Health Care System Evolution, Organizational Essay

Diabetes: Continuum of Care

Source: Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The continuum of care for diabetes begins at the moment that the individual is found to have diabetes and continues across the individual's health care providers and across the varying stages of progression of the disease and the age progression of the individual with Diabetes. This continuum of care should be addressed by health care providers, Medicare/Medicaid, as well as the Centers for Disease Control and Prevention.

Changes in the workforce in developing the diabetes continuum of care is stated to have included the following: (1) Increase in number of dieticians; (2) Increase in number of diabetic specialist nurses; (3) Increase in podiatrists; (4) Education for primary care team; (5) Move DSN to primary care to take straight referrals; (6) Insulin for life training with continuous CPD support; (7) Increase capacity in general practice; (8) Psychologist input; (9) DSN provides education/advice for practices; (10) Increase confidence of G.Ps and Practice nurses to deliver care; (11) Out of hours service accessibility to advice post 6 p.m. (for patients and clinicians); and (12) DSN for elderly. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Clinical accommodations were stated to include: (1) Care pathways; (2) Identification of patient on admission to acute to pharmacist, DSN; (3) Continuity of care throughout the service where possible patient sees the same clinician; (4) Need shared templates, guidelines, protocols; (5) Retinal screening; and (6) Eye screening for housebound. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Communication accommodations supporting diabetes continuum of care included: (1) Countywide register accessible to all clinicians; (2) Increase family/school liaison; (3) Developed links between services; (4) Diabetic link nurses on all wards; (5) Shared templates/paperwork; (6) Use of available technology email referrals/advice etc.; (7) Information that flows freely to all parts of the service; and (8) Good data. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Public health and education accommodations to support diabetes continuum of care included: (1) Better transport; (2) Healthy diet; (3) Playing fields; (4) Educating parents, children on healthy lifestyles; and (5) Tie diabetes to other strategies to tackle obesity. (Worcestershire Diabetes: a New model of care Stakeholder event, 2007)

Patient education accommodations for supporting diabetes continuum of care is stated to include: (1) Structured patient education for type 2; (3) Structured patient education for type 1; and (3) Cluster-based training for newly diagnosed diabetics. The action along with the purpose taken in this diabetes continuum of care initiative are listed in the following table labeled Figure 2.

Diabetes Continuum of Care Actions/Purposes



Diabetes Network core group to meet

To agree terms of reference, structure and function of the network

Agree communication strategy.

Make final agreement on model of care following feedback

Decide how to deliver recommendations from the stakeholder event

Begin detailed action plan for circulation

Set up the Diabetes Structured Education Self-Care Group

To address the recommendations and requirements of NICE guidance, both technology appraisals and clinical guidelines, in relation to structured patient education, patient information and self-monitoring in accordance with the Worcestershire Model of Care for Diabetes. The group will be chaired by Sian Finn, Self-Care Programmes Manager for the PCT.

Complete the Diabetes Commissioning toolkit data collection

To benchmark our services. To provide baseline data to evaluate changes against. To ensure action plans can be prioritized appropriately based on health needs analysis.

To identify financial implications

Communicate outputs from Stakeholder event widely and gain feedback especially with patients groups.

To ensure all those with vested interest have a chance to contribute to the future of diabetes care in Worcestershire.

Identify and cost workforce options for delivering the model of care

To ensure robust workforce plans can be produced to support model of care

To allow open decision making process

Worcestershire Diabetes: a New model of care Stakeholder event (2007)

The 'elements of care' stated in the Diabetes continuum of care program are listed in the following table labelled Figure 3.

Diabetes Continuum of Care Elements





Prevention type 2

Heart disease/stroke##


Self-management information packs (1 group's idea that these should be provided for all patients)

Structured Patient education


Diagnosis type 2 adult

Initial management type 2

Continuing care type 1

Continuing care type 2

Regular surveillance adults

Erectile dysfunction

Foot issues (surveillance)


Treatment change e.g. insulin

Institutional care (moving to 3 as clinically appropriate)

Elderly/housebound (moving to 3 as clinically appropriate)

Diagnosis type 1 adult (3 groups)

Initial management...


Individuals with diabetes, either as a primary diagnosis or a comorbid condition, are no exception to this trend. This, combined with an end to the fee-for-service payment structure, has challenged home care clinicians to find effective ways of transitioning these patients from an acute episode of illness to a return to the community. Recognizing the impact of diabetes as an independent risk factor is key to achieving favorable health outcomes." (O'Reilly, 2005)
The work of Paul Straley (2007) entitled: "Diabetes: Adherence to Preventative Care" states of diabetes that in the U.S. The risk for developing Type 1 diabetes is higher than almost all other chronic illnesses of childhood" However, diabetes is manageable "if the individual is committed to monitoring blood glucose levels and practicing lifestyle modifications." (Straley, 2008) Straley's report addresses diabetes care among adolescents in the United States and relates that being diagnosed with diabetes is the trigger of a plethora of stressor for individuals who are in their teenage years. Identified as the best nursing practice for promotion of successful diabetes care in adolescent Type 1 diabetes is stated to be achievable through management of "...psychosocial risks and adhering to preventive care." (2008) Nursing strategies are identified as including:

1) Therapeutic communication;

2) Providing education; and 3) Promoting self-efficacy. (Straley, 2007)

This report highlights the role of the nurse and the nursing strategy in diabetes care and particularly in regards to the continuum of care of diabetes. It is stated that education is "an essential part of the third nursing strategy, promoting self-efficacy, and is supported by a collaborative multidisciplinary team." (Straley, 2007) Nurses assist patients with autonomy reinforcement and initiates choices and collaboration in establishment of a diabetes self-care plan. Straley reports that 'The Nurse Case Managed Integrated Care Model' was introduced by the American Diabetes Association in 1997 with the purpose of providing "a continuum of care through a variety of multidisciplinary teams to educate families and provide self-efficacy in managed care of adolescents' diabetes." (2007) Straley notes the work of Caravalho & Saylor (2000) who stated that "Increased self-efficacy is an integral part of an empowerment education program." (2007) Also reported was that self-efficacy "...was associated with better metabolic control." (Straley, 2007) Indentified as 'Barriers to Successful Nursing Interventions' by Straley are the following:

The patient has a lack of financial resources or insufficient insurance;

Nurses are burdened with limited time and resources to build a positive therapeutic relationship;

Because of high medical costs there is a lack of follow-up and increased non-compliance;

Nurses are unable to provide consistency of care and develop intra-personal relationships that are indicative to building a sense of trust

The lack of follow up can make it difficult for the nurse to assess and evaluate knowledge deficits as it relates to adolescents' diabetes and complications related to their illness. T

The limited ability to assess individual's specific needs can lead to slowed response to providing community resources and can lead to further secondary complications. (Straley, 2007)


The Centers for Disease Control and Prevention have failed to properly address the Continuum of Care for Diabetes however, the professional nursing staff is in a unique position to enable the education and self-care of diabetes patients. Continuum of care programs through the U.S. And throughout the world, while differing in scope, have common components that serve to enable Diabetes patients in a Continuum of Care supported by education and autonomy in self-care of their diabetes.


Betancourt, JR, Green, AR, and Carillo, JE (2002) Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches" (New York City: The Commonwealth Fund, 2002).

Center for Disease Control and Prevention (2006) Thomson Gale Corporation 2006.

Center for Disease Control and Prevention: Changes in Obligations and Activities before and after Fiscal Year 2005. (2008) Budget Reorganization. United States Government Accountability Office, Washington, DC. 25 Feb 2008. Online available at

Diabetes Continuum of Care (2007) Worcestershire Diabetes- a New model of…

Sources Used in Documents:


Betancourt, JR, Green, AR, and Carillo, JE (2002) Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches" (New York City: The Commonwealth Fund, 2002).

Center for Disease Control and Prevention (2006) Thomson Gale Corporation 2006.

Center for Disease Control and Prevention: Changes in Obligations and Activities before and after Fiscal Year 2005. (2008) Budget Reorganization. United States Government Accountability Office, Washington, DC. 25 Feb 2008. Online available at

Diabetes Continuum of Care (2007) Worcestershire Diabetes- a New model of care Stakeholder event St. Richards Hospice 12th September 2007. Online available at:
Evolution of Health Care, from 19th Century till today (nd) CESifo DICE. Online available at
Healthy Kids, Healthy Communities (2007) Local Government. Available at;Economic Research Service, "Food Assistance and Nutrition Programs: RIDGE Project Summary" (U.S. Department of Agriculture), available at
Heyman, KM, Schiller, JS, and Barnes, P. (2007) Early release of selected estimates based on data from the 2007 National Health Interview Survey," National Center for Health Statistics. Available at
Kindig, David and Stoddart, Greg (2003) What Is Population Health?" American Journal of Public Health 93 (3) (March 2003): 380-383, available at
O'Reilly, S. (2005) Managing the Care of Patients with Diabetes in the Home Care Setting. Diabetes Spectrum Online available at
Significance of Medicare and Medicaid Programs for the Practice of Medicine (2005) Health Care Financing Review. 22 Dec 2005. Online available at
Straley, Paula (2007) Diabetes: Adherence to Preventive Care. Best Nursing Practice for Promoting Successful Care in adolescent Type 1 Diabetes. Nursing Research 211, Fall 2007. Online available at
The Health Care Delivery System: A Blueprint for Reform (2008) Center for American Progress and the Institute on Medicine as a Profession. October 2008. Online available at

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