitian Managers- Kerry Freda Horan (064 70751/freda.horan@hse.ie) Cork North Yvonne O Brien (yvonne.obrien@hse.ie) Cork South Mary Murnane (mary.murnane@hse.ie) South East AnneMarie Tully (Annemarie.Tully@hse.ie) 2016 ICGP Guidelines http://www.icgp.ie/go/library/catalogue/item/B5C683DA-ECE8-2264- DD43F57101FDA2A6 Diabetes Ireland-Development Officer Pauline Lynch-021 4274229. www.diabetesireland.ie Structured Pt. Ed- Patients and HCP s can register patients to attend the next available course in their local area on: http://hse.ie/eng/health/hl/living/diabetes/Diabetes_Courses/ Refer to XPERT Program- Community Dietitians If patient unable to Attend XPERT (6 sessions) refer to CODE (Contact Pauline Lynch 087 2709418) Diabetes and Primary Care Journal-Free. Register- www.diabetesandprimarycare.co.uk
RESOURCES CONT. Health Promotion Unit Courses : Supporting Change: Skills for Health- 2 study days Diet and Diabetes Diet and Cardiovascular Disease National Institute for Cardiovascular Prevention: NIPC: Tel: +353 (0)91893299 Email: info@nipc.ie Website: www.nipc.ie- 2 Day Motivational Interviewing Courses Smoking Cessation Cork/Kerry- H.P.Unit Western Rd. 021 4921641 (group of 10-15 +individual).Priority given if pt.self refers Smoking Cessation/Exercise-Kilkenny/Wexford/Carlow/Waterford Susan Broderick, Health Information Officer HSE South Health Promotion Department, Dean Street, Kilkenny Tel. 056 7761400/Mob. 087 2103442 Email: frances.leahy@hse.ie Exercise Cork/Kerry- H.P.Unit Western Rd. 021 4921641 www.healthpromotion.ie www.getirelandactive.ie Ireland is currently developing a National Exercise for Health Referral Framework (NEHRF)
