Model of Integrated Care for Patients with Type 2 Diabetes

Objectives

The guidance sets out a national, evidence-based framework for improving prevention, diagnosis, treatment and long-term outcomes for people with Type 2 diabetes in Ireland. It supports the National Model of Integrated Care, aligned with Healthy Ireland, to provide accessible, high-quality and cost-effective care while addressing the growing burden associated with obesity and population ageing.[1][2][3]

• Prevent or delay Type 2 diabetes through risk identification, intensive lifestyle change and, where appropriate, medicines such as metformin.[4][5]
• Detect diabetes earlier through systematic and opportunistic case-finding, particularly among adults with overweight and additional risk factors, and ensure prompt diagnosis, registration and referral.[5][6]
• Deliver care according to clinical complexity: manage uncomplicated Type 2 diabetes in primary care, share care for complicated cases, and provide specialist secondary or tertiary care for complex diabetes presentations.[7][8][9]
• Improve clinical outcomes through individualised management of glycated haemoglobin, blood pressure, lipids, weight, smoking, diet, physical activity and medication use.[10][11][12]
• Prevent or reduce diabetes-related mortality, cardiovascular and cerebrovascular events, blindness, kidney disease, neuropathy, foot ulceration and lower-limb amputation.[3][13][14][15]
• Strengthen self-management by providing structured education, realistic personal goals and tailored support for people with disabilities, language barriers, cognitive needs, or family and carer involvement.[16][17]
• Support healthy ageing and quality of life through holistic long-term care, including obesity management, pre-pregnancy care, psychological wellbeing, sexual-health support and medication review.[1][18][19][20][21]

Implementation

The model integrates general practice, community services and consultant-led specialist care through defined care pathways, multidisciplinary working, shared information and clinical governance. General practitioners retain leadership and accountability for integrated care in their practices, while specialist diabetes teams support primary care with advice, education, rapid access and management of complex cases.[22][23][24]

• Provide structured primary-care reviews for uncomplicated Type 2 diabetes, generally every four months with a comprehensive annual review, covering clinical assessment, investigations, education, lifestyle advice and referrals.[12][25]
• Transfer suitable uncomplicated patients from secondary care to participating general practitioners, supported by discharge summaries and treatment information; maintain shared care or specialist management for people with complications.[24][9]
• Deploy practice nurses as core members of the diabetes team to undertake assessment, foot-risk classification, education, agreed-target setting, documentation, recall and liaison with patients, carers and relevant services.[22][26][27]
• Position Clinical Nurse Specialists in Diabetes Integrated Care as a link between primary and secondary care, with the specified role split of 80% primary-care and 20% secondary-care activity; provide registers, recall systems, joint clinics, case reviews and remote professional advice.[24][28]
• Integrate dietitians, podiatrists, pharmacists, diabetes nurse specialists, retinal screening, ophthalmology, psychology and hospital multidisciplinary teams into care delivery and referral pathways.[29][30][4]
• Provide structured education soon after diagnosis and throughout care, using programmes with a defined curriculum, trained educators, quality assurance and regular audit; offer individual dietetic input when group education is unsuitable.[7][31]
• Deliver annual retinal screening through the government-funded Diabetic RetinaScreen programme for people with diabetes aged 12 years and over, using retinal photography, image grading, timely results and referral to treatment where required.[14]
• Assess renal disease at least annually through urine albumin-to-creatinine ratio, serum creatinine and estimated glomerular filtration rate, and manage proteinuria and renal decline through appropriate blood-pressure, glycaemic and renin-angiotensin system treatment.[32][33]
• Examine feet at each diabetes clinic visit, classify risk as low, moderate, high or active disease, and ensure urgent specialist referral within 24 hours or the next working day for active foot disease.[15][34]
• Maintain a core dataset and up-to-date diabetes registers, with standardised demographic and clinical information shared between primary, secondary and tertiary services subject to consent and data-protection requirements.[35][30]
• Monitor quality through clinical audit, performance indicators, register maintenance and feedback to practices; the programme envisages national indicators developed through stakeholder consultation and a national diabetes register to support planning and population monitoring.[22][24][28][3]
• Assess progress against high-level targets, including a 10% reduction in diabetes-related and all-cause mortality among people with diabetes over five to ten years, a 20% reduction in myocardial infarction and stroke, and 90% coverage for annual foot examination, retinopathy-screening invitation and kidney-disease screening by year five.[13]

Monitoring & Evaluation

The programme combines patient-level clinical monitoring with practice audit, shared datasets and proposed national performance measurement. It aims to use integrated-care information to improve quality, safety, access, outcomes and resource use, although several reporting and accountability arrangements remain unspecified.[22][35][13]

• Maintain practice diabetes registers, collect a core dataset for people enrolled in general-practice integrated care, and share standardised demographic and clinical information between primary, secondary and tertiary services, subject to consent and data-protection requirements.[22][35][9][30]
• Record clinical status, care arrangements, referrals, medication, complications, management plans and pregnancy-related information; the dataset includes mortality details, including date and cause of death and International Classification of Diseases, 10th Revision coding where available.[30][4]
• Develop and report agreed key performance indicators following stakeholder consultation, while using high-level metrics to assess the National Model of Integrated Care. The supplied material does not list all of these indicators.[22][24][36]
• Measure programme outcomes through targets to reduce diabetes-related and all-cause mortality by 10% over five to ten years, and myocardial infarction and stroke among people with diabetes by 20% over the same period.[13]
• Monitor access and complication prevention through targets of 90% annual foot examination coverage, 90% invitation to retinopathy screening and 90% annual screening for early diabetic kidney disease by the end of year five.[13]
• Reduce new diabetes-related foot ulcers, lower-limb amputations, new blindness, and cases requiring vitrectomy or photocoagulation therapy by 40% within the specified five-year periods.[13]

Care-process monitoring is structured around regular general-practice review, usually every four months with an annual comprehensive assessment for people with Type 2 diabetes. Core measures include glycated haemoglobin, blood pressure, lipid profile, renal markers, weight and foot-risk assessment; retinal screening, renal screening and foot examination form important complication-surveillance mechanisms.[12][25][10]

• Check glycated haemoglobin and blood pressure at least three times yearly, assess lipids at least annually, and use individualised targets for glycaemic, blood-pressure and lipid management.[10]
• Review glycated haemoglobin more frequently when treatment targets are not achieved or therapy changes, and audit whether interventions are made for people outside target.[37][38]
• Check blood pressure at every clinic visit, audit target attainment and treatment action, and use 24-hour monitoring where high readings require diagnostic confirmation.[39][40]
• Monitor lipid profiles every four months during treatment adjustment and annually once patients are stable and within target, with audit of testing, interventions, target achievement and statin adherence.[41]
• Provide annual retinal screening for registered people with diabetes aged 12 years and over, using image quality, screening findings and referral requirements to determine recall, assessment or treatment.[12][14]
• Assess urine albumin-to-creatinine ratio, serum creatinine and estimated glomerular filtration rate at least annually, and audit nephropathy prevalence, target achievement and progression to end-stage renal disease.[32][33]
• Examine feet at every clinic visit or at diagnosis and annually as specified by the relevant pathway, classify risk, and audit screening, risk identification, appropriate treatment and timely referral for active disease.[15][42][34]

Audit is a principal quality-assurance mechanism across the model. Healthcare professionals involved in diabetes care are expected to participate in annual care audit, while practices should allocate responsibility, retain results centrally, use findings for internal learning and share them where possible.[10][43]Audit may assess diagnostic and treatment procedures, associated resource use, patient outcomes and quality of life, with individual key procedures audited at least once in a two-year cycle.[43]

Multidisciplinary services have additional evaluation measures. Dietetic services monitor referral volumes, waiting times, attendance, body mass index, glycated haemoglobin, lipids, empowerment and satisfaction.[44]Structured education programmes require quality assurance and regular audit and evaluation.[7]Medication-review indicators include annual clinical reviews, pharmacy medication-usage reviews for eligible people, post-discharge reviews and proportions meeting referral criteria.[45]

Governance assigns overall practice-level responsibility and accountability for integrated diabetes care to general practitioners, with practice nurses documenting care and returning data as required.[22][23]Clinical Nurse Specialists retain reporting accountability through relevant public-health-nursing or hospital nursing management structures while maintaining clinical relationships with general practitioners and Consultant Endocrinologists.[24][28]A national diabetes register is identified as essential for population-based planning, monitoring and intervention targeting, but the source does not provide a complete reporting timetable, full indicator set or unified formal accountability process.[3]

Costing & Financing

The material presents diabetes care as a substantial health-service resource issue and promotes cost-effective integrated care, but it provides very limited quantified financial information. Diabetes care is reported to consume up to 10% of the Irish healthcare budget.[46]

• Reduce overall hospital bed days by 25,000 per year as an operational objective of the integrated-care model.[3]
• Support structured diabetes care in general practice through the Cycle of Care reimbursement initiative introduced in October 2015, although no reimbursement rate, total allocation or funding gap is provided.[46]
• Recognise that up to 420,000 diabetes-related primary-care visits per year may be required, without attaching a cost or budget to this service volume.[36][22]
• Identify diabetes self-management education as cost-effective relative to usual care, without a monetary estimate or stated economic model.[31]
• Identify simvastatin as preferred over atorvastatin on stated cost-effectiveness grounds, while amitriptyline is described as cheaper and more cost-effective than pregabalin or duloxetine.[47][48]
• Classify some glucose-lowering regimens by relative medicine cost, including low, high or variable costs in pounds sterling, but provide no prices, total medicine expenditure or affordability analysis.[49][50][39]
• Describe Diabetic RetinaScreen as government-funded and free for annual screening and programme-recommended follow-up assessments, without stating expenditure or a funding allocation.[14]

Resource availability is recognised as affecting feasibility and quality of care, particularly for vulnerable groups, and the model identifies staffing and service-capacity needs such as multidisciplinary support and integrated-care nursing.[1][28]However, the supplied material does not specify an overall implementation budget, financing plan, funding sources beyond the cited screening programme and reimbursement initiative, resource-mobilisation strategy, funding gap, or economic assumptions for most services.[1][24][51]