Appendix 3: Diabetes care pathways

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Appendix 3: Diabetes care pathways

  1. 1. Diabetes care pathway Prepared in collaboration with Bupa Commissioning
  2. 2. Generic pathway Adolescent care pathway Blood pressure control Mental health and type 2 diabetes Patients in care homes or housebound Common components Initiation Initiation Initiation & ongoing care Ongoing care Initiation (1) Initiation (2) & annual check-up Medications (1) Medications (2) Ongoing care Common tests for all patients Common tests for adolescents Map of pathways – click on any map to start Pre- conception
  3. 3. Notes Notes Notes General Notes Preconception care for women with diabetes
  4. 4. Clinical review notes The model of “interactive preconception diabetes care” contains four main elements. MDT members should agree how these areas of support are allocated across the team: 1. patient education about the interaction of diabetes, pregnancy and family planning; 2. education in diabetes self-management skills; 3. planned medical care and laboratory testing; 4. counselling when indicated to reduce stress and improve adherence to the diabetes treatment plan. All four elements are important for patients to achieve the level of sustained glycemic control necessary to prevent excess congenital malformations and spontaneous abortions. <ul><li>If not scheduled, bring forward retinal examination to preconception support phase. </li></ul><ul><li>Working with the patient, set joint goals to plan and optimize management of nephropathy and hypertension to avoid ACE inhibitors. </li></ul><ul><li>Offer a renal assessment, including a measure of microalbuminuria, before discontinuing contraception. If (eGFR) is less than 45 ml/minute/1.73 m2, referral to a nephrologist should be considered before discontinuing contraception. </li></ul><ul><li>Discontinue statin treatment in fertile women without contraception. </li></ul><ul><li>Together with the patient, set an appropriate schedule for follow-up visits. </li></ul>Other models to illustrate good models of care Suggested actions and changes
  5. 5. <ul><li>There is good evidence that a multidisciplinary team – including a clinician with expert knowledge of diabetes, an obstetrician familiar with the management of high-risk pregnancies, diabetes educators (including a nurse), dietician and social worker – provides optimal pre-conception care for women with diabetes. </li></ul><ul><li>The aim of the specialist service is to make the woman with diabetes the most active member of the team, working with the other members for specific guidance and expertise to help her achieve her goal of a healthy pregnancy and newborn. </li></ul>Clinical review notes
  6. 6. <ul><li>Informed consent on the use of metformin in women with diabetes planning pregnancy should be obtained and documented. </li></ul><ul><li>Offer monthly measurement of HbA1c. </li></ul><ul><li>Offer a meter for self-monitoring of blood glucose. </li></ul><ul><li>Offer type 1 patients ketone testing strips to test for ketonuria or ketonaemia if they become hyperglycaemic or unwell. </li></ul>Clinical review notes
  7. 7. <ul><li>Lessons from current, best and emerging practice models: </li></ul><ul><li>In the CEMACH survey of maternity services, less than a fifth of maternity units in England, Wales and Northern Ireland provided structured multidisciplinary preconception care for women with diabetes. </li></ul><ul><li>A prospective study of the effect of preconception health promotion on planning of pregnancy shows that women in a family planning clinic who had received the intervention (22%) during routine visits were more likely to report intended pregnancies than those patients in the same clinic who were not exposed to the intervention. </li></ul><ul><li>Research indicates that providers and health-care organizations are more likely to engage in evidence-based or best clinical practices, after participation in quality improvement projects. </li></ul>General notes <ul><li>Moos MK, Bangdiwala SI, Meibohm AR, Cefalo RC. The impact of a preconceptional health promotion program on </li></ul><ul><li>intendedness of pregnancy . Am J Perinatol 1996;13:103--8. </li></ul><ul><li>2 National Committee for Quality Assurance. Checkups after delivery: improving program participation . Washington, DC: National Committee for Quality Assurance; 2002. </li></ul>
  8. 8. Generic diabetes care pathway: Detection and initial treatment
  9. 9. Generic diabetes care pathway: Ongoing management
  10. 10. Notes Notes Notes Notes Notes General Notes Adolescents: Diagnosis, initial treatment and management
  11. 11. Clinical review notes Every child newly diagnosed with type 1 diabetes should be evaluated and cared for by a diabetes team (consisting of a paediatrician with a particular interest in diabetes, a nurse educator, a dietician, and a mental health professional) qualified to provide up-to-date adolescent-specific education and support <ul><li>No local experience in the outpatient management of newly diagnosed children with diabetes </li></ul><ul><li>Inadequate staffing to provide comprehensive outpatient care </li></ul><ul><li>Patients with acidosis </li></ul><ul><li>Patients who require intravenous hydration </li></ul><ul><li>Distant referrals </li></ul><ul><li>Patients or families with significant psychosocial challenges that preclude outpatient education </li></ul>Other models to illustrate good models of care Indicators for inpatient treatment
  12. 12. Clinical review notes • Early evaluation of family barriers to concordance is essential to avoid these behaviours to become entrenched. • The presence of repeated episodes of DKA, other health problems (e.g. asthma, eating disorders), poor school attendance, learning disabilities, and emotional and behavioural disorders - including risk-taking behaviours resulting in challenging behaviour and depression - are indicators for barriers to concordance. • Certain family characteristics have been identified as risk factors for poor diabetes control. These include a single-parent home, chronic physical or mental health problems in a parent or other close family member (including substance abuse,) a recent major life change for the parent (e.g. loss of a job or a death in the family), complex child care arrangements, and health/cultural/religious beliefs that make it difficult for the family to follow current diabetes treatment plans. • Working with the patient and family, develop an exercise plan and support package including strategies to measure blood glucose levels manage hypoglycaemia, adjust carbohydrate intake and insulin doses. <ul><li>Essential to provide support and empowerment to maintain family involvement in diabetes care tasks and to identify and discuss ways to overcome barriers in successful diabetes management. </li></ul>Other models to illustrate good models of care Suggested actions and changes
  13. 13. <ul><li>Peer support models are a potentially low-cost, flexible means to supplement formal health care support. Peer support models also potentially benefit both those receiving and those providing support. </li></ul><ul><li>Reciprocal models for both receiving and providing peer support are being rigorously evaluated. The unifying feature of these programs is that they seek to build on the strengths, knowledge, and experience that peers can offer. </li></ul><ul><li>Peer support interventions build on the recognition that people living with chronic illnesses have a great deal to offer each other; they share knowledge and experience that others, including many health care professionals, cannot understand. </li></ul><ul><li>If carefully designed and implemented, peer support interventions can be a powerful way to help patients with chronic diseases live more successfully with their conditions. </li></ul><ul><li>There is still much to learn about how best to organize and deliver effective programs, which types of programs are best for different types of patients, and how best to integrate peer support interventions into other clinical and outreach services. </li></ul><ul><li>Many of the models discussed in this brief overview have not yet been rigorously evaluated in randomized, controlled trials or have only been evaluated in one or two studies. There is much to be done in testing different peer support models and building knowledge to inform the development of improved models of peer support for diabetes self-management. </li></ul>Clinical review notes
  14. 14. <ul><li>Medical history </li></ul><ul><li>• Symptoms and results of laboratory tests related to the diagnosis of diabetes </li></ul><ul><li>• Recent or current infections or illnesses </li></ul><ul><li>• Previous growth records, including growth chart, and pubertal development </li></ul><ul><li>• Family history of diabetes, diabetes complications, and other endocrine disorders </li></ul><ul><li>• Current or recent use of medications that may affect blood glucose levels </li></ul><ul><li>• History and treatment of other conditions, including endocrine and eating disorders, and diseases known to cause secondary diabetes (e.g. cystic fibrosis) </li></ul><ul><li>• Use of tobacco, alcohol and/or recreational drugs </li></ul><ul><li>• Physical activity and exercise </li></ul><ul><li>• Contraception and sexual activity (if applicable) </li></ul><ul><li>• Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia and family history </li></ul><ul><ul><li>Prior A1C records* </li></ul></ul><ul><ul><li>Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes and health beliefs </li></ul></ul><ul><li>• Results of past testing for chronic diabetes complications, including ophthalmologic and microalbumin screening </li></ul><ul><li>• Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia </li></ul><ul><li>• Current treatment, including medications, meal plan, results of glucose monitoring and patients’ use of data </li></ul><ul><li>• If signs and symptoms are suggestive of type 2 diabetes: </li></ul><ul><ul><li>Evidence of islet autoimmunity (e.g., islet cell [ICA] 512 or IA-2, GAD, and insulin autoantibodies) </li></ul></ul><ul><ul><li>Evidence of ß-cell secretory capacity (e.g. C-peptide levels) after 1 year, if diagnosis is in doubt </li></ul></ul><ul><li>• A1C </li></ul><ul><li>• Lipid profile </li></ul><ul><li>• Annual screening for microalbuminuria </li></ul><ul><li>• Thyroid-stimulating hormone (TSH) levels </li></ul><ul><li>• Celiac antibodies at diagnosis or initial visit if not done previously </li></ul>Clinical review notes (1)
  15. 15. <ul><li>Referrals and screening </li></ul><ul><li>• Yearly ophthalmologic evaluation </li></ul><ul><li>• Medical nutrition therapy (by a registered dietician) </li></ul><ul><ul><li>As part of initial team education and on referral, as needed </li></ul></ul><ul><ul><li>Generally requires a series of sessions over the initial 3 months after diagnosis, then at least annually, with young children requiring more frequent re-evaluations </li></ul></ul><ul><li>• Diabetes nurse educator </li></ul><ul><ul><li>As part of initial team education, or referral as needed at diagnosis; generally requires a series of sessions during the initial 3 months of diagnosis, then at least annual re-education </li></ul></ul><ul><li>• Behavioural specialist </li></ul><ul><li>• Depression screening annually for children ≥10 years of age, with referral as indicated: </li></ul><ul><ul><li>Annual screening for microalbuminuria should be initiated once the child is 10 years of age and has had diabetes for 5 years; more frequent testing is indicated if values are increasing. </li></ul></ul><ul><ul><li>Fasting lipid profile should be performed at the time of diagnosis (after glucose control has been established). If values fall within the accepted risk levels (measurement should be repeated every 5 years. </li></ul></ul><ul><ul><li>The first ophthalmologic examination should be obtained once the child is ≥10 years of age and has had diabetes for 3–5 years. After the initial examination, annual routine follow-up is generally recommended. </li></ul></ul><ul><ul><li>Annual foot exams should begin at puberty. </li></ul></ul>Clinical review notes (2)
  16. 16. <ul><li>• Nurses dedicated to communicating basic specialised diabetes education skills are required for adolescents. They require management skills within a context that addresses family dynamics and issues facing the whole family. </li></ul><ul><li>It is essential that substantial educational material (necessary for basic management, often referred to as &quot;survival skills&quot;) be conveyed to a family of a child with type 1 diabetes immediately after the initial diagnosis. </li></ul><ul><li>Studies suggest that to be effective, educational interventions need to be ongoing. </li></ul><ul><li>Frequent telephone contact, and both in-person care and telephone availability have been demonstrated to improve A1C. </li></ul>Clinical review notes
  17. 17. <ul><li>• A sample of 104 families of adolescents with inadequate control of type 1 diabetes was randomized to either remain in standard care (SC) or to augmentation of that regimen by 12 sessions of either a multifamily educational support (ES) group or 12 sessions of Behavioural Family Systems Therapy over 6 months. </li></ul><ul><li>BFST-D (targeting of diabetes-specific behavioural problems, extension of treatment from 3 to 6 months, training in behavioural contracting techniques for all families, a 1-week parental simulation of living with type 1 diabetes, and optional extension of therapeutic activities to other extra-familial social environments affecting the child’s diabetes management) was significantly superior to both SC and ES in effects on A1C 10 . </li></ul><ul><li>10 Randomized Trial of Behavioral Family Systems Therapy for Diabetes. Diabetes Care 30:555-560, 2007 </li></ul>Clinical review notes
  18. 18. <ul><li>Learnings from current, best and emerging practice models: </li></ul><ul><li>• Attention to such issues as family dynamics, developmental stages and physiologic differences related to sexual maturity are all essential in developing and implementing an optimal diabetes regimen in adolescents. </li></ul><ul><li>• Targets of education need to be adjusted to the age and developmental stage of the patient with diabetes and must include the parent or caregiver 1 . </li></ul><ul><li>• The goal should be a gradual transition toward independence in management through adolescence. Adult supervision remains important throughout the transition. </li></ul><ul><li>• Many of the demands of self-care for diabetes interfere with the adolescent’s drive for independence and peer acceptance. Peer pressure may generate strong conflicts. In this age-group, there is a struggle for independence from parents and other adults that is often manifested as suboptimal adherence to diabetes care. </li></ul><ul><li>• Adolescents whose parents exercise supervision in the management of diabetes have better metabolic control 2 . </li></ul><ul><li>1 Ingersoll GM, Orr DP, Herrold AJ, Golden MP: Cognitive maturity and self-management among adolescents with insulin-dependent diabetes mellitus. J Pediatr 108:620–623, 1986 </li></ul><ul><li>2 Grey M, Boland EA, Yu C, Sullivan-Bolyai S, Tamborlane WV: Personal and family factors associated with quality of life in adolescents with diabetes. Diabetes Care 21:909–914, 1998 </li></ul>General notes
  19. 19. General Notes Notes Mental health and type 2 diabetes
  20. 20. <ul><li>Individuals with schizophrenia and other serious mental illnesses have rates of type 2 diabetes more than four times higher than the rate in the general population. </li></ul><ul><li>Mental health teams should take on some responsibility for managing general health issues in their patients, e.g. providing education about healthy living, ensuring that screening for diabetes is done and that other services are involved when necessary. </li></ul><ul><li>Mental health stability before commencing long-term disease management as psychiatric illness poses significant barriers to care. </li></ul>General notes
  21. 21. <ul><li>Psychological interventions have shown some positive impact on glycaemic control. Depression seems to be particularly improved following these interventions. </li></ul><ul><li>It is preferable to incorporate psychological assessment and treatment into routine care rather that wait for identification of a specific problem or deterioration in psychological status. </li></ul><ul><li>Although the clinician may not feel qualified to treat psychological problems, using the patient-provider relationship as a foundation for further treatment can increase the likelihood that the patient will accept referral for other services. It is important to establish that emotional well-being is part of diabetes management. </li></ul><ul><li>Health and clinical psychologists with expertise in diabetes can support the multidisciplinary team and improve service. </li></ul><ul><li>Model of care: Diabetes Treatment Among VA Patients With Co-morbid Serious Mental Illness. </li></ul>Clinical review notes
  22. 22. Notes Mental health and type 2 diabetes
  23. 23. <ul><li>Partnership between patient and their clinical and support team can improve outcomes. </li></ul><ul><li>Mental health, social services and case management professionals may enhance compliance and follow up. </li></ul><ul><li>Patients whose difficulties in accepting their diagnosis compromise their treatment may benefit from cognitive behavioural therapy. </li></ul><ul><li>Psychological support will help people with diabetes identify barriers to managing their diabetes effectively. </li></ul><ul><li>Emotional and psychological support should be integral to diabetes care package. </li></ul><ul><li>Models of care: </li></ul><ul><li>Overview of Peer Support Models to Improve Diabetes Self-Management and Clinical Outcomes http://spectrum.diabetesjournals.org/cgi/content/full/20/4/214 </li></ul><ul><li>Psychological needs must be properly assessed in partnership with the individual. </li></ul><ul><li>The target for HbA1c should take into account psychosocial circumstance. </li></ul><ul><li>Mental health counsellors should be consulted where applicable. Appropriate counsellor should be considered if psychological factors prevent full adherence to medication regimen. </li></ul><ul><li>Psychological insulin resistance can discourage patients from starting therapy. Depression, stress and anxiety represent further obstacles to optimum self-care and the attainment of glucose goals. Healthcare professionals should endeavour to understand and accommodate these issues when setting personal treatment goals and developing plans to achieve them. </li></ul>Clinical review notes
  24. 24. Notes Care homes / housebound
  25. 25. <ul><li>Guidelines advocate fasting glucose for the routine diagnosis of diabetes, but failure to fast could cause false-positive results. </li></ul><ul><li>An OGTT would have been a gold standard, but poor adherence among frail elders has been observed, and screening may not have been completed with the added work and cost involved in using an OGTT. </li></ul><ul><li>Therefore there is a physiological basis for use of PPG particularly in the elderly and PPG (using the threshold for casual glucose of 200 mg) could increased pick up. This is especially relevant for leaner diabetic subjects with possible failure of insulin release in response to a dietary load, whom were found less likely to have diagnostic fasting glucose alone levels. </li></ul><ul><li>For diabetes screening in this population, it is recommended that fasting glucose be augmented by PPG estimation, particularly in the leaner elderly population. Targeted screening of elderly residents with dementia is also likely to identify the highest rates of undiagnosed diabetes 3. </li></ul><ul><li>3 Asprey, T. et al., Diabetes in British Nursing and Residential Homes: A pragmatic screening study . </li></ul>Clinical review notes
  26. 26. Notes Care homes / housebound
  27. 27. <ul><li>Skill, competency and team requirements: </li></ul><ul><li>Each care team that cares for diabetics in the home or institutionalized care setting must AGREE, DOCUMENT AND AUDIT a series of outcome determinants to assist in assessing the quality of diabetes care delivered. </li></ul><ul><li>Models of care: </li></ul><ul><li>Sinclair AJ, Turnbull CJ, Croxson SCM. Document of care for older people with diabetes. Clinical guidelines. Postgrad Med J 1996; 72:334-338. </li></ul><ul><li>Norman A, French M, Hyam V, Hicks D. Development and audit of a home clinic service. J Diabetes Nurs 1998; 2(2): 51-54. </li></ul><ul><li>Evercare evaluation interim report: implications for supporting people with long-term conditions – The nursing home model and vulnerable older people of http://www.erpho.org.uk/Download/Public/13212/1/evercarereport1_1.pdf </li></ul><ul><li>Appoint a local diabetes nurse specialist to liaise with and support the care team. This person can play a very important role in educating all parties, including the resident and care staff (including catering staff). </li></ul>Clinical review notes (1)
  28. 28. <ul><li>Models of care: </li></ul><ul><li>Sinclair AJ, Turnbull CJ, Croxson SCM. Document of care for older people with diabetes. Clinical guidelines. Postgrad Med J 1996; 72:334-338. </li></ul><ul><li>Norman A, French M, Hyam V, Hicks D. Development and audit of a home clinic service. J Diabetes Nurse 1998; 2(2): 51-54 </li></ul><ul><li>TCCP - Transforming Chronic Care. University pf Birmingham. Evidence about improving care for people with long-term conditions http://www.hsmc.bham.ac.uk/staff/pdfs/Transforming_Chronic_Care.pdf </li></ul><ul><li>Identify and liaise with a community dietitian to support the care team especially with Diabetics on Insulin therapy. </li></ul><ul><li>Educate , support and monitor career, catering or kitchen staff to ensure familiarity with the key principles of dietary planning for residents with diabetes and who is able to provide meals in accordance with these. </li></ul><ul><li>Ensure access to transport facilities to enable access to specialist treatment. </li></ul><ul><li>For each patient identify a designated doctor (usually the GP) who will accept overall medical responsibility </li></ul><ul><li>Ensure availability, maintenance and knowledge of glucose monitoring of capillary samples from residents with diabetes. The older adult who has diabetes and whose individual targets are not being met should have his or her A1c levels measured at least every 6 months and more frequently, as needed or indicated. For persons with stable A1c over several years, measurement every 12 months may be appropriate. </li></ul>Clinical review notes (2)
  29. 29. Common set of tests for all patients over 18 undergoing diabetes management
  30. 30. Notes Notes Notes Notes Notes Common set of tests for adolescents undergoing diabetes management
  31. 31. <ul><li>Symptoms and results of laboratory tests related to the diagnosis of diabetes. </li></ul><ul><li>Recent or current infections or illnesses. </li></ul><ul><li>Previous growth records, including growth chart and pubertal development. </li></ul><ul><li>Family history of diabetes, diabetes complications, and other endocrine disorders. </li></ul><ul><li>Current or recent use of medications that may affect blood glucose levels. </li></ul><ul><li>History and treatment of other conditions, including endocrine and eating disorders, and diseases known to cause secondary diabetes (e.g. cystic fibrosis). </li></ul><ul><li>Use of tobacco, alcohol and/or recreational drugs. </li></ul><ul><li>Physical activity and exercise. </li></ul><ul><li>Contraception and sexual activity (if applicable). </li></ul><ul><li>Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history </li></ul><ul><ul><li>Prior A1C records* </li></ul></ul><ul><ul><li>Details of previous treatment programs, including nutrition and diabetes self- management education, attitudes, and health beliefs </li></ul></ul><ul><li>Results of past testing for chronic diabetes complications, including ophthalmologic examination and microalbumin screening. </li></ul><ul><li>Frequency, severity and cause of acute complications such as ketoacidosis and hypoglycemia. </li></ul>Clinical review notes
  32. 32. <ul><li>Fasting lipid profile should be performed at the time of diagnosis (after glucose control has been established). </li></ul><ul><li>If values fall within the accepted risk levels measurement should be repeated every 5 years. </li></ul>Clinical review notes
  33. 33. <ul><li>As part of initial team education and on referral, as needed; generally requires a series of sessions over the initial 3 months after diagnosis, then at least annually, with young children requiring more frequent re-evaluations by a diabetes nurse educator. </li></ul>Clinical review notes
  34. 34. <ul><li>Annual screening for microalbuminuria should be initiated once the child is 10 years of age and has had diabetes for 5 years; more frequent testing is indicated if values are increasing. </li></ul>Clinical review notes
  35. 35. <ul><li>The first ophthalmologic examination should be obtained once the child is ≥10 years of age and has had diabetes for 3–5 years. After the initial examination, annual routine follow-up is generally recommended. </li></ul>Clinical review notes
  36. 36. Generic diabetes care pathway: Blood pressure management
  37. 37. Generic diabetes care pathway: Medications (1)
  38. 38. Generic diabetes care pathway: Medications (2)

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