Anne O'Sullivan, CNS Diabetes

A Seamless Service for Patients with Diabetes

Anne O SullivanCNS Diabetes Integrated Care

30th September 2015

Overview

• National Clinical Programme for Diabetes Care

• Role of the Clinical Nurse Specialist Diabetes Integrated Care

• Benefits of the service

• Future visions

It is estimated that there is approx 220,000 withdiabetes in Ireland (IPW 2013) 5.9% of the

populationPrevalence increasing approx 60% over the next

10-15 years for Type 2 Diabetes MellitusWHO states diabetes is the greatest health

challenge of the century10% of the Irish Health Care budget spent on

diabetes – €1.35 billion annually

• National Diabetes Working established• Findings: ad hoc, care disjointed, frequent

duplication of tests, working independently• Group to devise a National Model of care• All different strands of diabetes care

Integrated Care In patients diabetes management Diabetes in pregnancy Foot care Structured care Paediatric diabetes care

Overall aim: Improve diabetes care

National Clinical Programme for Diabetes Care

National Integrated Care programme

• 17 CNS Diabetes Integrated Care

• Endorsed & supported -1wte post

• Mid Western area• Inaugural post • Network 3 & 7• 20 Practices engaged• 2014~600 PC • 25/9/15 ~600

Diabetes Care structure

Person with Diabetes

Uncomplicated T2DM

Primary Care

Type 1 Diabetes Pregnancy care

Secondary Care

Complicated T2DM

Role of CNS Diabetes Integrated care – Patient Journey

Primary Care

• Support general practices. • Review patients, newly

diagnosed, uncontrolled glycaemia,

• Manage injectable therapies

Every 6-10 week Diabetes clinics within the

practice Patient referred by GP/PN Patient seen within weeks Full assessment carried Individualised goals

Review date organised Fast track to secondary

care Patient attends OPD 1-

2weeks Reviewed by CNS Joint consultation with Cons

Endocrinologist Care plan devised & action Feedback to GP~ Diabetes

mediform

Diabetes Medi-Form

Role of CNS Diabetes Integrated care

Secondary Care 0.2 post

• Consultant: case discussions• Fast track patient into system• Discharge planning• Patient education• Maintaining skill (e.g. Type 1 DM, GDM,

specialised clinics) • Management of complicated patients• Multidisciplinary team meetings

Role Of CNS Diabetes Integrated care

• Education / support – HCPs

• Coordinate / deliver Structured Education Programmes

• Education & Screening

• Diabetes prevention & promote awareness of Diabetes

• Link Primary care ↔ secondary care

Benefits

The patient is seen by the appropriate HCP at the different stages of their Diabetes journey

Reduce unnecessary referral

Reduce hospital waiting list

Secondary care ~complex patient

Using resources in a much more efficient manner

Cost effective

• Patient satisfaction is increased

• More informed & knowledgeable

• Seen nearer home • Patients kept out of

hospital• Outcomes improved• Care is structured/

organised

Vision

• Diabetes integrated service to cover all areas of Mid western area

• National Model of care

“Teamwork can make the dream come through”

Thank you

[email protected]