Diabetes integrated care: Are we there yet?

Abstract

To integrate diabetes care, indeed to ensure quality care and optimise outcomes, requires both the patient and the clinical team to be activated, knowledgeable, skilled and supported. Various ‘systems’ have now been tried in different ways to deliver these characteristics with varying outcomes. Success would deliver population benefits of reduced hospitalisation and diabetes complications, reduced societal cost (not cost shifting) and for the significant sub-groups of patients (e.g. type 1 diabetes) improved access to complex specialist care. A range of factors facilitate patient self-management including continuity of care, team working, systems to overcome barriers to care, management of co-morbidities, diabetes education and promotion of self-management, reducing costs and where needed case management. Evidence is also growing for peer support, access to health records and wider e-health interventions. On the diabetes team member side, shared electronic health records, electronic communication and defined referral pathways, guidelines and risk stratification are at the core. Keeping up to date and abreast of ongoing changes is a challenge to busy clinicians and hence clinical activity needs to be underpinned by decision support and clinician education. However, in some of the work undertaken to date, having these activities in place has been insufficient, it is clear that there has to be a milieu that minimises perverse incentives (e.g. those related to payment systems), maximises workforce flexibility (so clinician may mean a number of medical, nursing, allied health and other health-worker roles) and focuses on population outcomes. At the end of the day, diabetes integrated care requires integrated population based clinical, financial and organisational governance, with a culture that embraces flexibility and patient-focused quality care, and strong articulation with systems that activate, educate and support both patients and clinicians. Are we there yet? Our examples would say… Nearly!.