Empowering diabetes care in primary practice: Lessons from the Midwest DESMOND Programme

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Reference: November 2025 | Issue 11 | Vol 11 | Page 33

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Type 2 diabetes mellitus (T2DM) is a growing public health challenge in Ireland, particularly among older adults.¹ With prevalence rates rising and complications increasing, the need for scalable, evidence-based interventions is urgent. Structured diabetes self-management education (DSME) has emerged as a cornerstone of diabetes care, equipping patients with the knowledge, skills, and confidence to manage their condition effectively.^2,3

One such programme – Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) – has been implemented in the Midwest of Ireland since 2010. Facilitated by trained dietitians and diabetes nurse specialists in primary care, DESMOND is an evidence-based group education programme for people with T2DM that focuses on long-term self-management through behaviour change.^4,5

Participants complete six hours of education (either one full day or two half days) in groups of up to 12 people, with the opportunity to be accompanied by a support person if desired.⁶ In the HSE Midwest service, local policy is to offer a follow-up session after six months. Despite the programme’s proven benefits, uptake of DSME remained inconsistent in the Midwest.

To better understand this, we conducted two complimentary studies between 2019 and 2021:

1. A retrospective evaluation of clinical outcomes among DESMOND participants.⁷

2. A qualitative study exploring healthcare professionals’ experiences, barriers, and enablers related to DSME referral and delivery (unpublished).

Together, these studies provide a comprehensive view of both the clinical impact and the practical realities of implementing DSME in routine primary care.

Clinical effectiveness: What the data show

The retrospective study evaluated adults with T2DM who attended both the DESMOND programme and a locally developed six-month follow-up session.⁶ Participants had a mean age of 63 years, with a wide range in time since diagnosis (three months to 11 years). Clinical outcomes were measured at baseline and follow-up, focusing on HbA1c (glycated haemoglobin), weight, and body mass index (BMI).

Among the 66 participants who completed both the DESMOND programme and the locally developed six-month follow-up, the data revealed encouraging improvements in clinical outcomes. Glycaemic control improved significantly, with average HbA1c levels dropping from 58mmol/mol to 52mmol/mol, a reduction that brought more participants below the recommended target threshold.⁷ At baseline, just over half of the group met the target of less than 53mmol/mol, but by follow-up, this had increased to 71 per cent.

Changes in body weight were more modest overall, with an average reduction of 1.4kg. However, a closer look showed that 13 per cent of participants achieved a weight loss of more than 5 per cent, a clinically meaningful change associated with improved metabolic health.⁸

Shifts in BMI categories also reflected positive trends: The proportion of individuals in the normal weight range increased, while those classified as overweight decreased. Although the percentage of participants in the obese category remained unchanged, more than half of those individuals recorded meaningful weight loss, suggesting that even small changes may be achievable and beneficial within this cohort.

These results reinforce the value of structured education in improving metabolic outcomes, particularly when delivered by trained professionals in a supportive group setting. Importantly, the study also highlighted the potential for sustained benefits when education is followed by targeted follow-up.

Implementation challenges: What providers say

In parallel, our qualitative study explored the attitudes, knowledge, and referral practices of eight healthcare professionals across the Midwest. Participants included nurses, podiatrists, physiotherapists, and occupational therapists, some of whom were active referrers to DESMOND, while others were not.

Despite broad support for patient education, several barriers to DSME uptake were identified:

• Unclear referral pathway: Many professionals were unsure whether they could refer directly or lacked clarity on eligibility criteria. Even among those familiar with the DSME, uncertainty about the referral process and lack of feedback on patient attendance were common frustrations.
• External barriers: Issues such as frailty, transport, rural location, and digital literacy were cited as obstacles, particularly for older adults. While the DSME moved online during the Covid-19 pandemic, participants noted that many older patients struggled with technology or lacked access to devices.
• Internal barriers: Patient-related factors such as denial, stigma, and low self-efficacy were recurring themes. Our professionals observed that some patients resisted the diagnosis or preferred to manage their condition independently, while others were reluctant to attend group sessions due to embarrassment or fear of judgment.
• Low programme visibility: Several providers had never heard of DSME before being contacted for the study. Others expressed a desire for more information, including printed materials, opportunities to observe sessions, and updates via webinars or team meetings.

Why this matters for clinical practice

Our findings highlight that DSME’s clinical benefits can only be fully realised when supported by clear systems and processes. Integration into routine care depends on several key factors:

1. Streamlined referral pathways
Many healthcare professionals, particularly those outside of general practice, were unsure whether they could refer patients directly or were unfamiliar with the process. This uncertainty can lead to missed opportunities for patient engagement, especially in the critical early months following diagnosis.⁹ Addressing this gap by streamlining referral protocols and ensuring all members of the multidisciplinary team are informed and empowered to refer could significantly improve uptake.

2. Improved access and flexibility
Patients living in rural areas, those with mobility challenges, or those reliant on carers often face logistical difficulties in attending in-person sessions. While the shift to online delivery during the Covid-19 pandemic offered some flexibility, digital literacy and technology access remain limiting factors for many older adults.¹⁰ Expanding the programme through community-based venues, telehealth options, and flexible scheduling could help reach those who are currently underserved. In addition, the inclusion of family members or carers at DSME sessions not only improves accessibility but also strengthens the support network around the individual.¹¹

3. Feedback loops for referrers
Clinicians who refer patients to DSME often receive no confirmation of attendance or outcomes, making it difficult to reinforce learning or tailor follow-up care. Establishing a feedback loop would support continuity of care and help clinicians better understand the programme’s impact on their patients.^12,13

4. Enhanced programme visibility
Finally, visibility of the programme within the healthcare system is essential. Several participants had never heard of the DSME prior to the study, and others expressed a desire for more information, such as printed materials, webinars, or opportunities to observe sessions. Raising awareness through team meetings, professional development events, and targeted outreach to underrepresented professions could help embed DSME more firmly within the culture of diabetes care.^13,14

Conclusion

Within the Midwest, DESMOND offers a proven DSME model for empowering patients with T2DM to manage their condition effectively. Its success depends not only on programme quality but also on system-level support for implementation. By addressing barriers to referral and attendance, and by centring the programme within integrated care pathways, clinicians can help ensure that structured education becomes a routine and impactful part of diabetes care in Ireland.

In recent years, diabetes care in Ireland has evolved significantly, supported by national strategies and local service developments. The HSE Integrated Model of Care for People with T2DM (2024) provides a clear, standardised framework for where and how individuals with diabetes should receive care across the spectrum, from prevention and diagnosis to complex management.⁶

Locally, the establishment of integrated care hubs and the expansion of multidisciplinary teams have further enhanced access to care. Increased staffing, including additional diabetes nurse specialists and dietitians, has enabled the delivery of DSME programmes like DESMOND in more community-based venues, bringing care closer to where people live. These developments have not only improved accessibility but also reinforced the integration of education and self-management support within routine care.

Together, these national and regional initiatives create a strong foundation for embedding DSME as a standard component of diabetes management in Ireland. By addressing remaining barriers to referral and engagement, and by leveraging the new integrated care infrastructure, clinicians can help ensure that structured education becomes a truly universal and impactful element to diabetes care.

As the burden of diabetes continues to grow, particularly among older adults, the need for accessible, evidence-based education is more urgent than ever. The experience from the Midwest demonstrates that when supported by system-level innovation and local collaboration, DSME can empower people with diabetes to take an active role in their health and improve outcomes across the continuum of care.