Download Diabetes Service Coordination

Diabetes Service
Coordination Program
Diabetes – Connecting the team
together
29 May 13
WARNING: Aboriginal and Torres Strait Islander people
should be aware that this presentation may contain images
or names of people who have since passed away. PNML
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Diabetes Service Coordination
Program - Staff
Senior Program Manager – Rangi Pouwhare
[email protected]
9201 0044
Program Officer – Leisha Aberle
[email protected]
9201 0044
Diabetes Service
Coordination Program
Program aims to:
1. Enhance communication between primary health
care providers;
2. Increase consumer and health professional
knowledge of the local services and programs
available; and
3. Build the capacity of primary health care
providers to deliver multidisciplinary care.
Target Group
Primary
 General Practitioners
 Service Providers
 Specialist services
Secondary
 Individuals with pre-existing diabetes Type 1 or 2 who
are commencing new treatment regimes or having
difficulty gaining glycaemic control.
PNML Diabetes Programs
 Diabetes Service Coordination Program
 Multidisciplinary Diabetes Program
 Live Well Program
Multidisciplinary Diabetes Program
 At risk of / diagnosed with diabetes (Type 1 or 2)
 GP referral
 Free access to:
 Diabetes Educators
 Accredited Practising Dietitian
 Accredited Pharmacist
 Choice of venues:
 Osborne Park / Mirrabooka / Joondalup
Multidisciplinary Diabetes Program
 Improve blood pressure, cholesterol and blood
glucose levels
 Increase motivation with practical ideas
 Improve confidence and attitude to positive healthy
lifestyle changes
 Follow up consultations with DE and Dietitian
 Scheduled 3 and 12 months review appointments
 One to one appointment or as a group review.
Live Well Program
 Self management program for people living with a
long term medical condition
 Peer supported
 Free to join
 No referral required
 6 week course 2.5 hour weekly sessions led by 2
trained group leaders
Live Well Program
 Anyone living with a long-term condition and/or
carers, partners or families
 Workshop covers:
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Symptom relief and management
Safe use of medications
Effective communication
Goal setting and problem solving
Relaxation
Pain and fatigue management
Building better relationships
Improve partnership with GP and health providers
Dealing with emotions
Planning for the future
Diabetes
346 million
— Estimated number of people worldwide
with diabetes
According to the International Diabetes
Federation, the number of people with
diabetes will double by 2030, and half of
those currently living with the disease
remain undiagnosed, and are unaware of
their condition. Each year, 4.8 million die of
diabetes, half of them under age 60. [via
Reuters 2013]
What’s going on here?
4% of Australians have diabetes. That's around 898,000
people. This rate has risen from 1.5% in 1989.
222,544 people began using insulin to treat their diabetes
(2000-2009).
1 in 20 pregnancies are affected by diabetes. That was
44,000 women between 2005 and 2007.
Australian Institute of Health and Welfare 2013
But wait …. There’s more
3 to 1 The proportion of people with diabetes in the
Indigenous population compared to the proportion of
people with diabetes in the non-Indigenous
population.
Over half of adults are overweight or obese, which
puts them at greater risk for diabetes.
3 in 5 of people with diabetes also have
cardiovascular disease.
Australian Institute of Health and Welfare 2013
What they found out …..
 Most T2D are managed in the community.
 As T2D and it’s complications is largely preventable we
have to invest more in diabetes awareness and prevention.
 We need systematic management BUT there is
- Lack of co-ordination
- Lack of communication
between the various providers
The Model of Care Objectives
 Prevent and/or delay the onset of diabetes.
 Prevent and slow the progression of diabetic
complications.
 Improve the quality of life of diabetics.
 Reduce inequities in diabetes service provision.
Model of Care – Key Priorities
 Enhance community-wide and targeted healthy
lifestyle to prevent diabetes and increase awareness
of health impact of diabetes.
 Improve coordination of community based diabetes
prevention and management services.
 Reconfigure specialist services for optimal
effectiveness.
 Ensure ready access to protocols, guidelines,
decision aids and service directories.
Model of Care – Key Priorities
 Develop systems to improve communication and
data sharing.
 Increase investment in workforce training and
development.
 Ensure availability of new technology for diabetes.
 Foster and support basic and clinical research in
diabetes
Know your team
Diabetes Support
Group
General
Practitioner
Pharmacists
Specialists:
Endocrinologist,
Cardiologists,
Ophthalmologists,
Renal Physicians
Nurse
Practitioners
Diabetes
Educators
Practice Nurse
Community
Diabetes Care
Programmes
Insulin Educator
Optometrists
Podiatrists
Dietitians
Exercise
Physiologists
PNML MULTIDISCIPLINARY
DIABETES PROGRAM
The program brings together a Diabetes Educator,
Dietitian and Pharmacist to support GPs in diabetes
care.
The session provides clients with skills and knowledge
on topics such as self blood glucose monitoring and
HbA1c, healthy eating, active lifestyle changes,
medication and communicating with your Health Care
Team.
The Diabetes Educator and Dietitian offer follow up
consultations for clients as required, including the
scheduled 3 and 12 months review appointments which
are undertaken on a one to one appointment or as a
group review.
PNML MULTIDISCIPLINARY
DIABETES PROGRAM
Referrals are welcome for people over the age of 18
who require education and further specialist services
to manage Type 1 and Type 2 diabetes; Latent
Autoimmune Diabetes in Adults (LADA [1.5]); Patients
who are "at risk" of developing type 2 diabetes and/or
cardiovascular disease (CVD); and/or are experiencing
impaired glucose tolerance (IGT) or impaired fasting
glucose (IFG) who have type 1 diabetes, as well as
people who have had type 2 or have Latent
Autoimmune Diabetes in Adults (LADA [1.5]).
PNML MULTIDISCIPLINARY
DIABETES PROGRAM
Diabetes Education Resources
To access Diabetes Self Management Education Resources
including referral forms, follow the link to the Resource
Centre on our website.
Click the link to download the MDP GP Referral Form.
To download a copy of the Program flyer, click here
Click here to access the PNML Diabetes Risk Assesment
Tool.
Identify undiagnosed diabetes
and prediabetes
Consider testing plasma glucose if the person is:
* Age 45 or older
* An overweight adult with another risk factor
Risk factors for type 2 diabetes
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Family history: 1st degree relative with diabetes
Race/Ethnicity: Aboriginal, TSI, Pacific Islander
Gestational diabetes
Hypertension: BP >140/90
Abnormal lipid levels
IFG or IGT
Signs of insulin resistance: PCOS or acanthosis nigrans
History of vascular disease
Inactive lifestyle
Prevent or delay the onset of T2D
and it’s complications
 Lifestyle modification
 Medications and surgery
Lifestyle modification
 Nutrition therapy
 Physical therapy
 Behaviour therapy
 Weight loss
 Follow-up and referral
Ongoing self-management education
 Self-management training
 Education and ongoing support process
 Communication strategies
 Financial resources
 Recognition of quality of care
Self-care behaviours
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Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Reducing risks
Healthy coping
ABC treatment goals for T2D
A1c
Blood pressure
Cholesterol
The Model of Care Objectives
How are we doing?
 Prevent and delay the onset of diabetes.
 Prevent and slow the progression of diabetic
complications.
 Improve the quality of life of diabetics.
 Reduce inequities in diabetes service provision.
Identifying Gaps Through Case Studies
What type?
Type 1 diabetes
β-cell destruction
Type 2 diabetes
Progressive insulin secretory defect
Other specific types of diabetes
Genetic defects in β-cell function, insulin action
Diseases of the exocrine pancreas
Drug or chemical-induced
Gestational diabetes mellitus (GDM)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.
Case study – Sally
History
20 year old non-indigenous with
a 4 weeks urinary frequency.
Drinking a lot more to treat
assumed urine infection.
Weight loss 2.5Kg in 2 months.
Always careful about her weight.
Medication – OCP.
Due to go overseas in 1 month
so wants urine problem cleared.
Non-smoker
No FH of diabetes,
hypertension, CHD and
autoimmune diseases
Examination
Weight 62Kg [BMI = 21]
BP 126/80 PR = 80/min
Systems examination
normal
Case study - Sally
Fingerstick glucose 27.7mmol/l
Urine – glucose 3+, SG 1.010, ketones 2+
Sodium 132mmol/l – other electrolytes normal
FBC normal
 What would you do now?
 Can you access all the resource you
need?
 What about follow-up?
T1 or T2?
eMedicineHealth Medical Reference from Healthwise
Case study - Shane
History
54 year old caucasian
Non smoker Mod. alcohol
Raised FBGL [6.2mmol/l]
and HbA1c 6.2% found on
life insurance screen.
History of dyslipidaemia
Takes fish oil 1.5g a day
No FH of diabetes, heart
disease, hypertension and
autoimmune disease
Examination
Weight 78Kg [BMI 26.2]
BP 142/82 PR 88/min
GTT 2h hour glucose =
12.2mmol/l
TC = 5.6 mmol/l, TG = 3.1
mmol/l, HDL = 0.7 mmol/l
LFT ALT 76 U/L otherwise
normal
FBC, U&E&Cr, LFT, TSH
and urinalysis normal
What would do you think?
Latent autoimmune diabetes in
adults LADA
 Latent Autoimmune Diabetes in Adults (LADA) is a
form of autoimmune (type 1 diabetes) which is
diagnosed in individuals who are older than the
usual age of onset of type 1 diabetes.
 Alternate terms that have been used for "LADA"
include Late-onset Autoimmune Diabetes of
Adulthood, "Slow Onset Type 1" diabetes, and
sometimes also "Type 1.5
 Often, patients with LADA are mistakenly thought
to have type 2 diabetes, based on their age at the
time of diagnosis.
LADA
Case study - Darren
You receive a call from Darren’s next door neighbour
because he has been checking Darren’s blood sugars
and has found them to be high.
Darren has promised to go to see the doctor but he
has been unable to get hold of the friend who usually
takes him as he has been in hospital.
You check Darren’s medical record.
Case study - Darren
 54 year old aboriginal
living alone in
homeswest
accommodation.
 Right hemiplegia
following stroke. Uses
electric wheelchair.
 Other medical
conditions: obesity,
hypertension,
dyslipidaemia, cirrhosis.
 PH of pancreatitis and
bowel ischaemia.
Medications:
Metformin 2g/day
Sitagliptin 100mg/day
Ramipril 10mg/day
Atorvastatin 40mg/day
Cholecalciferol 25mcg/day
HbA1c =
11.2%
Case study: Wally
 You are asked to see a 15 year old Aboriginal boy, Wally,
who has been unwell for 2 weeks.
 There is concern the child has a urine infection as he is
passing urine frequently.
 Urine test showed glucose 4+, no ketones, and no
evidence of infection.
 RBGL = 12.8mmol/L
Examination
 Wt = 76Kg Ht = 165cm BMI = 28
 BP = 135/85 PR = 72/min Reg
 Both tympanic membranes scarred with possible
middle ear effusions
 Acanthosis nigrans affecting neck and axillae
 The remainder of the examination was normal
Discussion
Is Wally overweight or obese?
Does he have hypertension?
What is the significance of acanthosis nigrans?
How would you proceed?
Laboratory Investigations
FBGL = 8.1 mmol/L
Chol = 6.0 mml/L, TG = 3.0 mmol/L,
HDL = 0.7 mmol/l
LFT – marginally raised Alk Phos and
GGT
U&E&Cr, FBE, TFT – all normal
ECG normal
Discussion
Does Wally have diabetes?
Is it Type 1 or Type 2 Diabetes?
How would you proceed?
Criteria for diagnosing T2DM
in indigenous children and
adolescents
Random laboratory-measured venous BGL
≥ 11.1 mmol/L and symptoms of both polyuria and
polydipsia (particularly when these symptoms are
nocturnal)
or
Fasting laboratory-measured venous BGL ≥ 7.0mmol/L
or
Random laboratory-measured plasma BGL
≥ 11.1mmol/L on at least two separate occasions
Discussion
What treatment would you initiate?
How would you monitor treatment?
When would you screen for
complications?
When would you refer to a
specialist?
What are the challenges?
Treatment
Lifestyle modification program
Metformin
Insulin?
What are your challenges?
Challenges in health care delivery
Health seeking
Limited contact with health services, relating to:
perceived “health” despite significant morbidity
Clinics not being adolescent friendly
Demographic
Remoteness, limited telecommunication facilities, poor school attendance, poor
socioeconomic health, no fixed address
Sociocultural
Potential shame of diagnosis
Acceptance of poor health status (by individuals and the health system)
Many competing health needs
Challenges in health care delivery
Physical resources
Limited resources for lifestyle modification
Food insecurity
Clinic resources — physical
Inaccessibility of essential resources (such as glycated haemoglobin testing) in
many remote clinics
Misplaced or broken blood glucose meters
Lack of infrastructure to start, maintain or safely store insulin
Clinic resources — staffing
Understaffing and high staff turnover
Overburdened clinic staff due to acute crisis care
Limited and poorly coordinated visiting health services
Summary
 Higher burden of T2D compared to non-indigenous
children
 Most asymptomatic at diagnosis
 Increased barriers to management, especially in rural
and remote settings
 Individualise management plans
 Target screening programs
 Promote preventive strategies
Communication and attitude
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Doctors and nurses need to show they do care and should
not get angry if they are upset with us.
Do not be patronising.
Take time to get to know each of us as a person, we are all
individuals that happen to have diabetes.
Young people need positive reinforcement, we do not
respond well to just criticism.
Offer us advice and ask what we want to do. Give us a
chance to voice our opinions.
Please don't see us as just 'the patient', dare to see us as
part of the team.
Be sensitive to our needs and our problems in managing
diabetes.
Advice and information
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You need to tell young people that they are in control of their
diabetes.
You will make young people understand better if you are
friendly to them about why they need to do their blood
glucose tests and their insulin injections.
Educate and inform the young person about diabetes. The
more they understand, the better they will feel about
managing it.
Give information first and then ask if we have any questions.
Many of us do not like to ask questions.
Provide us with a contact number for an out of clinic hours.
Web Service Directory
 Interactive search function allowing consumers and health
providers to navigate information on local services and
programs
 www.pnml.com.au
 Information linked to National Health Service Directory,
State and national peak bodies and organisations
 Scoping of all diabetes services in PNML region
 Written consent obtained
Web Service Directory
 Stage 1:
 GPs
 Podiatrists
 Pharmacists
 Credentialed Diabetes Educators
 Stage 2:
 Dietitians
 Diabetes Educators
 Physiotherapists
 Optometrists
 Ophthamologists
 Endocrinologists
 Community Programs
 Tertiary services
Web Service Directory
 General Practitioners
 Pharmacists
 Podiatrists
 Credentialed Diabetes Educators / DE’s
 Dietitians
 Physiotherapists
 Optometrists
 Ophthamologists
 Endocrinologists
 Tertiary services
 Community Programs
(98)
(105)
(35)
(11)
(33)
(52)
(31)
(10)
(1)
(6)
(16)
Web Service Directory
Diabetes Service Directory
Want to be added in the directory?
Send an email to:
[email protected]