Structured Structured Diabetes Care Diabetes Care

in General in General PracticePractice

Dr Velma HarkinsGP Lead National Diabetes Programme

NAGP AGM14th November 2014

Objectives of ProgrammeObjectives of ProgrammePrinciple is that the greatest benefit to patient wellbeing and the health service lies in the prevention, early detection and the management of complications

of diabetes [1]

• To reduce the number of people developing Type 2 diabetes through appropriate screening and early intervention

• To reduce the microvascular and macrovascular complication rate among those with Type 2 diabetes

• To reduce and manage the progression of microvascular and macrovascular complications

• To empower patients with Type 2 diabetes to be active partners in their care

[1]. Roberts, S. Turning the Corner: Improving Diabetes Care Report from Dr Sue Roberts, National Clinical Director for Diabetes, to the Secretary of State for Health June 2006

Quality ObjectivesQuality Objectives

To develop and implement an integrated care system for

people with Type 2 diabetes based on best practice guidelines to improve diabetes control.• By developing all healthcare professional’s practice so that they can

be confident and competent in managing patients with Type 2 Diabetes over their lifetime

• By focusing on prevention through the provision of 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 the patient’s 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 foot care screening and treatment service to prevent foot ulceration and subsequent amputation.

• Develop a National Diabetes Register.

Access ObjectivesAccess ObjectivesTo expand availability of primary care diabetes

structured care programmes to all of Ireland.• All patients diagnosed with Type 2 diabetes invited to enroll in

structured integrated diabetes programme • GPs will provide highest proportion of care patients with Type 2

diabetes• Access to specialist hospital-based services available for patients

with identified clinical need e.g. at diagnosis, onset of complications or immediate support in complicated cases. Patient care pathways supported by fast-track referral systems agreed locally between primary and hospital care.

• Access to structured patient education programmes provided to compliment one-to-one patient education at GP practice and hospital level.

• All patients diagnosed with Type 2 diabetes will have structured review at Primary Care level at least 3 times per year

• To ensure patients have up to date information in relation to availability of diabetes services in their local area.

National Diabetes National Diabetes Working GroupWorking GroupIn the context of this a National In the context of this a National

Diabetes Diabetes Working Group was established.Working Group was established.

Cost Objectives• 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 and the overreliance on OPD services.

Work was divided into the following work streams:

Uncomplicated Type 2 Diabetes

Primary

CareComplicated

T2DMSecondary

Care

Type 1 Diabetes

Person with

Diabetes

National IntegratedNational IntegratedModel of CareModel of Care

– Patients with Type 1 diabetes, complex & genetic will be managed in Secondary Care only (30,000 patients)

– Patients with Uncomplicated Type 2 Diabetes will be managed in Primary Care only (100,000 patients)o 3 visits per year to GP -one to be annual reviewo Practices to be supported by community based Diabetes Nurse

Specialists

– Patients with Complicated Type 2 Diabetes will be managed by both Primary and Secondary Care (60,000 patients) o 2 visits per year to GPo Annual review to secondary care

Integrated Care Integrated Care Diabetes PackageDiabetes Package

Hospital CareHospital Care• All Type 1 diabetes• Pregnancy and diabetes• Diabetes and Continuous Subcut Insulin Infusion - CSII (usually

T1 diabetes)• Adolescent diabetes• Maturity Onset Diabetes of the Young - MODY • Cystic Fibrosis Related Diabetes - CFRD • Insulin resistance syndromes• Secondary causes of diabetes • Transplant diabetes• Genetic causes of diabetes (Turners/Klinefelters etc.) • Diabetes in adults <30 years of age (would envisage some

care could be shared)• Complicated type 2 diabetes (refer on) (depending on level of

complications most type 2 tend have some level of complications)

• Type 2 diabetes on insulin (this may evolve into the community once community DNS in place)

Referral from Primary Care to Referral from Primary Care to Predominantly Hospital CarePredominantly Hospital Care

Complicated Type 2 diabetes ~ History of lower limb amputation ~ Active or history of foot ulcer ~ High risk foot (as per national model of foot care) ~ Renal failure (Creatinine >150umol/l or eGFR <60ml/min) refer

nephrology ~ Painful peripheral neuritis ~ Symptoms of autonomic neuropathy (except for erectile

dysfunction) ~ Diabetic eye disease with active proliferative retinopathy /

maculopathy or recent laser therapy (last 24 months) ~ Steroid induced hyperglycaemia (can be referred back once off

steroids or blood glucose levels settle) ~ Failing 2 or more glucose lowering agents - HBA1c >7.5% on

maximum glucose lowering agents ~ Type 2 diabetes requiring insulin – not necessary to refer all

once Community DNS in place ~ Weight loss + symptoms +/- ketones

Educational SupportEducational SupportDevelopment of:• Education package for GPs &

Practice Nurses• Materials covering Targets,

Guidelines, Treatment Algorithms etc• Patient Education Package

Provision of Regular Multi-disciplinary Meetings

Role of the GPRole of the GPThe GP carries overall responsibility and leadership

in the running of integrated diabetes care in the

community.

Responsibilities:• Ensure practice staff members familiarised with agreed programme models

of care, including algorithms, patient information, guidelines etc.

• Ensure all members of team are aware of their roles and responsibilities

• Ensure that patients are treated in accordance with National Diabetes Programme Protocols

• Ensure appropriate governance in place in order to ensure continuing improvements in quality, safety, access and cost effectiveness.

• Maintain an up to date register of patients with type 2 diabetes.

• Ensure regular register management takes place.

• Be willing to adapt to new guidelines as they are developed

• Other roles may arise in the future

Role of the Role of the Practice NursePractice Nurse

• Provide regular routine care in the practice to patients with diabetes as per visits set out in agreed model

• Maintain practice diabetes register

• Set targets with patients

• Provide patient education re diet / lifestyle / exercise etc

• Carry out initial and annual foot assessment as per national model

• Refer patients to community diabetes nurse specialist, and refer patients for retinal screening, dietetics and podiatry as per national model

• Refer agreed patients to secondary or tertiary care as per agreed model

• Return patient data as required

Role of the Role of the CommunityCommunityDiabetes Nurse SpecialistDiabetes Nurse Specialist

• See individual patients referred to him / her by the GP / PN

• Provide training and support to Practice Nurses within the GP practice to set up and deliver integrated diabetes care package

• Deliver education programmes, in conjunction with the local nursing education units, for example the HETAC Certificate in Diabetes, along with annual multidisciplinary master classes

• Liaise with secondary care and actively participate in team discussions regarding best quality care is provided for all diabetes patients

• Carry out research and audit, including using audit data to influence the delivery of the integrated diabetes care package at practice level

• These nurses are highly skilled and have specialist post graduate training in diabetes care.

DiagnosisDiagnosisSymptoms of diabetes plus random plasma glucose concentration > 11.1 mmol/l.Random is defined as any time of day without regard to time since last meal.

orFasting Plasma Glucose ≥ 7.0 mmol/l.*Fasting is defined as no caloric intake for at least 8 hours

or2-hr plasma glucose > 11.1 mmol/l during a 75g Oral Glucose Tolerance Test. the test should be performed as described by W.H.O., using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

orA HbA1c ≥ 48 mmol/mol (≥ 6.5%)* †the test should be performed using a standardised assay *In the absence of unequivocal hyperglycaemia, the result should be confirmed by repeat testing on a different day. †A HbA1c value of < 6.5% (IFCC < 48mmol/mol) does not exclude diabetes diagnosed using the other glucose tests

Practice Management Practice Management

StructureStructure Initial Assessment By GP/PN

Record B/P, BMI, Waist Circumference Record baseline blood investigations Review family & medical historyAssess lifestyle issuesScreen for complicationsRefer for dietetic, chiropody, ophthalmic consultEducate Offer baseline diabetes self management education

Practice nurse educates on self management issues• Review aims of Diabetes care • Home blood glucose monitoring & calibration, if appropriate*• Medication management• Psychological support

*The guidelines for self-monitoring of blood glucose are currently under review

4 Monthly Review4 Monthly ReviewPractice Nurse & G.P Role

Investigations Hba1c, Lipids (if raised at last visit), ACR, Serum Creatinine, Iron, Transferrin (if ferritin previously raised)Assess feet, injection sitesAssess smoking status & physical activity levelFollow up on dietetic, podiatry, ophthalmic consults and annual review

Practice nurse educates on self management Issues

• Hypo/Hyperglycaemia

• Entitlements LTI/DFI

• Employment /Driving /Travel advice

• Pre-conceptual advice

Targets Targets – should be individualised– should be individualised

  

Glucos

e

Control

HbA1c ≤ 53mmol/mol (≤7.0%) is appropriate for the majority of patients with T2DM and has been shown to reduce diabetes related complications

HbA1c ≤ 58mmol/mol ( ≤7.5%) or less stringent A1c goals may be appropriate for patients with a history of severe hypoglycaemia, limited life expectancy, advanced micro vascular or macro vascular complications, extensive co-morbid conditions or where social circumstance may prevent tight glucose control

  

Blood

Pressu

re 

 

Systolic ≤ 130mm/hg Diastolic < 80mm/hg

Hypertension should be treated aggressively with lifestyle modification and drug therapy . Measure blood pressure annually and at every routine practice visit if found to be above target level .Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.

Targets Targets – should be individualised– should be individualised

 

Lipid

Managemen

t and

Statins

 

Primary target is the LDL cholesterol. Patients should be treated with a statin* with the aim to reduce

LDL Cholesterol: ≤ 2.6mmol/l for patients without overt cardio-vascular diseaseLDL Cholesterol: ≤ 1.8mmol/l for patients with history of overt cardio-vascular disease*except for patients <40 years with low risk of CVD, patients planning pregnancy or pregnant.

In patients treated with maximum dose statins who do not reach target LDL, a reduction of 30-40% in LDL cholesterol from baseline is an alternative therapeutic goal.HDL cholesterol levels of ≥ 1.0mmol/l in men and 1.3mmol/l in women and fasting serum triglycerides of ≤ 1.7mmol/l are desirable, but the LDL cholesterol is primary target.

Anti-platelet

Agents

Anti-platelet therapy should be offered to all patients with T2DM (secondary prevention) who have a previous history of a cardiovascular or a cerebrovascular event.(For use of anti-platelet therapy in other patients see section on anti-platelets)

Targets Targets – should be individualised– should be individualised

  

Lifestyle 

 Patients should be encouraged to lose weight if necessary, exercise regularly, eat healthily and all patients should be encouraged to stop smoking and given access to prescription medications which encourage smoking cessation.

 

Renal

Disease

Serum creatinine and urine albumin/creatinine ratio (ACR) should be measured at diagnosis and annually thereafter.

Foot Care All patients should have feet checked at each visit and classified as either low, moderate, high risk or active according to National Model of Foot Care

Eye Care All patients with diabetes should have eyes examined at diagnosis and annually thereafter by Ophthalmologist or Retinal Screening Programme

Flu

VaccinationAll patients with diabetes should be offered flu vaccination annually

Prevention of Prevention of ComplicationsComplicationsGlucose Control

Blood Pressure Control

Anti-platelet Therapy

Smoking

Lipids

Diabetic Foot Disease

Eye Disease – Diabetic Retinascreen Programme

Renal Disease

Painful Diabetic Peripheral Neuropathy

Erectile Dysfunction

Foot AssessmentFoot AssessmentOn diagnosis of diabetes and at annual review thereafter trained practice nurse will examine patient’s feet and lower limbs for risk factors, this should include:•Testing vibration and 10g monofilament sensation•Palpation of dorsalis pedis & posterior tibial pulses in both feet•Inspection of any foot deformity•Inspection of footwear

Feet will be classified into three categories:Low Risk At Risk Active Foot Disease

Moderate Risk High Risk

Low Risk Low Risk FootFootCLINICAL FINDINGS•Normal Sensation – intact pressure & vibration sensation•No Peripheral Artery Disease (PAD) - all pedal pulses present - no signs/symptoms of PAD•No previous ulcer or lower limb amputation•No foot deformity•Normal vision

MANAGEMENT PLAN•Annual foot screening in primary care by practice nurse•Clinical Nurse Specialist &/or podiatrist to provide education to practice nurse to provide screening•Foot screening will be provided within structured care in GP practice 4 monthly or at least annually•Patient education / smoking cessation

At Risk Foot At Risk Foot --Moderate Moderate RiskRiskCLINICAL FINDINGS

Any one of the following:

•Loss of sensation / peripheral neuropathy•Peripheral Artery Disease •Structural foot deformity•Significant visual impairment•Physical disability (e.g. stroke or gross obesity)

MANAGEMENT PLAN•Annual foot screening by foot protection team & on-going review by podiatrist member of foot protection team based either in the hospital or community•Education in foot protection•Vascular assessment, biomechanical, orthopaedic assessment and orthotics if indicated•Referral to community podiatry for non diabetic foot pathology

At Risk Foot – At Risk Foot – High High RiskRiskCLINICAL FINDINGS •Peripheral Artery Disease and Sensory loss

and/or •Previous diabetes related foot ulcer or lower limb amputation

and/or •Previous Charcot neuroarthropathy

MANAGEMENT PLAN•Called for formal annual review by foot protection team & routine on-going review by GP/practice nurse/hospital diabetes clinic•Examination for deformity, neurological status, footwear and orthotics as indicated•Education in foot protection•If ulceration present then refer within 24 hours to multi-disciplinary foot care service (model 4 hospital)

Active Foot Active Foot DiseaseDisease

CLINICAL FINDINGS •Active Foot Ulcerationand/or•Charcot neuroarthropathy

MANAGEMENT PLAN•Referral with rapid access (within 24 hours/next working day) to multidisciplinary foot care service in tertiary centre•Access to vascular, orthopaedics and orthotics•Access to vascular laboratory, radiology, microbiology & infectious disease

HEALED ULCER•Once ulcer healed refer patient back to the foot care team in the referral model 3 hospital•If the healed ulcer belongs to a patient who originated from the model 4 hospital they remain under the care of the specialist diabetes foot service in that hospital