Challenges to the implementation
of a national model of integrated
care for diabetes in Ireland
Dr Sheena McHugh, Research Fellow
Department of Epidemiology & Public Health, University College Cork
Integrated Diabetes Care
• National and international emphasis on
integrated care
• Organisation of disease management within
settings and the coordination of care
between settings (1-3)
• Diabetes “exemplifies the complex
nature of chronic disease” (4)
Diabetes Care in Ireland
2011: Quality of Care in Existing Initiatives (8)
• 10 existing diabetes initiatives
2010: qualitative study (6):
• Hospital specialist service is ‘an essential support’
• Lack of coordination leads to uncertainty about
boundaries of responsibility, ‘in the meantime’
care, avoidable duplication
Structured care characterised
by regular recall, review &
nurse coordination
2010: Survey of hospitals in Ireland (7):
• Endocrinology-led services had more developed subspecialty clinics and
access to specialist allied health professionals
• But waiting times were longer and discharge rates to primary care were
lower than for non-specialty led services.
2008: National GP survey (5):
• management largely unstructured: 46% using a register, 55% using
guidelines and 50% engaged in routine recall.
• <10% had a formal shared protocol or had ever had a joint meeting
with the hospital team
‘Ad hoc opportunistic management’
5.
6.
7.
8.
Mc Hugh, S., J. O'Keeffe, A. Fitzpatrick, A. de Siún, M. O'Mullane, I. Perry and C. Bradley (2009). "Diabetes care in Ireland: A survey of general practitioners." Prim Care Diabetes 3(4): 225-231.
Mc Hugh, S., M. O'Mullane, I. J. Perry and C. Bradley (2013). "Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice." BMJ Open 3(8).
O'Donnell, M., A. de Siún, M. O'Mullane, D. Smith, C. Bradley, F. Finucane and S. Dinneen (2013). "Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led
services." BMC health services research 13(1): 493.
Mc Hugh, S., P. Marsden, C. Brennan, K. Murphy, C. Croarkin, J. Moran, V. Harkins and I. J. Perry (2011). "Counting on commitment; the quality of primary care-led diabetes management in a system with minimal
incentives." BMC Health Serv Res 11(1): 384-393.
Existing Initiatives
• 10 existing diabetes initiatives
• Range from shared care to
structured care led by GPs to
hospital-led models
• Different quality improvement
strategies including patient
registration, audit & feedback,
education, protocols, remuneration,
referral pathways.
National Model of Integrated Care
• Defined patient pathways
National
Model of
Integrated
Care
Model of care
for children
and young
adults with
T1DM
Retinopathy
Screening
Programme
Structured
Patient
Education
Gestational
diabetes
guidelines
National
Foot-care
model
• Type 1 diabetes, genetic, diabetes in
pregnancy and other complex diabetes
managed in hospital centres.
• Uncomplicated Type 2 diabetes care in
primary care with ‘annual’ input from
hospital centres.
• Complicated Type 2 diabetes patients will
be managed by both primary and
secondary care.
• Remuneration
• Integrated Care Diabetes Nurse
Specialist (ICN)
• Facilitate integration between primary and
secondary care
• 80% community/20% hospital-based
Changing context of implementation
FEMPI Cuts
• National Model of Integrated
Care drafted but not released
GP Contract
dispute
ICGP
withdrawal
from Clinical
Care
Programmes
Aim
• To examine the implementation of the national model of
integrated care.
• To identify the barriers and enablers to the implementation.
Methods
Design
• Qualitative study with
national level
stakeholders involved
in programme
development
• Timeline:2010-present
Eligible
Participants
• Current and former
members of
National Working
Group.
• 19 participants (14
current + 5 former
members)
• Health care
professionals,
management,
patient advocacy
Method
• Semi-structured
interviews
• July 2014 - Jan 2015
• Documentary Analysis
• Interviews recorded,
transcribed &
analysed
Findings
‘Some Implementation on the Community
Diabetes Nursing side of integrated care’
• 2013: 17 Integrated Care Nurses employed
‘They were never intended to go in on their own,
they were intended to go in as part of an
integrated programme where GPs and practice
nurses were providing the routine care and they
go in as specialist help.’ (#6)
• Full model of care not resourced due to wider
dispute about GP contract:
Fig. Deployment of ICN posts & existing initiatives
‘the [political] will wasn’t there to do that [sort the
contract], but definitely when the GPs realised that
they weren’t going to get paid; what we were
actually going to be putting in was nurse support…
we couldn’t [progress]. (#15)
1. Varied uptake of ICN resources
It depends on what area they’re working in; what GPs are in there area (#11)
“some places
they’re wanted…
• Distance from hospitals & access
to specialist input
• Practices with large numbers
• Existing initiatives: ‘a program
for nurses to join in with’
…some places they’re
getting a blank wall”
(#8)
• In some areas, access to ICN limited
to practices already enrolled in preexisting initiative
• Lack of remuneration
Remuneration for widespread implementation
I can’t see how it can be resolved in a systematic way without a
contract. We’ve tried all the ‘goodwill’ options’. (#12)
2. Fidelity with intended model of care
Specialist
clinical input
Training &
education
Manage patient
pathway
(referral &
discharge)
Support GP/PN
management
‘Smooth
interface with
hospital’
Figure. Intended role of ICN as part of the National Model of Integrated Care
Pragmatic approach to implementation
In some cases its a case of how much they are allowed to do, whether
somebody will let you in the door or not, because they might not want to.
If they let you in its positive and it will probably lead to something else but
it varies from area to area in what way its being implemented.
Some nurses are very involved in education of healthcare
professionals and maybe the public. Others are straight into clinics
and there is just a huge amount of clinical work. (#18)
Adapting to pre-existing models of care
These pockets of excellence around the country are
using all slightly different models. Now they’re not a
thousand miles away but they’re not the National Model
of Care. And we haven’t had the opportunity or the
ability to standardise it because we weren’t paying for
it….
They’re probably having to adopt [or] adapt [to] the
locally-existing model of care as opposed to the
National Model of Care (#12)
3. ‘Integrated care is the big ticket item’
‘The foot-care strand, retinal screening, gestational diabetes, … the ICT section, clearly
research, structured group education, they all sort of dovetail into integrated care really.
(#18)
Table 1. Risk stratified pathway for management of diabetic foot disease
Cycle of Care
• Holders of medical cards and GP Visit
Cards who have Type 2 Diabetes.
• 2 visits to GP for a structured review
(annual review and follow up visit)
• review and recording of blood results,
medication review, assessment of blood
pressure, BMI, education, symptomatic
foot review, participation in the eye
screening programme and onward
referral if appropriate
• GPs will receive a €30 registration fee per
visit in the first year and €50 for each
consultation.
Facilitate implementation
• Increase engagement with ICN resources?
• Need for increased investment in integrated care nurse support
• Increase implementation fidelity?
• Potential for inequity in standard of care and outcomes among
non-GMS patients
Next phase of research
Phase 2
• Case studies:
• 4 regions
Aim
• To what extent to
have plans been
implemented,
adapted and accepted
at a local level?
• Impact of recent
changes
ESPRiT
Method
• Interviews with
health professionals &
patients
• Activity data from
ICN
• National Diabetes
Nurse Survey
Evidence to Support PRevention Implementation and Translation
Monitoring & evaluating implementation
• Fidelity data, quality assurance data,
and outcomes data with supportive
feedback mechanisms
• Built into routine practice
• Accessible at actionable levels
• Used to make decisions
• Health professionals collectively
discussed data on quality of care (8)
• Helped break down barriers between settings
• Established a self-supporting system to increase
quality
• Only integrate care structures that
include an integrated quality
management system are sufficient
• Ensure improvements in quality, access & cost
Acknowledgements
On behalf of:
• Professor Patricia Kearney
• Marsha Tracey- PhD student
• Fiona Riordan – PhD student
• Kate O’Neill- PhD student
In collaboration with the National Clinical Programme for
Diabetes
Contact:
https://www.ucc.ie/en/esprit/research/
Email: s.mchugh@ucc.ie
References
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2.
3.
4.
5.
6.
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Mc Hugh, S., J. O'Keeffe, A. Fitzpatrick, A. de Siún, M. O'Mullane, I. Perry and C. Bradley (2009). "Diabetes care in
Ireland: A survey of general practitioners." Prim Care Diabetes 3(4): 225-231.
Mc Hugh, S., M. O'Mullane, I. J. Perry and C. Bradley (2013). "Barriers to, and facilitators in, introducing integrated
diabetes care in Ireland: a qualitative study of views in general practice." BMJ Open 3(8).
O'Donnell, M., A. de Siún, M. O'Mullane, D. Smith, C. Bradley, F. Finucane and S. Dinneen (2013). "Differences in the
structure of outpatient diabetes care between endocrinologist-led and general physician-led services." BMC health services
research 13(1): 493.
Rothe, U., G. Müller, P. E. H. Schwarz, M. Seifert, H. Kunath, R. Koch, S. Bergmann, U. Julius, S. R. Bornstein, M.
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