Examples Of Service Models For Diabetes

SERVICE MODELS FOR CONSULTATION

KEEPING IN TOUCH: THE SYSTEMATIC IDENTIFICATION AND FOLLOW-UP OF PEOPLE WITH DIABETES

Objective
To ensure that all people with diabetes, including those living in residential or custodial settings, are identified in general practice clinical information systems and are receiving regular care.

Description
Systematic identification of all people with diagnosed diabetes on general practice information systems – virtual practice-based diabetes registers.
Systematic documentation of key information on the care and support provided to people with diabetes:
• date of review
• surveillance undertaken, eg for cardiovascular risk factors and long-term complications
• results of any tests undertaken
• care provided

Systematic approaches for ensuring that people with diabetes receive the care agreed in their care plans:
• invitation and/or reminder system to people with diabetes to attend for their annual review
• systematic identification of those people with diabetes who have not had an annual review so that they can be followed up and reminded that their annual review is overdue
• outreach to and assertive follow-up of non-attenders and exploration about how they would like their diabetes care to be organised in future.
Benefits
• regular review of metabolic control
• regular surveillance for, and management of, any cardiovascular risk factors
• regular surveillance for the long-term complications of diabetes so that these can be detected and treated at an earlier stage
• higher proportion of people with diabetes receiving appropriate care
• better health outcomes.

ONE-STOP DIABETES SERVICES

Objective
To improve the quality of diabetes care provided and to minimise the burden and inconvenience of care for people with diabetes.

At presentation, all adults with newly diagnosed diabetes should be assessed to determine whether they need to be referred to a specialist diabetes service.

4. The following people should be referred:

• Adults who are clearly unwell, or who have ketones in their urine, or who have a blood glucose level >25.0 mmol/l, should be referred urgently by telephone to a specialist diabetes team (or by fax/email where fax/email referral systems are in place) for admission to hospital for initiation of insulin therapy. Those who present with diabetic ketoacidosis (DKA) or diabetic hyperosmolar non-ketotic syndrome (HONK) will require immediate treatment in hospital to correct these abnormal metabolic states.
• Young adults (aged under 30 years) should also be referred to a specialist diabetes team. The majority will require insulin therapy, the initiation of which can usually be undertaken on an out-patient basis.

5. Those that are found to have diabetes during an admission to hospital for another reason
(e.g during an admission for a heart attack) should be referred during the admission to the diabetes team for initial management of their diabetes. Liaison with, and/or referral to, the diabetes team should occur within 24 hours. For many people, it will be appropriate for the continuing management of their diabetes to be provided within primary