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Integrated diabetes care in the community setting

By Caitriona Gaffney, RGN, H.Dip, CNS/PN, Graiguenamanagh Medical Centre, Co Kilkenny - 29th Aug 2019

Close up of woman hands using lancet on finger to check blood sugar level by Glucose meter using as Medicine, diabetes, glycemia, health care and people concept.

Providing care to diabetes patients in the community needs to be done in a structured manner

Type 2 diabetes (T2D) is a chronic, multi-system condition that occurs when there is an absolute or relative deficiency of insulin.

Due to its slow and gradual progression, T2D may be asymptomatic for years.

Care for T2D is integrated between hospital-based clinics and GP practices. The diabetes cycle of care in primary care initiative was introduced in 2015. This allows all T2D patients who hold a medical card or a GP visit card to have a structured review of their diabetes by their own GP/practice nurse twice a year; one annual review and one routine review. Previously, diabetic patients may have been managed in an opportunistic manner, but now the service is focused on a structured system of care.

There are many health professionals involved in providing community care to T2D patients, with GPs taking the lead, including:


Practice nurses.


Community dieticians.

Community podiatrists.

Diabetic nurse specialists.

Role of the practice nurse

Practice nurses are based in your local GP surgery and provide care to patients on a range of topics that are pertinent to practice, including men, women and child’s health, mental health, immunisations, diabetes, cardiac and respiratory care. Practice nurses are the key to the success of a structured diabetic clinic and in most cases, they carry out the day-to-day care of patients with diabetes. The practice nurse who runs the diabetic clinic should be appropriately trained and have a special interest in diabetes, aiming to deliver a responsive, effective and efficient service.

Annual review

After the initial diagnosis, the practice nurse is often the discipline who addresses the topics to be covered with the patient. The following should be discussed and recorded in the annual assessment:

Education: Explain in simple terms what diabetes is and how it can be treated, taking into account the patient’s level of understanding. Start slow and increase the patient’s awareness of their own situation. Set small, achievable, realistic targets. Being too ambitious may be difficult to sustain and can lead to failure. It may take more than one visit for the initial review. Discuss if the patient is open to undertaking a diabetes self-management programme. Self-management programmes encourage patients to become confident in their own healthcare. There are currently three structured diabetes education programmes in Ireland run by trained healthcare professionals. Discuss the prevention, early detection and management of complications. The basic foundation for good diabetes care focuses on healthy eating, physical exercise and taking medication (Harkins, 2008).

History: Ascertain family history, medical history and current medications.

Investigations: There can be an extensive list of blood tests. At a minimum, the following should be taken: HbA1c, U&E, ACR, lipids, plus BMI, and BP. Patient to ring for their blood results one week later.

Lifestyle issues: Discuss smoking, alcohol and driving rules. Inform patients of their entitlements to an LTI card and to have influenza and pneumococcal vaccines.

Exercise: Taking regular physical activity is essential in managing diabetes. It controls blood sugars, along with improving cholesterol, blood pressure and reducing weight. PNs can educate patients of the many benefits of being more active. Experts recommend 30 minutes per day, five days a week. Again, start off slowly.

Educate on use of a glucometer: How to use it, what it measures, how often to measure and what times. Provide sharps bin and explain the importance of washing hands, rotating fingers and changing the needle. Explain to write readings down in a notepad or if the device can store the readings. Discuss the importance of a family member being able to use the glucometer in times of sickness and sick day rules (check glucose levels more frequently and continue to take prescribed medications). Go through the interpretation of high and low readings and how to manage both. Agree on blood glucose targets. Organise a prescription for glucagon, instruct patient how and when to use it and how to store.

Provide a foot assessment annually and refer as per the HSE Model of Care for the Diabetic Foot: Diabetic foot disease is one of the most common complications of diabetes, as nerve endings and blood supply to your feet may be affected over time. Studies show that foot care education and proper screening can reduce the incidences of diabetic foot disease (Harkins, 2016). The practice nurse should be appropriately trained to examine foot pulses, vibration and monofilament testing.

Participation in the national diabetic retinopathy screening programme, Diabetic RetinaScreen. The programme uses special digital photography to look for changes that could affect sight. This is a Government-funded screening programme that offers free, regular diabetic retinopathy screening to people with diabetes aged 12 years and older. Freephone 1800 45 45 55 or go to for more information.

Administration: Arrange the next appointment. The success of any structured system of care seems to rely on the call and recall process. The call and recall process operates by issuing letters to patients on the practice diabetic register, inviting them to make an appointment with their GP/PN for their next due diabetic appointment. IT packages such as Socrates have software to identify new and existing patients.

Provide relevant literature to the patient.

Routine review

The routine review need not be as comprehensive as the annual assessment. The following should be addressed and recorded:

Education: This should be discussed at each appointment, slowly increasing the patient’s knowledge. Assess how they are coping with their diabetes. Discuss the long-term complications of high blood sugars and the effect poorly-controlled diabetes can have.

Investigations: HbA1c, U&E, BP, BMI. Repeat lipids and ACR if elevated at preceding review.

Preventative lifestyle factors discussed at each visit: Smoking, alcohol, exercise, weight control and provide brief intervention and referral if appropriate.

Assess if all referrals are up-to-date: (Diabetic RetinaScreen, podiatry, dietician) and that the patient is proficient with glucometer use. Review the blood sugars readings.

If there is a persistent failure to achieve target HbA1c, refer the patient to the community diabetic nurse specialist, who has specialist post-grad training in diabetes care and facilitates the integration of diabetes care between primary and secondary services. They review patients directly referred to them by the GP or practice nurse at agreed primary or secondary care locations.

Carry out a clinical audit every two years to monitor quality of care and maintain or improve standards. The GP/practice nurse who is running the diabetic clinic carries out the audit. Audits have multiple benefits, such as identifying good practice, ensuring best use of resources and can improve working relationships.


Cases of T2D are continuing to increase, primarily due to lifestyle factors. Good-quality diabetes care is becoming an integral part of the service provided by general practice and to which the practice nurse plays a central role. Maintaining an efficient diabetes clinic is worthwhile and beneficial to the patients and practice, if approached in a logical and structured manner.

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