Initial Assessment
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Initial Assessment

Patients are seen at the Primary Care Diabetic clinics either as new cases or as follow ups. In the case of follow ups these can be either received directly from Mater Dei Hospital or follow up from the of registered diabetic clinic population.

 
New case can be referred either by the General Practitioners from within the respective health centers, or from private GPs. In both situations the standard ticket of referral is used as a standard when referring the patient to the Diabetic clinic. In the case of follow ups received from Mater Dei Hospital these will be accompanied by a file and computer print outs with the latest clinical information. 

For the compulsory complication screening specific forms are used for retinopathy and podiatry screening. These are registered as PHD 139 and PHD 140 respectively.


Patient care pathways for patients with Diabetes (newly diagnosed) at Primary Care
Protocol for shared care Diabetes_Page_07_Edited_NewCase_Pathway.jpg
Once a newly diagnosed patient is registered into the shared care Diabetes Program the following obligatory steps are followed:

  1. Registering patient data in the Diabetes Management Computerised System.
  2. Recording all biochemical and haematological parameters in the Diabetes management Computerised system and in the patient register.
  3. Patient Education plan by the Diabetes Nurse.
  4. Clinical management plan by GP.
  5. Apply for Schedule V card for free medicinces.
  6. Book an Appointment with Consultant Diabetologist.
  7. Book Appointments to screening for Diabetic retinopathy and Diabetic foot problems.
  8. Refer for ECG and Chest X Ray if there is presence if Hypertension or Ischaemic Heart Disease according to cardiovascular assessment.
  9. Referral to specialist clinics accordingly (Nephrology, Neurology, Vascular etc.)
  10. Follow up appointment every 6 months at diabetes clinic (Primary Care) or refer back to private GP for follow up.

 

Patient care pathways for patients with Diabetes (follow up) at Primary Care

Diabetes shared care protocol follow-up pathway.jpg
Follow up of patients with established Diagnosis of Diabetes are received from within the system itself or from the Mater Dei Hospital and from private GP's. 

In all cases the following steps are followed:

  1. Checking that patient data is entered into the Diabetes Management computerised system and updating it.
  2. Requesting routine blood investigations and other specified tests required.
  3. Diabetes nurse will ensure self management and patient education.
  4. Patient adherence to established management plan by GP.
  5. Organise appointments for screening.
  6. Organise appointment to see consultant at least once a year.
  7. Six monthly follow up by GP.

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Urgent Referal to Hospital Specialist

An agreed mechanism has been set up and is in place for the immediate access to consultant Diabetologist and fast tracking of patients needing urgent assessment of glycaemic control. General practitioner /Diabetes Nurse contacts the Department of Diabetes and Endocrinology at Mater Dei Hospital and case discussed with consultant or Resident Specialist Diabetologist. The current IT system allows for real time online consultation and management plan communicated accordingly.

 
Visiting Hospital Specialist Diabetologists

The Diabetic clinics will receive visiting hospital Diabetologists on a twice monthly basis. They have the role of liaison between general practitioners and also to see and discuss specific cases and provide rapid access of expertise to patients with diabetes.
 

Clinical Audit

The National Institute for Clinical Excellence, defines a clinical audit as “A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.” General Practitioners have long recognized the importance of audit to assess outcomes and quality of care that they provide to their patients and this protocol provides for the conduct of an audit process to analyze and improve the quality of diabetes care in Primary Care.
  • This shared care model shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies.
  • Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity.
  • Comparison of the health needs of local populations with national data could be used to inform commissioning services.
  • However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.