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A comprehensive overview of the new chronic disease management programme in general practice
“The way we currently care for (people with) chronic conditions is relatively ineffective, inefficient and ultimately unsustainable. Too many people end up needing hospital admission…too many depend on hospital OPD. We need a better way of caring for people with chronic diseases…affecting approx. 1 million people.”
In this article I will outline the new chronic disease management (CDM) programme recently launched by the HSE, and focus on management of type 2 diabetes mellitus (T2DM) within this programme. I will especially focus on our clinical role in the foot assessment of people with T2DM.
There are approximately one million people in Ireland with one or more chronic diseases. These people should receive care of high-quality that is readily accessible and at modest cost to our health service.
We clinicians in general practice deliver these core principles of quality, access, and cost. The CDM programme is a most welcome initiative, supporting high-quality management of diabetes, COPD, asthma, and cardiovascular diseases. Many people have three or more chronic diseases, presenting clinical challenges in older patients. The current unstructured care pathways are “relatively ineffective, inefficient, and ultimately unsustainable”. The CDM programme should modernise our care for these patients.
The CDM programme supports two structured clinical reviews per year. These will most commonly include both practice nurse and GP. The programme is limited to people with medical cards, commencing with patients aged 75 years of age and over, with phased expansion to include all adults with GMS cards by 2023.
Many of us already undertake this CDM work. We need to implement efficient workflows and avoid duplication. We can deliver the right care, at the right time to the right patient.
The practice nurse visit will usually include ‘talking (patient education), tests and tasks’.
Talking: Patient education is an integral part of managing chronic disease. Practice nurses routinely address the key lifestyle issues of smoking, exercise, alcohol, weight/BMI. Many clinicians will benefit from support around how best to raise and address these issues in a sensitive fashion.
Tests: There are no ‘routine bloods’ and we should not tick every box on the laboratory form: Excessive blood testing is a poor use of costly laboratory resources and increases the work of reviewing results and patient follow up. The GP software systems will prompt which blood tests are required. It is important to document height, weight, BP, and waist circumference in the appropriate data field in your IT system to enable auto-population. Expect some teething problems.
Many GP practices are upskilling a phlebotomist, releasing clinician time for more complex patient care. Schedule the blood test so results are available for the CDM review with the GP.
Tasks will include, pulse, BP, weight, height, waist circumference, influenza, and, where appropriate, pneumococcal vaccine, 24-hour ABPM, ECG, and possibly referral to dietetics/retina-screen/podiatry, etc, as appropriate. Some nurses with appropriate training and equipment (128Hz tuning fork, 10g monofilament) may undertake the annual foot assessment (see below).
The patient care plan is a new concept, formalising sharing information with patients. The care plan shares information and engages our patients in their healthcare. There is an evidence-base underlying the patient held care plan, identifying and incorporating our patient preferences, priorities and goals. The computer system will ‘auto-populate’ much of the patient care plan. The care plan is an important aspect of supporting our older, complex, multimorbid, and increasingly frail patients to identify and prioritise their personal goals.
The GP visit will include:
- Review, management and follow-up of investigation results.
- Clinical review of the patient.
- Patient education.
- Medication review and optimisation.
The CDM programme will support general practice to deliver high quality care to our older patients. In summary: Each GMS patient over 75 years (and all GMS adults by 2023) will have two such visits each year. There will be appropriate blood testing followed by a clinical assessment.
Key objectives and targets in T2DM
- Early and accurate diagnosis of all people with T2DM.
- Weight loss 5-10 per cent (or >10kg), document Waist circumference.
- Target HbA1c = 58, ideally <53.
- Target BP 120-139/70-79.
- Lifestyle interventions: document exercise, smoking, alcohol.
- Recommend a statin if ≥40 years, Target LDL cholesterol <2.
- Foot care: examine regularly and refer if abnormal (Foot care is often neglected).
- Flu and pneumococcal vaccine, audit to drive quality improvement.
- Retinopathy: Refer and attend retinopathy programme, audit your practice?
- Think kidneys: Check ACR and eGFR.
- Mental health matters.
Diabetes is the leading cause of adult blindness (excluding trauma). The national diabetic retinopathy screening programme, RetinaScreen, has made substantial progress in recruiting people. There are still many eligible people not availing of retinopathy screening, however. Please check if your patients are registered and attending.
Diabetes and foot disease
We have made very substantial progress in reducing the number of people with T2DM having toe/foot amputations in Ireland. However, there remains scope for substantial improvement.
People with diabetes often develop peripheral sensory impairment. This sensory loss predisposes to tissue damage in the foot. Impaired circulation delays healing. The combination of ischaemia with sensory loss cause a downward spiral of skin damage, ulcers, infection, osteomyelitis, gangrene, and amputation.
Foot ulcers are harbingers of impending amputation. Most ulcers can be prevented with good foot care and foot screening.
Key messages in diabetic foot disease
- Foot ulcers affect 10 per cent of people with diabetes and almost half die <5 years of developing a foot ulcer. Most ulcers can be prevented with good foot care.
- Examine foot at diagnosis and at least yearly: Inspection, sensory, and vascular assessment.
- Loss of vibration sense at the big toe is a very early sign of neuropathy: Refer to podiatry.
- Stratify into normal and abnormal feet; refer people with ‘abnormal’ feet.
- Most amputations start with foot ulcers. Refer people with foot ulcers or foot infection to hospital immediately or next working day.
Provide foot-care education to all patients with T2DM.
The foot in diabetes: EXAMINE, STRATIFY, PROTECT.
Foot examination: Three components to a systematic concise foot assessment
- Inspection: Assess skin, nails, bones and footwear: check for macerated web spaces, ulcers, hair loss, deformed toenails and foot deformity.
- Sensory assessment: This has two components:
- 10g monofilament: Test at between four-to-10 sites on each foot.
- Vibration sense: use a 128Hz tuning fork at tip of big toe. Can your patient identify the vibration, and cessation of vibration? Absent sensation suggests sensory neuropathy.
- Circulation assessment: Assess capillary refill time, posterior tibial and dorsalis pedis pulses, oedema, skin temperature, oedema etc. This is often quite difficult, even for experienced clinicians. Your local podiatrists are a fantastic resource for training.
The American Academy of Physician Assistants has an excellent diabetic foot examination 10-minute training video (www.youtube.com/watch?v=GemhbvnoR6w).
Stratify the foot in T2DM
A very simple binary approach stratifies the foot examination into ‘normal’ or ‘abnormal”. People with any foot abnormality should be referred to the HSE podiatry service.
Normal examination: A patient with no history of ulcers, normal skin-nails-bones, normal foot pulses (vascular assessment), and no sensory loss. These patients are managed in general practice, with patient education and an annual foot examination.
Abnormal foot examination: Patients with any abnormality should be referred, ideally to HSE podiatry services. Foot ulcers or infection are an emergency and should be referred to hospital immediately or next working day. Ask the GP to make these emergency referrals. The referral pathway will be influenced by local podiatry service provision. It is regrettable that many areas are deficient in podiatry services.
Patient foot care education in T2DM
Some practices use a ‘note template’ to document foot education in T2DM: ‘Address nail care, emollient use to dry skin, but not between toes. Encourage daily self-examination of the feet, never walk in bare feet (including beach), check footwear and hosiery before wearing, never ‘break shoes in’. Never use hot water bottles, always check bath and shower temperature with hand and not foot. Avoid home remedies, eg, corn plasters. Contact GP if any injury, ulcer, swelling, warmth, redness or pain in your legs or feet. The online HSE foot care leaflets are excellent.
Summary and conclusion
The CDM programme is a great initiative to support general practice in delivering high-quality care to our patients. Many of our patients have multiple chronic diseases and we are skilled in managing these patients. The CDM programme is evidence-based, promotes high-quality care, and many of us are already doing this work. The practice nurses currently undertake patient education, phlebotomy, and a host of other tasks when providing patient care.
Many practice nurses are skilled in the management of people with T2DM. This article touched on the key targets, then drilled down into foot care in people with T2DM. Assessment of the foot in diabetes involves a clinical examination of the foot, with sensory and vascular assessment. We divide the outcome into either ‘normal’ or ‘abnormal’. People with any abnormal finding on foot assessment should be referred, usually to HSE podiatry. Education of our patients around foot care is fundament to supporting our patients and protecting their feet.
The ICGP recently published Diagnosis and Management of uncomplicated T2DM: A succinct practical guide for Irish General Practice. This is readily available on the ICGP website, www.icgp.ie.
References on request