anne o'sullivan, cns diabetes
TRANSCRIPT
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”
