This document provides an overview of a national clinical program for diabetes care in Ireland and the role of clinical nurse specialists in integrated diabetes care. It notes that approximately 220,000 people in Ireland have diabetes, with prevalence increasing 60% over the next 10-15 years. The program aims to provide seamless, integrated care for diabetes patients across primary and secondary care through clinical nurse specialists. The specialists support general practices, provide education, and help coordinate care between primary and secondary care providers to improve outcomes while reducing costs and hospital visits. The vision is for an integrated diabetes service to cover the entire mid-western area of Ireland based on a national model of care.

1. A Seamless Service for
Patients with Diabetes
Anne O Sullivan
CNS Diabetes Integrated Care
30th September 2015

2. Overview
• National Clinical Programme for Diabetes
Care
• Role of the Clinical Nurse Specialist
Diabetes Integrated Care
• Benefits of the service
• Future visions

3. It is estimated that there is approx 220,000 with
diabetes in Ireland (IPW 2013) 5.9% of the
population
Prevalence increasing approx 60% over the next
10-15 years for Type 2 Diabetes Mellitus
WHO states diabetes is the greatest health
challenge of the century
10% of the Irish Health Care budget spent on
diabetes – €1.35 billion annually

4. • 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

5. 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

6. Diabetes Care structure
Person with Diabetes
Uncomplicated
T2DM
Primary Care
Type 1 Diabetes
Pregnancy care
Secondary Care
Complicated
T2DM

8. 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

9. Diabetes Medi-Form

10. 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

11. 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

12. 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

13. Vision
• Diabetes integrated
service to cover all
areas of Mid western
area
• National Model of
care
“Teamwork can make the dream come
through”

14. Thank you
Anne.osullivan11@hse.ie