Challenges to the implementation of a national model of integrated care for diabetes in Ireland

Dr Sheena McHugh, Research Fellow

Department of Epidemiology & Public Health, University College Cork

• National and international emphasis on integrated care• Organisation of disease management within

settings and the coordination of care between settings (1-3)

• Diabetes “exemplifies the complex nature of chronic disease” (4)

Integrated Diabetes Care

Diabetes Care in Ireland

‘Ad hoc opportunistic management’

Structured care characterised by regular recall, review & nurse coordination

2008: National GP survey (5): • management largely unstructured: 46% using a register, 55% using

guidelines and 50% engaged in routine recall. • <10% had a formal shared protocol or had ever had a joint meeting

with the hospital team

2010: qualitative study (6): • Hospital specialist service is ‘an essential support’ • Lack of coordination leads to uncertainty about

boundaries of responsibility, ‘in the meantime’ care, avoidable duplication

5. Mc Hugh, S., J. O'Keeffe, A. Fitzpatrick, A. de Siún, M. O'Mullane, I. Perry and C. Bradley (2009). "Diabetes care in Ireland: A survey of general practitioners." Prim Care Diabetes 3(4): 225-231.6. Mc Hugh, S., M. O'Mullane, I. J. Perry and C. Bradley (2013). "Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice." BMJ Open 3(8).7. O'Donnell, M., A. de Siún, M. O'Mullane, D. Smith, C. Bradley, F. Finucane and S. Dinneen (2013). "Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led

services." BMC health services research 13(1): 493.8. Mc Hugh, S., P. Marsden, C. Brennan, K. Murphy, C. Croarkin, J. Moran, V. Harkins and I. J. Perry (2011). "Counting on commitment; the quality of primary care-led diabetes management in a system with minimal

incentives." BMC Health Serv Res 11(1): 384-393.

2010: Survey of hospitals in Ireland (7): • Endocrinology-led services had more developed subspecialty clinics and

access to specialist allied health professionals • But waiting times were longer and discharge rates to primary care were

lower than for non-specialty led services.

2011: Quality of Care in Existing Initiatives (8)• 10 existing diabetes initiatives

• 10 existing diabetes initiatives

• Range from shared care to structured care led by GPs to hospital-led models

• Different quality improvement strategies including patient registration, audit & feedback, education, protocols, remuneration, referral pathways.

Existing Initiatives

National Model of Integrated Care

National Model of

Integrated Care

Retinopathy Screening

Programme

Gestational diabetes

guidelines

National Foot-care

model

Structured Patient

Education

Model of care for children and young adults with

T1DM

• Defined patient pathways• Type 1 diabetes, genetic, diabetes in

pregnancy and other complex diabetes managed in hospital centres.• Uncomplicated Type 2 diabetes care in

primary care with ‘annual’ input from hospital centres. • Complicated Type 2 diabetes patients will

be managed by both primary and secondary care.

• Remuneration• Integrated Care Diabetes Nurse Specialist (ICN) • Facilitate integration between primary and

secondary care• 80% community/20% hospital-based

Changing context of implementation

• National Model of Integrated Care drafted but not released

FEMPI Cuts

GP Contract dispute

ICGP withdrawal

from Clinical Care

Programmes

Aim

• To examine the implementation of the national model of integrated care.

• To identify the barriers and enablers to the implementation.

Methods

Method• Semi-structured

interviews• July 2014 - Jan 2015 • Documentary Analysis• Interviews recorded,

transcribed & analysed

Eligible Participants• Current and former

members of National Working Group.

• 19 participants (14 current + 5 former members)

• Health care professionals, management, patient advocacy

Design• Qualitative study with

national level stakeholders involved in programme development

• Timeline:2010-present

Findings

• 2013: 17 Integrated Care Nurses employed

• Full model of care not resourced due to wider dispute about GP contract:

‘Some Implementation on the Community Diabetes Nursing side of integrated care’

‘They were never intended to go in on their own, they were intended to go in as part of an

integrated programme where GPs and practice nurses were providing the routine care and they go

in as specialist help.’ (#6)

‘the [political] will wasn’t there to do that [sort the contract], but definitely when the GPs realised that they weren’t going to get paid; what we were actually going to be putting in was nurse support… we couldn’t [progress]. (#15)

Fig. Deployment of ICN posts & existing initiatives

1. Varied uptake of ICN resources

It depends on what area they’re working in; what GPs are in there area (#11)

• Distance from hospitals & access to specialist input

• Practices with large numbers• Existing initiatives: ‘a program

for nurses to join in with’

“some places they’re wanted……some places they’re getting a blank wall” (#8)

• In some areas, access to ICN limited to practices already enrolled in pre-existing initiative

• Lack of remuneration

Remuneration for widespread implementation

I can’t see how it can be resolved in a systematic way without a contract. We’ve tried all the ‘goodwill’ options’. (#12)

2. Fidelity with intended model of care

Specialist clinical input

Support GP/PN

management

‘Smooth interface

with hospital’

Manage patient pathway

(referral & discharge)

Training & education

Figure. Intended role of ICN as part of the National Model of Integrated Care

Pragmatic approach to implementation

In some cases its a case of how much they are allowed to do, whether somebody will let you in the door or not, because they might not want to.

If they let you in its positive and it will probably lead to something else but it varies from area to area in what way its being implemented.

Some nurses are very involved in education of healthcare professionals and maybe the public. Others are straight into clinics and there is just a huge amount of clinical work. (#18)

Adapting to pre-existing models of care

These pockets of excellence around the country are using all slightly different models. Now they’re not a thousand miles away but they’re not the National Model of Care. And we haven’t had the opportunity or the ability to standardise it because we weren’t paying for it…. They’re probably having to adopt [or] adapt [to] the locally-existing model of care as opposed to the National Model of Care (#12)

3. ‘Integrated care is the big ticket item’

‘The foot-care strand, retinal screening, gestational diabetes, … the ICT section, clearly research, structured group education, they all sort of dovetail into integrated care really. (#18)

Table 1. Risk stratified pathway for management of diabetic foot disease

Cycle of Care

• Holders of medical cards and GP Visit Cards who have Type 2 Diabetes.

• 2 visits to GP for a structured review (annual review and follow up visit) • review and recording of blood results,

medication review, assessment of blood pressure, BMI, education, symptomatic foot review, participation in the eye screening programme and onward referral if appropriate• GPs will receive a €30 registration fee per

visit in the first year and €50 for each consultation.

Facilitate implementation

• Increase engagement with ICN resources?• Need for increased investment in integrated care nurse support

• Increase implementation fidelity?• Potential for inequity in standard of care and outcomes among

non-GMS patients

Next phase of research

Method• Interviews with health professionals & patients• Activity data from ICN• National Diabetes Nurse Survey

Aim• To what extent to have plans been implemented, adapted

and accepted at a local level?• Impact of recent changes

Phase 2• Case studies:

• 4 regions

ESPRiT 

Evidence to Support PRevention Implementation and Translation

Monitoring & evaluating implementation

• Fidelity data, quality assurance data, and outcomes data with supportive feedback mechanisms• Built into routine practice • Accessible at actionable levels• Used to make decisions

• Health professionals collectively discussed data on quality of care (8)• Helped break down barriers between settings • Established a self-supporting system to increase

quality

• Only integrate care structures that include an integrated quality management system are sufficient• Ensure improvements in quality, access & cost

Acknowledgements

On behalf of:• Professor Patricia Kearney• Marsha Tracey- PhD student• Fiona Riordan – PhD student• Kate O’Neill- PhD student

In collaboration with the National Clinical Programme for Diabetes

Contact:https://www.ucc.ie/en/esprit/research/ Email: s.mchugh@ucc.ie

References

1. Kodner, D. and C. Spreeuwenberg (2002). "Integrated care: meaning, logic, applications, and implications–a discussion paper." International Journal of Integrated Care 2.

2. Gröne, O. and M. Garcia-Barbero (2001). "Integrated care: a position paper of the WHO European office for integrated health care services." International Journal of Integrated Care 1(e21): 1-16.

3. Johnson, M. and E. Goyder (2005). "Changing roles, changing responsibilities and changing relationships: an exploration of the impact of a new model for delivering integrated diabetes care in general practice." Quality in Primary Care 13(2): 85-90.

4. McKee M, Nollte E. Chronic Care. In: Smith P, Mossialos E, Papanicolas I, Leatherman S, editors. Performance Measurement for Health System Improvement. New York: Cambridge University Press; 2009.

5. Mc Hugh, S., J. O'Keeffe, A. Fitzpatrick, A. de Siún, M. O'Mullane, I. Perry and C. Bradley (2009). "Diabetes care in Ireland: A survey of general practitioners." Prim Care Diabetes 3(4): 225-231.

6. Mc Hugh, S., M. O'Mullane, I. J. Perry and C. Bradley (2013). "Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice." BMJ Open 3(8).

7. O'Donnell, M., A. de Siún, M. O'Mullane, D. Smith, C. Bradley, F. Finucane and S. Dinneen (2013). "Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led services." BMC health services research 13(1): 493.

8. Rothe, U., G. Müller, P. E. H. Schwarz, M. Seifert, H. Kunath, R. Koch, S. Bergmann, U. Julius, S. R. Bornstein, M. Hanefeld and J. Schulze (2008). "Evaluation of a Diabetes Management System Based on Practice Guidelines, Integrated Care, and Continuous Quality Management in a Federal State of Germany: A population-based approach to health care research." Diabetes Care 31(5): 863-868.