Abstract
Acknowledging the role of inter-professional relationships within a chronic disease ambulatory hub – an integrated patient-centred approach to chronic disease prevention and management, close to the patient’s home.
Service users with Type 2 diabetes mellitus are seen by multidisciplinary team to manage their chronic disease, with focus on delivery of care within their local community. The aim of this is to save eyes, lives and limbs of those living with Type 2 diabetes (National Framework for the Integrated Prevention and Management of Chronic Disease in Ireland 2020-2025).
Case study: 68 year old man presented for routine assessment to community podiatry clinic within the chronic disease hub (CDH). Medical history included Type 2 diabetes mellitus, hypertension, peripheral arterial disease and aortic stenosis. Attends Podiatry for routine foot care every three months due to high risk of diabetic foot complications associated with Type 2 diabetes mellitus and peripheral arterial disease. During assessment diabetes control was discussed. Patient reported BSL of 20-25mmol in recent weeks. Reported GP stated he was ‘maxed out on oral treatment’ and referral sent to hospital endocrinologist for review.
Engagement initially involved the patient and podiatrist and as a result of holistic care onward engagement and referrals were arranged to other key members of the CDH team including dietician, diabetes advanced nurse practitioner (ANP) and consultant endocrinologist.
Urgent referral sent to consultant endocrinologist and ANP within the CDH.
Results: Patient was reviewed by consultant endocrinologist and ANP within two hours of receiving urgent referral. On review point of care HBA1C was suboptimal at 86 mmol/l (10.1%). He was commenced on insulin therapy (LANTUS) and educated and issued with DEXCOM G7 sensor to facilitate closer monitoring. DEXCOM results were reviewed weekly with subsequent insulin titration. To date estimated DEXCOM HBA1C is now 72 mmol/l (8.7 %), which is a significant improvement. Additionally patient was reviewed by dietician to further manage his diabetes health.
This demonstrates the effectiveness of inter-professional relationships managing patient care in a timely, patient-centered manner. The overall impact is huge as intervention and delivery of care happened much quicker than waiting to be seen in the acute service.
This case identifies how integrated care systems successfully deliver care in communities, improve population health outcomes and support self-management to live well with chronic disease. This case recognises elements of the 9 Pillars of integrated care including:
- People as partners in health and care as patient care was coordinated and patient-centered.
- Resilient communities/new alliances as integrated CDH team managed care in local community, which prior to the establishment of community services would have been referred to hospital service.
- Workforce capacity and capability as CDH team worked together to provide an integrated, multi—disciplinary approach to ensure best patient outcome in a local, timely manner.
Due to the success of this case and others we aim to establish more regular specific integrated care clinics to ensure patients receive input from all members of the CHD to prevent future disease complications and allow patients to live well with diabetes.