1. Structured Diabetes Care in General Practice
Dr Velma Harkins
GP Lead National Diabetes Programme
NAGP AGM
14th November 2014

2. Objectives of Programme
Principle is that the greatest benefit to patient well
being 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

3. Quality 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.

4. Access Objectives
To 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.

5. National Diabetes Working Group
In the context of this a National Diabetes
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:

6. National Integrated Model of Care
Uncomplicated Type 2 Diabetes
Primary
Care
Complicated T2DM
Secondary Care
Type 1 Diabetes
Person with Diabetes

7. Integrated Care Diabetes Package
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)
3 visits per year to GP -one to be annual review
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)
2 visits per year to GP
Annual review to secondary care

8. Hospital 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)
While this care will be managed in the hospital, the development of integrated care will likely improve general delivery of diabetes care to these patients by their general practitioner

9. Referral from Primary Care to Predominantly 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
These patients may have their care shared between the hospital and primary care or care kept within the hospital depending on local expertise

10. Educational Support Development of:
Education package for GPs & Practice Nurses
Materials covering Targets, Guidelines, Treatment Algorithms etc
Patient Education Package
Provision of Regular Multi-disciplinary Meetings

11. Role of the GP
The 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

12. Role of the Practice 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

13. Role of the Community Diabetes 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.

14. Diagnosis Symptoms 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. or
Fasting Plasma Glucose ≥ 7.0 mmol/l.*
Fasting is defined as no caloric intake for at least 8 hours
2-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.
A 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

15. Practice Management Structure
Initial Assessment By GP/PN
Record B/P, BMI, Waist Circumference Record baseline blood investigations Review family & medical history
Assess lifestyle issues
Screen for complications
Refer for dietetic, chiropody, ophthalmic consult
Educate 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

16. 4 Monthly Review Practice Nurse & G.P Role
Investigations Hba1c, Lipids (if raised at last visit), ACR, Serum Creatinine, Iron, Transferrin (if ferritin previously raised)
Assess feet, injection sites
Assess smoking status & physical activity level
Follow 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

17. Targets – should be individualised  
Glucose 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
Pressure
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.

18. Targets – should be individualised
Lipid Management 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 disease
LDL 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)

19. Targets – 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 Vaccination
All patients with diabetes should be offered flu vaccination annually

20. Prevention of Complications
Glucose 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

21. Foot Assessment
On 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

22. Low Risk Foot CLINICAL 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

23. At Risk Foot -Moderate Risk
CLINICAL 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

24. At Risk Foot – High Risk Peripheral Artery Disease and Sensory loss
CLINICAL FINDINGS
Peripheral Artery Disease and Sensory loss
and/or
Previous diabetes related foot ulcer or lower limb amputation
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)

25. Active Foot Disease CLINICAL FINDINGS Active Foot Ulceration
and/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