The purpose of these supplements has been to share new models and ideas in diabetes care, so that we can learn, adapt, and, in some cases, know who to ask for further advice! However, I feel it would be naïve to suggest two things – that new models of care are the domain of diabetes services alone, and that diabetes is the only aspect of healthcare with Government targets and imposed change.
The two articles in this supplement explore this further, both prompted by rising populations, increased healthcare costs and imposed targets. The strategies, however, are different in terms of patient population.
Managed care/Evercare
The first article by Anne Wells (p99) explores the managed care or Evercare model. Anne explains its US origins and rationale, how it has been piloted and applied in the UK, and how it is being implemented in the Adur, Arun and Worthing area in which she works.
How this model will or could fit with existing specialist services such as diabetes will be explored, as there is a real risk of duplication and silo thinking if the interface between these managed care nurses* and specialist nurses and their teams is not proactively managed.
These nurses need to be up-skilled in aspects of chronic diseases, elderly care, nursing and organisational strategy, and we as a specialist diabetes nursing team have been involved in this planning, and will deliver this training. Gatekeeping, following the patient into hospital and after discharge, and referring to specialist clinicians will all require clarification as well as authority and processes to support these actions.
Collaboration could improve patient care in diabetes, particularly for those people not currently seen by specialist care, who could benefit from such intervention. This is particularly true of patients in nursing homes, and those who attend casualty regularly, or are re-admitted due to insufficient discharge planning and support.
This may feel like yet another imposed change on service areas such as diabetes, which are already creaking under the burden of more to do, and no more resources. It will be interesting to review the impact of this model on chronic disease management next year, and in particular, diabetes care.
Three-tier model for integrated and structured care
The second article, by Margaret Bannister, Nurse Consultant in Diabetes in Bradford (p102), discusses the service changes made with the purpose of delivering integrated and structured diabetes care which is accessible to all. A three-tier model was developed so that patients would receive care at the appropriate level for their clinical need. This was to encourage movement in both directions instead of the traditional one-way referral process.
This model required review and change of current systems and processes, built on a satellite system, which included integration of the diabetes specialist nursing service to promote equity of access and consistency of approach, and a ‘buddy’ system to link remaining practices to the current system. This change enabled primary care clinicians to be better supported, and structured education linking with this structured clinical care model is the next planned step. s
* Also called advanced nurse practitioners in some areas
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