Health Care System Evolution, Organizational Essay

(Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

The continuum of care for the diabetic patient is shown in the following illustration labeled Figure 1.

Diabetes: Continuum of Care

Source: Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The continuum of care for diabetes begins at the moment that the individual is found to have diabetes and continues across the individual's health care providers and across the varying stages of progression of the disease and the age progression of the individual with Diabetes. This continuum of care should be addressed by health care providers, Medicare/Medicaid, as well as the Centers for Disease Control and Prevention.

Changes in the workforce in developing the diabetes continuum of care is stated to have included the following: (1) Increase in number of dieticians; (2) Increase in number of diabetic specialist nurses; (3) Increase in podiatrists; (4) Education for primary care team; (5) Move DSN to primary care to take straight referrals; (6) Insulin for life training with continuous CPD support; (7) Increase capacity in general practice; (8) Psychologist input; (9) DSN provides education/advice for practices; (10) Increase confidence of G.Ps and Practice nurses to deliver care; (11) Out of hours service accessibility to advice post 6 p.m. (for patients and clinicians); and (12) DSN for elderly. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Clinical accommodations were stated to include: (1) Care pathways; (2) Identification of patient on admission to acute to pharmacist, DSN; (3) Continuity of care throughout the service where possible patient sees the same clinician; (4) Need shared templates, guidelines, protocols; (5) Retinal screening; and (6) Eye screening for housebound. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Communication accommodations supporting diabetes continuum of care included: (1) Countywide register accessible to all clinicians; (2) Increase family/school liaison; (3) Developed links between services; (4) Diabetic link nurses on all wards; (5) Shared templates/paperwork; (6) Use of available technology email referrals/advice etc.; (7) Information that flows freely to all parts of the service; and (8) Good data. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Public health and education accommodations to support diabetes continuum of care included: (1) Better transport; (2) Healthy diet; (3) Playing fields; (4) Educating parents, children on healthy lifestyles; and (5) Tie diabetes to other strategies to tackle obesity. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Patient education accommodations for supporting diabetes continuum of care is stated to include: (1) Structured patient education for type 2; (3) Structured patient education for type 1; and (3) Cluster-based training for newly diagnosed diabetics. The action along with the purpose taken in this diabetes continuum of care initiative are listed in the following table labeled Figure 2.

Diabetes Continuum of Care Actions/Purposes

Action

Purpose

Diabetes Network core group to meet

To agree terms of reference, structure and function of the network

Agree communication strategy.

Make final agreement on model of care following feedback

Decide how to deliver recommendations from the stakeholder event

Begin detailed action plan for circulation

Set up the Diabetes Structured Education Self-Care Group

To address the recommendations and requirements of NICE guidance, both technology appraisals and clinical guidelines, in relation to structured patient education, patient information and self-monitoring in accordance with the Worcestershire Model of Care for Diabetes. The group will be chaired by Sian Finn, Self-Care Programmes Manager for the PCT.

Complete the Diabetes Commissioning toolkit data collection

To benchmark our services. To provide baseline data to evaluate changes against. To ensure action plans can be prioritized appropriately based on health needs analysis.

To identify financial implications

Communicate outputs from Stakeholder event widely and gain feedback especially with patients groups.

To ensure all those with vested interest have a chance to contribute to the future of diabetes care in Worcestershire.

Identify and cost workforce options for delivering the model of care

To ensure robust workforce plans can be produced to support model of care

To allow open decision making process

Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The 'elements of care' stated in the Diabetes continuum of care program are listed in the following table labelled Figure 3.

Diabetes Continuum of Care Elements

SUPPORTED Self-CARE

GP/PRACTICE NURSE

INTERMEDIATE CARE (DSN LED in the COMMUNITY)

ACUTE CONSULTANT LED

Prevention type 2

Heart disease/stroke##

Screening

Self-management information packs (1 group's idea that these should be provided for all patients)

Structured Patient education

Screening

Diagnosis type 2 adult

Initial management type 2

Continuing care type 1

Continuing care type 2

Regular surveillance adults

Erectile dysfunction

Foot issues (surveillance)

Proteinuria

Treatment change e.g. insulin

Institutional care (moving to 3 as clinically appropriate)

Elderly/housebound (moving to 3 as clinically appropriate)

Diagnosis type 1 adult (3 groups)

Initial management type 1 adult (2)

Psychological support (2)

Eye problems (1)

Initial management children and young people (moving to 4 as clinically appropriate)

Foot issues

Severe hypos (moving to 4 as clinically appropriate)

Diagnosis type 1 adult (1 group)

Initial management type 1 adult (2)

Psychological support (2)

Eye problems (1)

Diagnosis type 1 children and young people

Regular surveillance children and young people

Pregnancy - women with diabetes

Pregnancy - gestational

Ketoacidosis

Non-diabetes admission

Diagnosis type 1 adult (1 group)

Initial management type 1 adult (1)

Eye problems (2 groups

Source: Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The work of O'Reilly (2005) entitled: "Managing the Care of Patients with Diabetes in the Home Care Setting" published in the journal of Diabetes Spectrum states that patients "are released from hospitals and rehabilitation centers earlier in the continuum of care than ever before. Individuals with diabetes, either as a primary diagnosis or a comorbid condition, are no exception to this trend. This, combined with an end to the fee-for-service payment structure, has challenged home care clinicians to find effective ways of transitioning these patients from an acute episode of illness to a return to the community. Recognizing the impact of diabetes as an independent risk factor is key to achieving favorable health outcomes." (O'Reilly, 2005)

The work of Paul Straley (2007) entitled: "Diabetes: Adherence to Preventative Care" states of diabetes that in the U.S. The risk for developing Type 1 diabetes is higher than almost all other chronic illnesses of childhood" However, diabetes is manageable "if the individual is committed to monitoring blood glucose levels and practicing lifestyle modifications." (Straley, 2008) Straley's report addresses diabetes care among adolescents in the United States and relates that being diagnosed with diabetes is the trigger of a plethora of stressor for individuals who are in their teenage years. Identified as the best nursing practice for promotion of successful diabetes care in adolescent Type 1 diabetes is stated to be achievable through management of "...psychosocial risks and adhering to preventive care." (2008) Nursing strategies are identified as including:

1) Therapeutic communication;

2) Providing education; and 3) Promoting self-efficacy. (Straley, 2007)

This report highlights the role of the nurse and the nursing strategy in diabetes care and particularly in regards to the continuum of care of diabetes. It is stated that education is "an essential part of the third nursing strategy, promoting self-efficacy, and is supported by a collaborative multidisciplinary team." (Straley, 2007) Nurses assist patients with autonomy reinforcement and initiates choices and collaboration in establishment of a diabetes self-care plan. Straley reports that 'The Nurse Case Managed Integrated Care Model' was introduced by the American Diabetes Association in 1997 with the purpose of providing "a continuum of care through a variety of multidisciplinary teams to educate families and provide self-efficacy in managed care of adolescents' diabetes." (2007) Straley notes the work of Caravalho & Saylor (2000) who stated that "Increased self-efficacy is an integral part of an empowerment education program." (2007) Also reported was that self-efficacy "...was associated with better metabolic control." (Straley, 2007) Indentified as 'Barriers to Successful Nursing Interventions' by Straley are the following:

The patient has a lack of financial resources or insufficient insurance;

Nurses are burdened with limited time and resources to build a positive therapeutic relationship;

Because of high medical costs there is a lack of follow-up and increased non-compliance;

Nurses are unable to provide consistency of care and develop intra-personal relationships that are indicative to building a sense of trust

The lack of follow up can make it difficult for the nurse to assess and evaluate knowledge deficits as it relates to adolescents' diabetes and complications related to their illness. T

The limited ability to assess individual's specific needs can lead to slowed response to providing community resources and can lead to further secondary complications. (Straley, 2007)

SUMMARY & CONCLUSIONS

The Centers for Disease Control and Prevention have failed to properly address the Continuum of Care for Diabetes however,…