- Diabetes care in the community
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- Providing Diabetes Care in General Practice : A Practical Guide to Integrated Care
Expert Coaching: The diabetes expert team offers support and advice during joint patient visits. Clinical Decision Support for Physicians: The guidelines are available both in print and on-line at every clinical computer workstation. Patient-Specific Decision Support: Specific patient education materials exist for each guideline requiring patient self-management activities for example, there is a patient contract for protective foot care behavior for patients with "high-risk feet".
Detailed patient education notebooks have been written and made available at no cost to diabetic patients since May These notebooks contain comprehensive self-management support covering all aspects of diabetes care. Our approach to diabetes self-management support and its theoretical and empirical underpinnings are detailed elsewhere The collaborative aspects of self-management support priority setting, treatment planning, problem solving, and follow-up are provided by the primary care team, usually by the practice nurse.
Diabetes care in the community
This collaboration is supported by written education materials called Right Track that are intended to both provide information and address the patient's stage of readiness to be actively involved in self-management behaviors. The materials are provided in a three-ring binder so that the information can be customized for each patient and linked directly to his or her treatment plan. The notebook is available to the patient only through a pharmacy prescription from the primary physician or nurse; this method of distribution allows us to track notebooks through the pharmacy's automated system.
Furthermore, the dispensing of a notebook is noted in the Diabetes Registry, and this activates the patient's diabetes education screen. It is on this screen that all self-management instruction encounters date of encounter, content of encounter, and patient's stage of readiness for self-management are electronically tracked.
The effect of the Roadmap on the use of HbA1c testing, retinal screening, foot care, and screening for microalbuminuria was evaluated by examining temporal trends in the indicators over the period before and after guideline implementation. For all areas except foot care, the data were derived from GHC administrative systems utilization and laboratory. Foot care was assessed by completion of the foot evaluation screen in the Diabetes Registry. For all indicators except retinal screening, the denominator was the number of diabetic patients who met Diabetes Registry entry criteria in a specific period.
The prevalence of smoking among diabetic patients in GHC was assessed by an annual survey of randomly sampled diabetic patients. A subset of these items was administered in to 60 randomly chosen primary care physicians. The effect of the diabetes expert team was assessed by comparing the performance over time of a random sample of primary care practices that had joint patient visits with the diabetes expert team in with that of a sample of 30 practices that did not have joint visits.
The opportunity to meet with the diabetes expert team was communicated to all GHC clinics through letters, voice mail messages, e-mail messages, and clinic leaders, but participation was voluntary. From January through April , the diabetes expert team made joint visits at the primary care clinical practice sites; these visits involved primary care providers and diabetic patients. From all primary care practices that made joint visits with the diabetes expert team in and had at least 20 diabetic patients in their care, we randomly chose 30 group A.
We also chose 30 primary care practices that had not made joint visits with the diabetes expert team group B. The practices in the two groups were similar in size and had delivered a similar level of diabetes care according to their rates of dilated eye examinations, HbA1c testing, and other variables before the Roadmap interventions.
Table 2 shows the baseline information on the 60 practices. We compared groups A and B in calendar year with respect to various measures of clinical care. The comparisons within groups from to were done by using the Wilcoxon rank-sign test; comparisons between groups A and B were done by using the Mann-Whitney U-test. Figure 1 shows the period prevalence of HbA1c testing at least one measure and dilated retinal examinations by at least one eye care provider in the year before implementation of the Roadmap and the 2 years after implementation.
Since that time, these rates have increased steadily. By , almost two thirds of diabetic patients in GHC were receiving annual dilated retinal examinations from an eye care provider. Until the implementation of the Diabetes Registry in May , there was no way short of patient survey or chart audit to determine whether a diabetic patient was receiving foot examinations or foot care education.
The GHC foot care guideline recommends beginning with a standardized evaluation of risk for foot lesions. Figure 3 shows the cumulative percentage of diabetic patients in GHC who had a foot evaluation recorded in the Diabetes Registry. Although the microalbuminuria guidelines were not formally implemented until November , the Roadmap and the diabetes expert team were recommending screening before that time.
Figure 4 shows that the number of urinary microalbumin tests ordered increased rapidly once this test was offered within GHC. An important element of the GHC Roadmap program is smoking prevention and cessation. This is especially critical in the diabetic population, which has a substantially increased risk for coronary heart disease.
The identification and alleviation of risk factors for coronary heart disease are a primary objective of the Roadmap. Figure 5 shows the self-reported prevalence of cigarette smoking among surveyed diabetic patients before and after initiation of the Roadmap.
The effect of the diabetes expert team was assessed by comparing the diabetes practice activities of the two random samples of GHC primary care practices: group A, which was visited by the diabetes expert team during , and group B, which did not request a visit. The two samples did not significantly differ at baseline in number of diabetic patients or in mean rates of dilated retinal examinations or glycohemoglobin testing. Rates of dilated retinal examinations among group A practices increased from The percentage of patients who had at least one glycohemoglobin test rose from The mean HbA 1c level for diabetic patients in was 7.
No data are available for foot care examinations the Diabetes Registry was not available until or microalbuminuria screening this test was not done in GHC laboratories until In , the rate of documented foot examinations was more than threefold higher in group A Similar results were seen for microalbuminuria screening Group A providers were also much more likely to have used the Diabetes Registry 8.
Table 2 shows the percentage of randomly sampled primary care physicians who rated various diabetes-related resources as very good or excellent in and The percentage of physicians rating all four resources as excellent or very good increased significantly after the implementation of Roadmap interventions. To assess the effect of the expert role of the local registered nurse or RN certified diabetes educator, we compared rates of microalbuminuria screening among three groups of clinics: those with an active registered nurse or RN certified diabetes educator full support , those with partial support by a registered nurse or RN certified diabetes educator, and those without this support.
Figure 6 shows that the amount of support was directly related to guideline compliance. Our work shows that a multifaceted program of support for primary care teams can positively influence the care of many diabetic patients by taking an organized, efficient population-based approach to patients at the primary care practice site. We have demonstrated that diabetes care at GHC changed in accordance with evidence-based guidelines after the implementation of a coordinated set of system changes. Before generalized interpretations and extrapolations are made from our work, some of its limitations must be recognized.
This study was not set up as a randomized, controlled clinical trial.
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The Roadmap was gradually implemented over a 3-year period; data on process measures, outcomes, and provider satisfaction were collected before and throughout implementation. Therefore, we cannot be certain that the improvements seen were the results of our activities as opposed to larger secular influences, such as publicity generated by the national debates on health care reform or the initiation of HEDIS reporting. Also, because we implemented several interrelated components of the program simultaneously, it is difficult to ascribe particular improvements to particular interventions.
However, some temporal trends were seen. The retinal screening guideline was the first guideline to be implemented, and rates have risen steadily since then. In contrast, rates of screening for microalbuminuria remained low in and despite considerable national press coverage about the merits of screening and the benefits of angiotensin-converting enzyme inhibitors. Rates of screening for microalbuminuria began rising early in when we made the assay readily available, at low cost, in the GHC laboratory; these rates climbed steeply after the evidence-based guideline was implemented later that year.
It is difficult to know how beneficial a program such as ours would be in other clinical settings. We have implemented it in a staff model HMO where we have easy access to pharmacy, laboratory, and administrative data and where all patients under the care of each primary care provider are GHC enrollees. For providers practicing in an independent provider organization or fee-for-service setting, implementation will be harder. However, the principles of a population-based approach that uses explicit evidence-based guidelines and takes diabetes expertise out to primary care sites could be implemented in most settings.
We have recently begun implementing aspects of the program with these providers and are already seeing some improved outcomes. The most difficult aspect of the program to replicate outside of the staff model structure is the on-line, continually updated Diabetes Registry, but simple alternatives such as card files or spreadsheets could be used to provide a population-based approach to diabetes care. The order in which we implemented the components of the program was determined by a variety of clinical, practical, and political factors.
From the outset, we communicated the vision of the overall program throughout GHC but made it clear that implementing all aspects would take time. Visits by the diabetes expert team began immediately in Developing the patient education material and programming for the Diabetes Registry took several months. Because of the rigorous approach used to create each guideline 18, 19 , guidelines were done sequentially. Because the HEDIS reports in highlighted a major deficiency in diabetic retinal screening practices, this area was targeted first.
The foot care guideline was the second one implemented because we felt that the gap between current and ideal practice was large and that the potential for simultaneously improving outcomes and reducing costs was great Microalbuminuria screening was added next, and the guideline on glycemic control was delayed until Although the importance of improving blood glucose levels in the diabetic population was acknowledged and promoted, we emphasized cardiac risk reduction and the management of diabetic complications in the first 3 years of our program.
These are areas of diabetes management that we felt could be handled well in a primary care setting if a systematic, organized approach was taken. We wanted to establish effective new systems of care for diabetes management in the primary care teams before adding the expectation of a more consistent and intensive approach toward the improvement of glycemic control. This expectation has been added in the past few months, and we expect that rates of HbA1c testing and mean HbA1c levels will improve over the next few years.
One of the most unusual aspects of our program was having the diabetes expert team travel to all of the primary care sites on a regular, ongoing basis to provide on-site coaching of primary care teams. By reinforcing all aspects of the program and demonstrating how to use the Diabetes Registry and how to set appropriate priorities, the diabetes expert team has tried to increase confidence and competence in diabetes management. Not surprisingly, the diabetes expert team visits have been logistically difficult and time-consuming to organize. We identified a nursing or administrative contact person at each of the 25 clinical sites.
These persons were sent a schedule of dates for future diabetes expert team visits and were asked to arrange to bring in two to three patients from each of the four to six providers so that joint consultations could take place with the patient, the primary care team, and the diabetes expert team together at the same time. This was not always possible because of scheduling changes or unforeseen emergencies, but the program has been generally well received.
As we enter our fourth year of diabetes expert team visits, the main feedback we have received is that more clinical sites including contracted network providers want to be involved and that most sites would like the diabetes expert team to come more often, even if for less time. In the future, rather than spending a whole day at each site every 3 months, we are planning for each clinic to have the on-site support for half days every 6 weeks.
It is difficult to estimate the economic implications of these programs. Some additional staff time has been required to develop and support the ongoing implementation of the guidelines and the on-line registry. However, the economic effect of diabetes on a managed care organization is obviously large 28 , and the potential for cost savings is huge. We have already begun to identify the major sources of cost of care for our diabetic patients at GHC 27, 29 , and we plan to follow these costs prospectively over the next few years as this program is fully implemented and refined.
Diabetes was selected, along with a few other conditions, as a target for comprehensive improvement efforts at GHC in Others have shown that the mere availability of guidelines and the use of didactic lectures do not substantially change physician behavior. More personalized physician education accomplished through tutorials 33 , academic detailing 34 , or consultation conferences 35 has proven to be more effective. Others 15, 36 have shown that using nurses to manage the caseloads of diabetic patients under the supervision of diabetologists results in improved outcomes.
In our study, however, each nurse was the case manager for about diabetic patients, and one diabetologist oversaw four nurses With almost 15 diabetic patients at GHC, this approach would require as many as 60 new certified diabetes educators and 14 new diabetologists. We do not suggest that all diabetic patients can be managed in a primary care setting, but we believe that routine care can be substantially improved by paying systematic attention to the elements in our improvement model. In many health care organizations, the criteria used to determine which diabetic patients are seen in a primary care setting and which are referred to an endocrinologist or diabetologist are arbitrary and are based more on patient preferences than on objective evidence of the complexity of the patient's illness.
We hope that by improving the routine aspects of diabetes care with the diabetes expert team and the comprehensive data collected in the Diabetes Registry, we will be able to use objective criteria to identify subsets of diabetic patients who should be seen by a specialty team and will be able to ensure better care for the majority of diabetic patients with less complicated illness.
Organizing care for patients with chronic illness. Milbank Q. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. Implications of generalists' slow adoption of zidovudine in clinical practice. Arch Intern Med. Relationship between physician specialty and the selection and outcome of ischemic stroke patients. Health Serv Res. Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes.
Am J Med. Hayes TM, Harries J. Randomised controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics. Attending the diabetes center is associated with increased 5-year survival probability of diabetic patients: the Verona Diabetes Study.
Diabetes Care. Results from the Medical Outcomes Study. Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Prompting the clinical care of non-insulin-dependent type II diabetic patients in an inner city area: one model of community care. MacKinnon M. General practice diabetes care: the past, the present, and the future.
Carlson A, Rosenqvist U. Diabetes control program implementation. On the importance of staff involvement.
Scand J Prim Health Care. Evaluation of a structured treatment and teaching program for non-insulin-treated type II diabetic outpatients in Germany after the nationwide introduction of reimbursement policy for physicians.
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Quality of outpatient care provided to diabetic patients. A health maintenance organization experience. Wagner EH. Population-based management of diabetes care. Patient Educ Couns. Practicing population-based care in an HMO: evaluation after 18 months.
HMO Pract. An evidence-based approach to evaluating and improving clinical practice: guideline development. An evidence-based approach to evaluating and improving clinical practice: implementing practice guidelines. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Throughout the analysis, the language and expressions of the GPs were maintained as far as possible to avoid losing the meaning and context. Following separate first wave analysis, the researchers examined the convergence and divergence of their findings.
Divergence arose from two conditions: 1 different labels or codes applied to the same concept or 2 unique concepts emerging from a researcher's analysis not identified by the other researcher. Occasionally, unique codes emerged from one researcher's analysis, which were discussed with the wider group. Three interviews from each researcher were subject to inter-coder reliability by an independent party not involved in data collection but familiar with the design and aims of the study CB.
Memo writing was also used as an analytical tool to identify avenues for analysis and interpretations to pursue, connections or comparisons between data and to uncover the assumptions of the participant as well as the researcher. None of the participants requested changes to the interpretation of the data. The participants in this study represented the diversity of diabetes care arrangements in Ireland. Although most participants were from computerised practices, the extent to which they utilised electronic records varied. There were also different experiences of sharing care with hospital specialists.
Hence, barriers and facilitators were rooted in the context of care delivery; a particular support or resource could be a barrier or facilitator depending on its presence or absence in a participant's practice. Barriers and facilitators occurred at multiple levels within the health system and had knock-on effects. The main barriers to optimal management occurred at the health system level: lack of remuneration for diabetes management, lack of coordination between settings and deficient access to services, particularly in the community.
The figure was developed based on analysis of the transcripts. The connections identified within the diagram are based on the ramifications of various barriers as identified by participants themselves during the interview process. Barriers to, and facilitators in, delivering integrated diabetes care. The lack of targeted remuneration or financial incentives to provide structured diabetes management in general practice emerged as one of the main barriers.
Practices are paid an annual capitation grant to cover the cost of providing acute services to patients eligible under the General Medical Scheme. Despite the flaws of the current system, there were divided opinions about the most appropriate form of remuneration. Some participants related the lack of remuneration to the underlying differences in the priorities and values of healthcare professionals and management in the health system. Others called for a new contract which recognised general practice as the most efficient and economical place for managing chronic conditions. However, the lack of resources in the community was seen as a barrier to shifting chronic disease management from the acute setting.
Cost implications for patients without a medical card. Impeding practice development at an organisational level. We could keep flow charts and I'd get remuneration because there is none and this [work] takes a lot of time, manpower, secretarial time, nurse time, and at the moment there's no incentive to do that. Professional apathy. Those who referred to vocational incentives as a source of motivation had established a systematic structured approach to diabetes management, either as part of a local primary care initiative or independently within their own practice.
Job satisfaction. Patient feedback. Personal experience. He was on the ward and there were 7 other guys, it was a vascular ward, and they were all diabetics. Professional duty. Personal values and priorities. A small number of participants reported an unconstructive relationship with the hospital-based team, which was a barrier to delivering optimal care. According to participants, the primary barriers to integrated care did not occur at the professional level but at the level of the health system. The lack of coordination within the system manifested itself in a number of ways and had ramifications in both settings box 3.
It's just not possible. They're doing their best. I've no complaints about their service at all. It's difficult to make appointments, get access to services, especially when it's urgent. Participants called for the development of a shared protocol to reduce avoidable duplication and clarify the roles and responsibilities within each setting. Participants from non-computerised practices did not view non-computerisation as a barrier to integrated care or optimal diabetes management. It's what works for me. I'm updated in terms of training and meetings and all that kind of thing…But I would like to see us having a place in anything that would develop [in terms of the implementation of integrated diabetes care] GP, rural single-handed non-computerised.
Access to services such as dietetics and podiatry fell along a scale from good to bad, or bad to worst in some cases. Few participants had access to a complete range of services for their patients. The availability of services was further jeopardised by the ongoing government policy to freeze recruitment in the public sector due to the economic recession. As a result, maternity leave was not covered and those who retired were not replaced. Access in some cases resulted from the resourcefulness of healthcare professionals in establishing partnerships or optimising opportunities.
It was just something they tried themselves. They were based in the city, and they decided to put some outreach clinics out in the county, and they picked this town for one of their centres. Participants also referred to luck in relation to the availability of a dedicate nurse within the practice or access to a diabetes nurse specialist. This facilitated the delivery of structured care within the practice and coordination between settings and specialists.
Improvements in quality of patient care were attributed to enhanced nurse-led services in the practice and hospital setting. Time, resources and workload emerged as barriers to providing optimal diabetes care in general practice. We always have been willing to take on more and more stuff that is primary care-based [and] bring it out of secondary care but we're saturated now GP, rural group computerised. Although desirable, the barriers to integrated care should not be underestimated.
These challenges have a ripple effect throughout the system at an organisational, social, professional and patient level. The aim of this study was to identify and understand the barriers to, and facilitators of, optimal diabetes care from the general practice perspective, in advance of the proposed reorganisation of services in Ireland. The national model of integrated care has yet to be implemented, and therefore the results of this study provide an opportunity to anticipate future barriers and plan solutions which take into account the local context of care provision.
Research from the fields of implementation science and quality improvement has focused on ways to overcome structural and contextual barriers through tailored incremental change and professional leadership. While the National Clinical Care Programme for Diabetes has proposed care pathways for different patient groups, the absence of a single electronic medical record and unique patient identifier complicates efforts to share information and track patient care. Appropriate investment and infrastructure is needed to foster and support widespread participation in quality improvement.
The distinction between types of incentive is congruent with existing theories of health worker motivation which identify individual, organisational and cultural determinants. Policymakers deciding on the ideal payment structure for chronic disease management should take into consideration the context 26 and the alignment of values between the professional and the organisation. Despite the nuances of this system, similar barriers and facilitators have been identified in other countries.
A metasynthesis of the barriers and facilitators to improvement should be conducted, to develop and understand the full extent of the evidence base. The survey sample was in line with the national profile of general practice in Ireland in terms of practice size, location and level of computerisation. While practice characteristics guided the sampling strategy, perceptions of the main barriers were largely consistent across the subgroups and attitudes were shaped to a greater extent by the context of care in terms of access to various supports and services.
The merits of involving more than one analyst in a qualitative study have been debated.
Pdf Providing Diabetes Care In General Practice A Practical Guide To Integrated Care
The technique is considered appropriate in the context of semistructured interviews whereby all participants are asked broadly the same questions in the same order. This study presents the barriers to, and facilitators of, optimal diabetes management from the general practice perspective. The other healthcare professionals involved in the delivery of diabetes care may face unique challenges within their setting or profession.
Furthermore, while participants highlighted barriers within the system for patients such as the out-of-pocket costs associated GP care in Ireland, further research with patients is warranted to garner their views on the introduction of integrated diabetes care in Ireland. The key ingredients of organisation and enthusiasm, highlighted in , 1 are reflected in the constellation of themes which emerged in this study of the barriers to, and facilitators of, optimal integrated care.
Given the proposals to reform diabetes services through the introduction of integrated care and the transfer of uncomplicated type 2 diabetes management to primary care, there is a need to understand the current challenges to delivery in this setting. Reorientation of care must be accompanied by the reorganisation of support and resources. The authors would like to thank the doctors and nurses who participated in this study. Contributors: The design of this study was developed in close collaboration among all four authors.
OBJECTIVE:To examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland. RESULTS:The main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level.
Providing Diabetes Care in General Practice : A Practical Guide to Integrated Care
There were 'pockets of interest' among GPs motivated by 'vocational' incentives such as a sense of professional duty; however, this was not sufficient to drive widespread improvement. The lack of coordination at the primary-secondary interface resulted in avoidable duplication and an 'in the meantime' period of uncertainty around when patients would be called or recalled by specialist services. The snippet could not be located in the article text.
This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article. BMJ Open. Published online Aug PMID: Correspondence to Dr Sheena Mc Hugh; ei. This article has been cited by other articles in PMC. Abstract Objective To examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland. Design Qualitative using semistructured interviews.
Setting Primary care in the Republic of Ireland. Participants Purposive sample of 29 general practitioners GPs and two practice nurses. Methods Data were analysed using a framework approach. Results The main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level.
Conclusions At present, intrinsic motivation is driving the improvement of diabetes care in Ireland. Article summary. Article focus Over the past two decades, most health systems have reoriented type 2 diabetes care from acute reactive services to regular integrated management in the primary care setting. In Ireland, there are plans to reorganise and standardise diabetes care through the introduction of a national model of integrated care whereby the regular management of uncomplicated type 2 diabetes would shift to primary care.
Key messages The main barriers to integrated diabetes care were at the level of the health system, including a lack of remuneration for chronic disease management in general practice and difficulties in coordinating care across the primary—secondary interface. These barriers had repercussions at an organisational, professional and patient level.
Efforts to improve diabetes care relied on vocational incentives and serendipitous access to services. There was a strong opinion that policy proposals to shift routine management to primary care needed to be supported by adequate resources and investment in community services. Strengths and limitations of this study The use of qualitative methods allowed us to understand the views of the healthcare professionals expected to be part of the implementation and maintenance of integrated diabetes care on the ground.
This study represents the views of those working in the general practice setting. Methods This qualitative research was part of a wider study examining the organisation of diabetes care in Ireland, barriers to, and facilitators of, optimal management and attitudes to quality improvement initiatives including the establishment of a national diabetes register. Open in a separate window. Interviews Face-to-face interviews were conducted between July and January , all of which took place in the participant's practice or home. Analysis Data were analysed iteratively, that is concurrently with data collection, to allow emerging themes to be explored in subsequent interviews.
Results The participants in this study represented the diversity of diabetes care arrangements in Ireland. Financial disincentives The lack of targeted remuneration or financial incentives to provide structured diabetes management in general practice emerged as one of the main barriers. Box 2 Vocational incentives. Risk of general practice becoming saturated Time, resources and workload emerged as barriers to providing optimal diabetes care in general practice. Discussion Although desirable, the barriers to integrated care should not be underestimated.
Conclusions The key ingredients of organisation and enthusiasm, highlighted in , 1 are reflected in the constellation of themes which emerged in this study of the barriers to, and facilitators of, optimal integrated care.