For some patients starting insulin is associated with scary tales from their families’ past – like an uncle who lost a leg or a granny who just got sicker and sicker.
With such family anecdotes foremost in their minds, it is maybe not surprising that some patients never find the time or courage to take up a referral to a specialist diabetes clinic at hospital.
The push in recent years is to remove some of the fear and barriers by offering greater diabetes support, including insulin start-up, in the familiar surroundings of their local general practice – and increasingly by their practice nurse.
Lorna Bingham, diabetes nurse specialist at Capital & Coast District Health Board, has long been a strong believer – along with endocrinologist Jeremy Krebbs – in taking secondary services into the community and upskilling staff along the way.
This recently has stepped up a notch with the Nursing Practice Partnership – a Diabetes Care Improvement Package (see overleaf – which is turning an ad hoc approach into a formal and structured programme by the DHB and local primary health organisations to mentor and upskill practice nurses in diabetes.
The package aims by the start of next year to partner diabetes nurse specialists (or nurses with a special interest and skills in diabetes) with nominated ‘diabetes champion’ nurses in all of the about 60 practices across the DHB. There will be up to 10 ‘partner nurses’ – some directly working for the DHB or a PHO and others employed in individual practices – working with a handful or so of practices each.
This builds on outreach work and diabetes services already developed by the DHB’s specialist service and Compass PHO’s diabetes nurse specialists with nurses and GPs at the like of Newtown Medical Centre, the Newtown and Porirua Union Health Services and other practices.
The partnership model is being rolled out this year, firstly to around 15 practices chosen because of their high numbers of patients with diabetes, or at risk of diabetes including those having high Mäori and Pacific populations.
The model of the Nurse Practice Partnership has been trilled with Karori Medical Centre, which Bingham and Krebbs first visited in 2011.
Bingham says up until then the secondary service had little direct contact with the very large practice – about 14,000 patients – which serves a largely middle-class community but also has pockets of poverty. (The ethnic breakdown of the centre’s patients is about 68 per cent European, 11 per cent Asian, 5 per cent Mäori and 5 per cent Pacific.)
Since then Bingham has been a regular visitor, offering specialist clinics at the centre with initially the centre’s first diabetes ‘champion’ Jacqui Levine, and later its additional champion Heather Wilson, sitting in to build their skills by watching and working alongside Bingham.
Levine and Wilson have both been in practice nursing for about five years and say prior to the partnership with Bingham, nurses at Karori Medical Centre had been offering diabetes annual reviews to the about 450 patients in the practice with diabetes. But they had not been offering other nurse-led diabetes care, as Care Plus services for people with chronic conditions tended to be doctor-managed.
The pair are now offering regular nurse-led diabetes clinics, including insulin start-ups, in league with Bingham and the patient’s GP; with Wilson needing to come on board because of demand for the nurse services. The pair built their competence and confidence by working with their mentor Bingham – who initially visited weekly to fortnightly and now is more often monthly or six weekly but is always only a phonecall or an email away. But they also built their knowledge through working their way through the free online diabetes learning modules developed for primary health care nurses (more information at
http://pro.healthmentoronline.com), which is being promoted strongly to all practice nurses in the DHB.
In May 2012, the Karori Medical Centre also started a pilot of working with 55 patients with elevated HbA1c results (over 75 mmols) to look at the impact of the Nursing Practice Partnership programme offering increased diabetes management support from within the practice. Nearly 80 per cent of the patients, including some who had insulin starts at the practice, dropped their HBA1C glucose to more manageable levels.
Robyn Taylor, the centre’s nurse manager, said the pilot also looked at other factors affecting their result, such as medication compliance, socio-economic factors and mental health issues. “It also showed the flow-in and out of the practice (of patients with elevated HbA1C) with diabetes patients leaving the practice, patients coming into the practice, and people being newly diagnosed with diabetes.”
For Bingham, the partnership is about building practice nurses’ competence and confidence in caring for people with diabetes so they are able to “opportunistically do more” or feel comfortable about contacting their ‘partner’ to seek advice.
The diabetes care improvement package is also upskilling GPs in practices, with specialists like Jeremy Krebbs and two other endocrinologists holding peer and case reviews with practice teams, including holding virtual clinics which nurse champions and GPs sit in on.
What form a practice’s enhanced diabetes care takes is up to each practice so they have “ownership” but each has to have a diabetes plan. Bingham says for practices just starting on their “diabetes journey” the plan might initially just involve regularly reviewing target figures, whereas for practices further along on the journey, such as Karori, it might include a target number of insulin starts.
Bingham says because starting insulin is now commonplace for people with type 2 diabetes, it increasingly needs to be done in primary care where that is practicable.
However, a practice needs to have high numbers of potential insulin clients, as from her experience teaching insulin start-up is most successful when a practice and its new diabetes nurse champion can do six starts in a row – roughly one a week over six weeks. “Traction” was needed early on to embed the skills and build confidence.
Bingham says five years ago the vast majority of insulin start-ups were done in the DHB’s secondary specialist clinics.
Likewise, Liz Dutton, one of the two diabetes nurse specialists employed by Compass Health (to which 54 of the DHB’s about 60 practices belong) to, says when she stepped into the role eight years ago none of the Compass practice nurses were starting insulin. Now, about 16 of its practices are trained to start insulin, bringing the number of practices across the DHB offering insulin start-up to about 20.
“It’s been a long haul,” says Dutton.
She says upskilling practices seemed the best solution, as she couldn’t cover all of the referrals from the 32 medical centres in her patch on her own.
GPs can also be “intimidated” at starting insulin with patients, says Dutton, so were quite happy to refer firstly to the nurse specialists and latterly to have their practice nurse upskilled so they can do start-ups. So standing orders are now available that Compass practice nurses trained in insulin start-up can use to titrate insulin dosages for their patients.
Devine and Wilson at Karori don’t have standing orders and are happy at present to work in a collaborative team approach with the patients’ GPs. The two diabetes champions, out of a workforce of eight nurses, now offer nearly all the diabetes annual reviews and pick up the patients who need more intensive involvement – about 150 or so – and enrol them in Care Plus and draw up a care plan in league with their GP.
Now, alongside their everyday practice nurse work, such as immunisations, acute care of walk-in patients and taking cervical smears, they run a diabetes clinic once a week for the reviews and Care Plus patients, and work closely one-on-one for the first few weeks of a patient starting insulin.
This includes meeting up with them prior to starting insulin to ensure they are “mentally prepared”, says Wilson, and finding out what expectations or experiences they’ve been exposed to.
“Because insulin and injections have changed over time and people often have horror stories about relatives with legs getting chopped off or getting sicker on insulin, they have a negative view of it.”
Bingham says a strength of having clinical nurse specialists working alongside champions like Devine and Wilson is they can share the skills and techniques they have built over the years to “tease out” the stories and fears that people have about diabetes – particularly starting insulin.
“For example, there was a gentleman who was very reluctant to start insulin and people often assume it is fear of needles, but when we talked to him we found he’d been a health professional in a previous life and the only people with diabetes he’d ever seen were people having severe hypoglycaemic attacks. So being able to tease that out, we were able to tell him he’d seen a very skewed part of the population and most people handle their diabetes very well and don’t need an ambulance.”
Bingham is excited that one long-term impact of the partnership programme some years down the track may be a decrease in demand for renal dialysis.
She says prior to the programme there has been a risk of people falling through the cracks when referred to secondary services as some of the most high-risk patients never show up.
By supporting practices to support in-house more complex patients with poorly controlled diabetes, rather than referring them to unfamiliar and distant clinics they may never attend, she hopes fewer will be lost and more will improve their diabetes self-management (which includes being supported to make appropriate lifestyle changes, take their medication regularly and start insulin when appropriate).
“In Karori, the work they did with people with HbA1c over 75 – which is really the hardest group to work with. We have made quite big inroads in improving those results.”
If that’s colled out wider so that all diabetes patients can get enhanced care close to home they maybe, just maybe, the escalating demand for dialysis may be slowed and even reversed.
Diabetes Care Improvement Packages
- Funding for Get Checked free annual diabetes review stopped on June 30 2012, after being offered for 10 years, because the scheme was not getting the desired results.
- The $8 million funding (upped to $11 million a year in 2013 budget) is instead redistributed to district health boards to develop primary-care focused Diabetes Care Improvement Packages.
- Diabetes annual reviews are no longer a formal target or nationally funded but are still encouraged as good practice and required by some DHBs and PHOs.
- The national health target of more heart and diabetes checks is aiming for 90 per cent of the eligible population to have had their cardiovascular (including diabetes) risk assessed in the last five years with the national average now sitting at 73 per cent.
MidCentral’s specialist diabetes nurses in practice project
Neighbouring MidCentral DHB and Central PHO also now has diabetes nurse specialists working alongside nurses and GPs in general practice.
Debbie Davies, lead clinical nurse specialist in primary health care in the DHB’s Health Care Development team, says it is employing diabetes nurse practitioner Pauline Giles and diabetes nurse specialist Lois Nokolajenko to offer specialist care in general practices at the same time as building capability in the general practice team.
The pair are working as part of the region’s Diabetes Care Improvement Package, as well as the Better Soon More Convenient business case, and are targeting 12 general practices –particularly the large integrated family health centres in outlying areas such as Horowhenua and Fielding.
Instead of providing an outreach service, the specialist nurses are working alongside the general practice teams, carrying a case load as well as providing collaborative consultations with the GP, practice nurse and the EnhancedCare+ community clinical nurse* to help build confidence, competence and an integrated multidisciplinary approach.
Davies says the Specialist Diabetes Nursing in General Practice project has been underway since the New Year and anecdotal feedback suggests one area it is impacting on is that people are turning up to specialist appointments when they are offered in a familiar setting with staff they already know.
But a full research study is also linked to the project to measure the impact on both clients’ and health professionals’ knowledge.
*The region has 23 community clinical nurses who are long-term condition nurses proficient in one long-term condition and competent in the others.