14 HealtH Matters
DIaBEtIC CarE
INTEgrATED DIAbETES
cArE PoINTS THE wAy
ForwArD
co-ordinating the actions of trained gPs and secondary care specialists can provide improved care to a
substantial number of diabetic patients writes James conway, Assistant National Director with the HSE’s
Integrated Services Directorate and dr orlaith o’reilly, HSE Director of Public Health based in Kilkenny.
t
he most important chapter of care disease receive increased levels of
during the life of a person with diabetes specialist care. a selection and approval
is the adequate prevention of complications process for patient entry into the system
through achieving increasingly strict of integrated care and an annual system
levels of glucose control, control of blood of review for continuation with input from
pressure, control of cholesterol and other both the participating specialist and general
factors in diabetes. practitioner in accordance with an agreed
Diabetes patients should not have to care plan are in place.
wait until complications have occurred Underpinning this spectrum of clinical
in order to be referred for specialist care. care is a complementary programme of
specialist referral and input should occur patient support. Many patients become
at diagnosis so that the diabetes patient is the main manager of their own chronic
provided with adequate care as soon as the disease and it is primarily their success in
condition is identified. controlling the disease by lifestyle choices
A model for Integrated Diabetes Care, and/or medication which determines the
developed by the Hse’s Diabetes expert severity and control of the disease and
advisory Group, points the way forward in subsequent progression/management
the management of diabetes patients. experience. Patient support programmes
Under the joint chairs of Dr Graham advocate patient self care. the
roberts, Consultant endocrinologist, programmes are built around the patient
Waterford regional Hospital and Dr Damien and tailored to his/her particular level of
Doyle, GP, Carnew, Co Wicklow a sub complexity and take account of potential
group was convened to develop the model risk factors.
of care. the development of this model of
Under the model, there is a spectrum of Community and voluntary services are integrated diabetes care was in the
services available to the patient, ranging needed to provide support to patients context of major transformation in the
from primary prevention services, self in their own communities. secondary health services with the reorientation
care, and primary care services, including care services are further developed to towards care in the appropriate setting
scheduled GP visits to underpin good allow for specialist clinics, integrated care which was predominantly primary care.
practice models of care for the patient’s systems and appropriate services for this reorientation also reflected the core
specific illnesses. In addition, the GP draws patients presenting with complex health concepts of chronic disease management.
on the services of the rest of the primary issues. Patient care plans are developed the new structural unit to enable
care team and the primary care network on an integrated care basis between the delivery of the integrated model
to focus on the particular clinical or social participating clinicians to identified patients of care for Diabetes as identified in the
problems. Other services such as screening needs. Patients with stabilised disease first report of the Diabetes eaG was
and community intervention team services are managed in programmes reflecting Managed Clinical Networks which would
can be accessed by the primary care team this model of care, largely in the primary ensure that care is planned, structured,
as appropriate. care setting. Patients with more complex shared and integrated.
HM Iss6.1 p1-70.indd 14 12/03/2010 15:13:22
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