Abstract
Background: Around 10,000 adults who live in the area referred to as ‘Midtklyngen’ in the Central Denmark Region are diagnosed with type 2 diabetes. ‘Midtklyngen’ consists of three municipalities served by two out-patient diabetes clinics and 150 general practitioners. The burden of type 2 diabetes varies throughout the life of a patient, and the social inequalities associated with incidence, prevalence and risk of complications are well described. Furthermore, it is evident that cross-sectoral collaboration in connection with type 2 diabetes often causes fragmented care delivery. Thus, it is of great value to develop a model for collaboration across sectors; a model that promotes and supports the individual patient’s chances of living a meaningful life, minimising the clinical consequences of type 2 diabetes through high-quality treatment and care.
Purpose: The purpose of the present study was to develop a collaboration model, founded on the principle of joint population responsibility across the healthcare disciplines in Denmark, which are all involved in the cross-sectoral treatment of patients suffering from type 2 diabetes.
Methods: Setting: The study was conducted in the three municipalities of Silkeborg, Skive and Viborg, often referred to as ‘Midtklyngen’, in the Central Denmark Region, and was performed in the hospitals, municipal healthcare centres and general practices in these three municipalities. Baseline was 1 January 2020 and the study will be completed by the end of March 2022.
Population: All adults living in the municipalities of Silkeborg, Skive and Viborg who were diagnosed with type 2 diabetes.
Design: The study was designed as a quality and improvement project.
Data sources: Both quantitative population data and qualitative data which were collected through field studies and interviews were applied in the study.
Interventions: The quantitative and qualitative data gave rise to four sub-projects. One sub-project was designed as a series of webinars, produced in collaboration with an endocrinologist from the hospital sector and offered to general practice as an educational tool to be used in the care of patients with type 2 diabetes. Two other interventions aimed at developing the collaboration between the GP clinics and the healthcare centres in the municipalities, with particular focus on patient participation and satisfaction, and also at maintaining healthier habits in the long-term secondary prevention of type 2 diabetes. Finally, the last intervention was an interview study where patients with type 2 diabetes were interviewed and asked about their attitudes towards collaboration between general practice, municipalities and hospital. The last intervention functioned as back ground material for the final collaboration model.
Outcomes: Based on the four sub-projects, a cross-sectoral collaboration model for type 2 diabetes will be developed in late 2021.
Results: The final work on the interventions and the cross-sectoral collaboration model for type 2 diabetes will be presented at the International Conference on Integrated Care, which will take place in Odense on 23–25 May 2022.