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Diabetes Prevention Strategies—Diabetes case care and quality control promotion strategies

This strategy will focus on Chung-Hua County, implementing the promotion of “Community-based model” and the trial of “Novel Strategies”. There are four main steps for the promotion of “Community-based Model”, which include: verification and certification, team-work care, quality control and monitoring, and project evaluation, and by utilizing these steps, it allows us to achieve “Community-based Diabetes care network model and its quality control measurement”. Based on past experiences, modification of this model and related procedures and its quality control mechanism will help to formulate a better guidelines and for policy forming. This proposed plan would incorporate with original model formulation agency to complete “Diabetes care and quality control booklet”. This plan will be under the supervision of Bureau of Health Promotion, Department of Health, Taiwan, R.O.C., and collaborate with 2 or 3 counties to promote his proposed model. In the aspect of trial of “Novel Strategies”, this proposed plan will implement the method mentioned above on local health clinics and evaluate its effects and benefits and integrate with “Community-based Model”.

●Background:

Chung-Hua County Bureau Health has promoted Diabetes care network within the county according to Department of Health, The Executive Yuan guideline since 1997. Prior to this, Lan-Yan (Yi-Lan County) Diabetes care network had been functioned for more than a year, and this network model effects at county level, and Bureau Health and area hospitals play major roles in integrating medical resources. The fundamental step of the plan is to ensure the quality control of care services and it has established the quality assurance procedures and has provided continuous educations for physicians. We want to provide health care from several angles, when Chung-Hua Bureau Health first designed the Diabetes care network; it used the Lan-Yan experiences as a model, but focused on community-based medical care. We choose Yuan-Lin Township to establish a Diabetes care network that provide community health care services because the township has fair easy community care assess, but overall care resources is limited and scarce. It has been three years, from July 1997 to December 2000, and the results demonstrate as following:

1. It is feasible to utilize community-based health care orientated Diabetes care network. This model used the existing medical resources: use local health clinics as main driving force; use area health care resources as center, and use medical centers as support.
2. The training courses provided by Diabetes Care Health Education Associations can improve care givers quality and will help to set up a standard to ensure the quality.
3. Patient support resource network can be used as a push to promote higher quality of health care.
4. Utilize community eye care resources, and utilize planning and referral services to provide Diabetes patients better retina care.
5. Under the umbrella of adequate referral system, Diabetes patients would receive kidney diseases screenings within the community.

According to the data from Bureau of National Health Insurance, Department of Health, The Executive Yuan, there are about 37% of Diabetes patients in Chung-Hua County seeking care in the local health clinics. But data from providers’ viewpoint shows that about 70% of local health clinics receive less than 50 Diabetes patients annually.

Data analysis on Diabetes health care improvement shows that about 1/4 of the Diabetes patients receive integrated Diabetes care, and most of the care are provided in major local hospitals. Only less than 4% of Diabetes patients received complete care in the local level compared to 60% of patients receive complete care in medical centers. It indicates that there is an urgent need to improve the care within in local level.

●Method and steps

It will be described in two parts.:

Part I: Based on “Community-based model” need to develop “Novel model”.

The “Novel model” will include the following 6 aspects:

1. Develop a simplified version of complete care to address the low patient admission issue in the local clinics.
2. Categorize patients and provide individual health education based on their needs to improve effectiveness of resources and services.
3. Specialty care in the local level, and to improve prescription quality and safety of drug administration to improve patients' willingness to follow doctors' orders.
4. Use patient support groups as base and collaborate with outpatient health education to develop community based self health education model.
5. Establish a public health based basic health care services for Diabetes patients in the community.
6. Information resources system for patients.

Diabetes patient care services and information system will be implemented after the implementation of these proposed strategies.

• To develop a simplified method to provide complete care services among local health clinics that have low patient admission and to provide health educations for those needed.
  Steps:
  For the first year

1. Survey those health clinics that have low patient admissions, and evaluate those if the doctors in those clinics are willing to participate in brief and complete care services network.
2. Study of those patients who seek care in those health clinics, especially for low admission clinics.
3. Formulate the human resources needed and its procedures for complete care services.

For the second year

1. Invite those clinics are low admission who intent to participate in our plan for a trail.
2. Conduct pilot study of Diabetes Care and complete the recruitment for DM cases.
3. Evaluate its effectiveness and modify the procedures if necessary.
4. Involve all low-admission the health clinics participating in the strategies.

• To develop a simplified method to provide complete care services among local health clinics that have low patient admission and to provide health educations for those needed.
  Steps:
  For the first year

1. Resource integration between Taichung county and Chung-Hua county.
2. Set up selection criteria for health education needs based on risk factors, disease complications, and patients’ cooperation.
3. Diabetes patient individual care model: outpatient service will be the priority, accompany with home visits to provide patients medical care, blood work, retinal care, urinary protein screenings, podiatry care, nutrition educations.

For the second year

1. Set up categorization standards and provide different education for patients needs
2. Provide trainings for health clinics' employees.
3. Categorize patients
4. Educate patients based on the category
5. Evaluate the effectiveness and modify the standards and education contents.

• Primary care and specialized physician integrated care to improve prescription safety and encourage patients to follow doctors' order. Organize case discussion, evaluate disease and prescription history. Establish network between primary care physicians and specialized physicians to promote drug safety. Improve the dialogues between doctors and patients in order for patients to follow with the doctors' prescription.
  Steps:
  For the first year

1. Organize primary-specialist integrated care team
2. Ask health clinics' physicians to analyze patients' conditions
3. Ask health clinics' physicians to analyze patients' prescriptions.

For the second year

1. Formulate guidelines for physicians to follow up with disease prognosis.
2. Formulation guidelines for physicians to ensure prescription quality
3. Trial on the formulate guidelines
4. Effectiveness evaluation.

• Use patient support group as foundation, collaborate with outpatient health education to develop community self care health education model. By working with patient support groups, implement community self care health education to increase patients' capability for self care. The health educations are promoted through population approach and individual approach.
  Steps:
  For the first year

1. Organize community self care health education campaign team
2. Assist patient support groups which organized by local health clinics to ensure their functionality.
3. Focus group discussion with patient support groups to understand the issues related to self care in order to design better community self care health education system.
4. Design a system to combine community self care health education and patient family support groups activities.

For the second year

1. Finalized the subjects and course outlines for self care health education.
2. Training of community self care health education team members
3. Execute self care health education.
4. Evaluate effectiveness.
5. Establish community Diabetes patients basic care system based on public health concepts

• This proposed system is mainly based on public health system, by utilizing fundamental health care delivery network, it can provide community Diabetes patients basic care services. Besides, integrate this care services with existing local health clinics health services, including screening for chronic diseases, blood sugar monitoring and so on. This is to ensure that we can provide quality care services to Diabetes patients, and in addition, we can minimize the potential impact due to the health care system changes.
  Steps:
  For the first year

1. Conduct analysis on the possible integration between local health clinics care services and Diabetes patients care services.
2. Formulate the Diabetes patient care services contents
3. Formulate the integration contents.
4. Feasibility analysis based on budget and human resources.
5. Design procedures and timeline.

For the second year

1. Choose health clinics to participate in trials.
2. Evaluate effectiveness and modify the plan accordingly.
3. Execute the plan at all levels.

• 6. Information management system which focus on patients' needs Use “Community-based Model” information system as a base, and focus on patients and their family's self care needs to provide necessary information for them.
  Steps:
  For the first year

1. Interview patients and their families to understand what kind of information they need regarding self care.
2. Finalize contents and issues of self care information.

For the second year

1. Organize self care information retrieving system and link with health education services.
2. Conduct system trial with input from patients and family members and modify the system accordingly.
3. Information system set up and test.
4. Promote the access of the system.
5. Feedback survey from patients and family members.

Part II: Focus on Chung-Hua county and promote “Community-based Model” and conduct trial of “innovative plan”.

Strategies and outlines

• The process of conducting “Community-based Model” and “Novel plan” should consider the following aspects: Capacity Building, Collaboration and Coalition Building, Community Involvement and integrating into Existing Systems. The primary target of this strategy would be local health clinics and local level private clinics. This plan would collaborate with basic care services provider teams, which would composed from local health clinics and local private clinics, to promote health care. In addition, the plan would select some health clinics and private clinics to participate “innovative model” plan.
• “Community-based Model” promoting strategies: Due to Diabetes care covers wide spectrum, how to effectively promote and ensure the quality of care will be the key of the strategies. In the preparation stage, the information regarding where the Diabetes patients reside and what are the existing care resources should be analyzed. This plan would consider the complexness and integration of the care services, and divide the Diabetes care services “Community-based Model” into four stages:
  Verification→Team care→Quality control→Evaluation
  
  1. Verification: include all the man power training, resource integration, and the organization of human resource database.
  2. Team care: include composition of the team, service model (completed and integrated care services), team function (singer or combined), team communication (case discussion), pateint self care (patient support groups), database set up, information system usage and referral procedures design.
  3. Quality control: include utilize information and network system to conduct self monitor, internal monitor and external monitor; also include test quality and assurance.
  4. Evaluation: include discussion regarding the plan execution (experiences share, focus groups, interviews), and model modification.

  These proposed strategies will follow the aforementioned steps, step by step to execute “Community-based Model” and proceed to plan evaluation. The results of the evaluation can be used as a blueprint for policy formulation.

• Pilot study for “Novel plan” of Diabetes Care Include basic team care service, patient categorization, primary-specialist physicians collaborating care, self care health educations and so on. Conduct trial and evaluate its effectiveness on selected local health clinics at first and then widely spread to the whole county.
  Goals:
  1. 80% of county local health clinics would conduct at least once Diabetes patient integrated team care.
  2. At least 10 private clinics would participate in “Diabetes health care service improvement” within the county, and would provide 300 Diabetes care services.

  Major steps include:

1. Establish this working group: the team should include contacted experts, scholars, care team, representatives from Bureau Health, and focus on model design and problem solving strategies.
2. Human resource recruit, training, and qualification procedures.
3. Collaborate with ophthalmologists to provide retinal screenings, and conduct screenings at rural areas.
4. Integrated with nutritionist resources.
5. Conduct trials at local health clinics.
6. Information system input and modification-- include demographic information, urine sample, podiatric examination results, integrated with hospital test information, nutrition education, and retinal care referral. The system should reflect the input from local health clinic workers, and allow health care managers and Diabetes care physicians to access the information.
7. Care experience sharing for Diabetes by report or discussion.
8. Organize urinary protein screenings, podiatric examinations and referral services.
9. HbA1c quality control and assurance.
10. Care quality index monitoring.
11. Evaluate model and assess the impact from external factors.

The goals for the second year:

1. 80% of county local health clinic Diabetes outpatient services would accomplish monthly analysis and provide quality improvement plan; complete this proposed strategy promotion booklets.
2. At least 3 private clinics would participate in Community-based Model strategies within the county, and would accomplish 200 Diabetes patient team care services.
3. Accomplish integration between care provider system and Diabetes care system.
4. Encourage and promote this model to other counties.

Major steps include:

1. Establish integrated system to link health providers and Diabetes care services.
2. Establish a self monitoring, internal monitoring, external monitoring, and quality assurance system.
3. Provide nurse chief trainings.
4. Assess the effectiveness of screenings and referral services.
5. Examine the effectiveness and accuracy of information system.
6. Conduct interviews and focus groups to evaluate the plan progress.
7. Publish the model promotion booklets.
8. Assist other counties who would follow this model and help them to conduction self evaluation.

●MExpect results

This proposed plan expects to promote Community-based Models to all the local health clinics within Chung-Hua county during the two year trial, and utilize basic health care team work structure to promote the collaboration between health clinics and private clinics, and as a result, the local health clinics would develop to become community Diabetes health education center and health management center. The experiences from executing this plan in our county would be applied and help other communities for policy making purpose.

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