Diabetes care pathway Prepared in collaboration with Bupa Commissioning

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Diabetes care pathwayPrepared in collaboration
with Bupa Commissioning
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Map of pathways click on any map to start
Generic pathway
Adolescent care pathway
Mental health and type 2diabetes
Patients in care homes or housebound
Initiation ongoing care
Initiation
Initiation
Initiation (1)
Ongoing care
Initiation (2) annual check-up
Ongoing care
Common components
Common tests for adolescents
Medications (2)
Common tests for all patients
Medications (1)
Blood pressure control
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Preconception care for women with diabetes
General Notes
Notes
Notes
Notes
4
Clinical review notes
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Clinical review notes

• 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.
• 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.

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Clinical review notes

• Informed consent on the use of metformin in women
  with diabetes planning pregnancy should be
  obtained and documented.
• Offer monthly measurement of HbA1c.
• Offer a meter for self-monitoring of blood
  glucose.
• Offer type 1 patients ketone testing strips to
  test for ketonuria or ketonaemia if they become
  hyperglycaemic or unwell.

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General notes

• Lessons from current, best and emerging practice
  models
• 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.
• 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.
• 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.

• Moos MK, Bangdiwala SI, Meibohm AR, Cefalo RC.
  The impact of a preconceptional health promotion
  program on
• intendedness of pregnancy. Am J Perinatol
  199613103--8.
• 2 National Committee for Quality Assurance.
  Checkups after delivery improving program
  participation. Washington, DC National Committee
  for Quality Assurance 2002.

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Generic diabetes care pathway Detection and
initial treatment
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Generic diabetes care pathway Ongoing management
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Adolescents Diagnosis, initial treatment and
management
General Notes
Notes
Notes
Notes
Notes
Notes
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Clinical review notes
12
Clinical review notes
13
Clinical review notes

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.

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Clinical review notes (1)

• Medical history
• Symptoms and results of laboratory tests
  related to the diagnosis of diabetes
• Recent or current infections or illnesses
• Previous growth records, including growth
  chart, and pubertal development
• Family history of diabetes, diabetes
  complications, and other endocrine disorders
• Current or recent use of medications that may
  affect blood glucose levels
• History and treatment of other conditions,
  including endocrine and eating disorders, and
  diseases known to cause secondary diabetes (e.g.
  cystic fibrosis)
• Use of tobacco, alcohol and/or recreational
  drugs
• Physical activity and exercise
• Contraception and sexual activity (if
  applicable)
• Risk factors for atherosclerosis smoking,
  hypertension, obesity, dyslipidemia and family
  history
• Prior A1C records
• Details of previous treatment programs, including
  nutrition and diabetes self-management education,
  attitudes and health beliefs
• Results of past testing for chronic diabetes
  complications, including ophthalmologic and
  microalbumin screening
• Frequency, severity, and cause of acute
  complications such as ketoacidosis and
  hypoglycemia
• Current treatment, including medications, meal
  plan, results of glucose monitoring and patients
  use of data
• If signs and symptoms are suggestive of type 2
  diabetes
• Evidence of islet autoimmunity (e.g., islet cell
  ICA 512 or IA-2, GAD, and insulin
  autoantibodies)
• Evidence of ß-cell secretory capacity (e.g.
  C-peptide levels) after 1 year, if diagnosis is
  in doubt

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Clinical review notes (2)

• Referrals and screening
• Yearly ophthalmologic evaluation
• Medical nutrition therapy (by a registered
  dietician)
• 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
• Diabetes nurse educator
• 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
• Behavioural specialist
• Depression screening annually for children 10
  years of age, with referral as indicated
• 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.
• 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.
• The first ophthalmologic examination should be
  obtained once the child is 10 years of age and
  has had diabetes for 35 years. After the initial
  examination, annual routine follow-up is
  generally recommended.
• Annual foot exams should begin at puberty.

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Clinical review notes

• 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.
• It is essential that substantial educational
  material (necessary for basic management, often
  referred to as "survival skills") be conveyed to
  a family of a child with type 1 diabetes
  immediately after the initial diagnosis.
• Studies suggest that to be effective, educational
  interventions need to be ongoing.
• Frequent telephone contact, and both in-person
  care and telephone availability have been
  demonstrated to improve A1C.

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Clinical review notes

• 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.
• 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 childs diabetes
  management) was significantly superior to both SC
  and ES in effects on A1C10.
• 10 Randomized Trial of Behavioral Family Systems
  Therapy for Diabetes. Diabetes Care 30555-560,
  2007

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General notes

• Learnings from current, best and emerging
  practice models
• 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.
• Targets of education need to be adjusted to the
  age and developmental stage of the patient with
  diabetes and must include the parent or
  caregiver1.
• The goal should be a gradual transition toward
  independence in management through adolescence.
  Adult supervision remains important throughout
  the transition.
• Many of the demands of self-care for diabetes
  interfere with the adolescents 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.
• Adolescents whose parents exercise supervision
  in the management of diabetes have better
  metabolic control2.
• 1 Ingersoll GM, Orr DP, Herrold AJ, Golden
  MP Cognitive maturity and self-management among
  adolescents with insulin-dependent diabetes
  mellitus. J Pediatr 108620623, 1986
• 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 21909914, 1998

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Mental health and type 2 diabetes
Notes
General Notes
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General notes

• 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.
• 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.
• Mental health stability before commencing
  long-term disease management as psychiatric
  illness poses significant barriers to care.

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Clinical review notes

• Psychological interventions have shown some
  positive impact on glycaemic control. Depression
  seems to be particularly improved following these
  interventions.
• 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.
  
• 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.
• Health and clinical psychologists with expertise
  in diabetes can support the multidisciplinary
  team and improve service.
• Model of care Diabetes Treatment Among VA
  Patients With Co-morbid Serious Mental Illness.

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Mental health and type 2 diabetes
Notes
23
Clinical review notes

• Partnership between patient and their clinical
  and support team can improve outcomes.
• Mental health, social services and case
  management professionals may enhance compliance
  and follow up.
• Patients whose difficulties in accepting their
  diagnosis compromise their treatment may benefit
  from cognitive behavioural therapy.
• Psychological support will help people with
  diabetes identify barriers to managing their
  diabetes effectively.
• Emotional and psychological support should be
  integral to diabetes care package.
• Models of care
• Overview of Peer Support Models to Improve
  Diabetes Self-Management and Clinical Outcomes
  http//spectrum.diabetesjournals.org/cgi/content/f
  ull/20/4/214
• Psychological needs must be properly assessed in
  partnership with the individual.
• The target for HbA1c should take into account
  psychosocial circumstance.
• Mental health counsellors should be consulted
  where applicable. Appropriate counsellor should
  be considered if psychological factors prevent
  full adherence to medication regimen.
• 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.

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Care homes / housebound
Notes
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Clinical review notes

• Guidelines advocate fasting glucose for the
  routine diagnosis of diabetes, but failure to
  fast could cause false-positive results.
• 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.
• 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.
• 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
  diabetes3.
• 3 Asprey, T. et al., Diabetes in British Nursing
  and Residential Homes A pragmatic screening
  study.

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Care homes / housebound
Notes
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Clinical review notes (1)

• Skill, competency and team requirements
• 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.
• Models of care
• Sinclair AJ, Turnbull CJ, Croxson SCM. Document
  of care for older people with diabetes. Clinical
  guidelines. Postgrad Med J 1996 72334-338.
• Norman A, French M, Hyam V, Hicks D. Development
  and audit of a home clinic service. J Diabetes
  Nurs 1998 2(2) 51-54.
• 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
• 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).

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Clinical review notes (2)

• Models of care
• Sinclair AJ, Turnbull CJ, Croxson SCM. Document
  of care for older people with diabetes. Clinical
  guidelines. Postgrad Med J 1996 72334-338.
• Norman A, French M, Hyam V, Hicks D. Development
  and audit of a home clinic service. J Diabetes
  Nurse 1998 2(2) 51-54
• 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
• Identify and liaise with a community dietitian to
  support the care team especially with Diabetics
  on Insulin therapy.
• 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.
• Ensure access to transport facilities to enable
  access to specialist treatment.
• For each patient identify a designated doctor
  (usually the GP) who will accept overall medical
  responsibility
• 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.

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Common set of tests for all patients over 18
undergoing diabetes management
30
Common set of tests for adolescents undergoing
diabetes management
Notes
Notes
Notes
Notes
Notes
31
Clinical review notes

• Symptoms and results of laboratory tests related
  to the diagnosis of diabetes.
• Recent or current infections or illnesses.
• Previous growth records, including growth chart
  and pubertal development.
• Family history of diabetes, diabetes
  complications, and other endocrine disorders.
• Current or recent use of medications that may
  affect blood glucose levels.
• History and treatment of other conditions,
  including endocrine and eating disorders, and
  diseases known to cause secondary diabetes (e.g.
  cystic fibrosis).
• Use of tobacco, alcohol and/or recreational
  drugs.
• Physical activity and exercise.
• Contraception and sexual activity (if
  applicable).
• Risk factors for atherosclerosis smoking,
  hypertension, obesity, dyslipidemia, and family
  history
• Prior A1C records
• Details of previous treatment programs, including
  nutrition and diabetes self- management
  education, attitudes, and health beliefs
• Results of past testing for chronic diabetes
  complications, including ophthalmologic
  examination and microalbumin screening.
• Frequency, severity and cause of acute
  complications such as ketoacidosis and
  hypoglycemia.

32
Clinical review notes

• 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.

33
Clinical review notes

• 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.

34
Clinical review notes

• 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.

35
Clinical review notes

• The first ophthalmologic examination should be
  obtained once the child is 10 years of age and
  has had diabetes for 35 years. After the initial
  examination, annual routine follow-up is
  generally recommended.

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Generic diabetes care pathway Blood pressure
management
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Generic diabetes care pathway Medications (1)
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Generic diabetes care pathway Medications (2)