CardioVascular Disease

1
Cardio-Vascular Disease and Diabetes Allied
Health Education Package
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Introduction

• Why is the program needed?
• What Information will be covered over the next
  couple of days?
• Who is the target audience?
• How will program delivery continue into the
  future?

3
History/Background

• Formation of the Diabetes Allied Health Task
  Group by Health Advisory Unit - Queensland
  Health
• Chaired by Principal Allied Health Adviser (3234
  1386)

4
History/Background

• Phase 1 - Diabetes Guidelines Recommended by
  Task Group
• Developed by Jackie Nankervis, Health Advisory
  Unit (3225 2328)
• Now developing CVD Guidelines

5
History/Background

• Phase 2 - Implementation of the Diabetes
  Guidelines
• Train the Trainer Education Sessions Contracted
  to the National Heart Foundation in association
  with Diabetes Australia Queensland
• CVD Guidelines training to be explored once the
  guidelines are developed

6
History/Background

• Phase 3 - Sustainable Resource for Diabetes CHD
  Guidelines being developed by National Heart
  Foundation
• In association with Diabetes Australia Queensland
• With Ongoing Management by Health Advisory Unit -
  Ian Callow (3234 1157)

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Queensland Health's Health Outcomes Plan for
Diabetes Mellitus in Queensland
1999-2004
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National Diabetes Strategy Goals

• Improve the capacity of the health system to
  deliver, manage and monitor services for the
  prevention of diabetes and the care of people
  with or at risk of diabetes
• Prevent the delay the development of Type 2
  diabetes
• Improve health related quality of life and reduce
  complications and premature mortality in people
  with Type 1 and Type2 diabetes

• Achieve long term maternal and child outcomes for
  gestational diabetes and for women with
  pre-existing diabetes equivalent to those of
  non-diabetic pregnancies
• Advance knowledge and understanding about the
  prevention, delay, early detection, care and cure
  of Type 1, Type 2 and gestational diabetes

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Queensland Health's Corporate Plan 1999-2004

• Increased proportion of the population with
  eating behaviours consistent with the NHMRC
  Dietary Guidelines for Australians (1992)
• Reduced prevalence of high blood pressure and
  high cholesterol in the general population

• Screening,education and promotion services in
  National Priority and Key State Service Areas to
  meet agreed benchmarks
• Demonstrated progress toward achieving health
  outcomes in National and State Priorities for
  Aboriginal and Torres Strait Islander Health
• Reduction in the prevalence and incidence of
  smoking in the general population increased
  community participation in exercise

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The Importance of Data Collection
EVIDENCE (I),(II),(III),(IV)
INDICATORS DATA COLLECTION
PLAN
GUIDELINES STRATEGY
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Primary Health Outcome

• Reduced rate of increase of diabetes mellitus,
  its health impact on the Queensland population,
  and its associated health system cost.

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How is the Primary Outcome going to be Achieved?

• PREVENTION
• EARLY DETECTION AND MANAGEMENT

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Prevention Strategic Priorities

• Increase community participation in regular
  physical activity
• Increase the proportion of the population with
  eating behaviours consistent with the NHMRC
  Dietary Guidelines for Australians (1992)

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Evidence Based Strategies

• Behaviour change
• Health promoting environments
• Communication and education
• Environmental/policy/behavioural
• Training
• High risk and identified groups

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Outcome Performance Indicators

• Age-standardised incidence and age-specific
  prevalence rates of diabetes
• Incidence rates for CHD
• Prevalence of overweight and obesity
• Rates of non-participation in regular sustained
  moderate aerobic exercise
• Prevalence of a high fat diet
• Awareness of the early symptoms of and risk
  factors for diabetes

• Access to factors which maintain health
• Opportunities for increased physical activity
• availability and access to healthy food choices
• adoption of health promoting organisational
  policies

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Model of Care - Type 1
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Aims

• Develop individualised Plans
• Optimal psychological adjustment
• Glycaemic control
• Normal growth development

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Type 1 - Service Delivery
Paediatric Endocrinologist Paediatrician/Physician
General Practitioner
Diabetes Educator, Dietitian, Mental Health
Worker
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Type 1 - Services

• Specialised hospital medical care
• Glycaemic Control
• Expert advice
• Screening

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Type 1 - Reviews

• Diabetes control and adjustment (3 monthly)
• Postpubertal adolescents who have had diabetes
  for two years
• Prepubertal children who have had diabetes since
  early childhood

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Model of Care Type 2
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Type 2 - Aims

• Consistent clinical management - guidelines
• Optimal psychosocial adjustment
• Optimal metabolic (glycaemic) control

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Type 2 - Core Services

• Specialised hospital medical care
• Glycaemic control
• Expert advice
• Screening
• Tailored care for people who have special needs

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Type 2 - Team Approach

• Endocrinologist/physician/general practitioner
• Diabetes educator
• Dietitian
• Podiatrist
• Health psychologist or social worker
• Client with diabetes

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Type 2 - Care Coordination

• General Practice Advisory Council - Standard
  Care Pathway for Diabetes
• Team approach across settings
• Essential management and referral steps
• General practice - preferred care coordinator

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Type 2 Reviews

• Annually review/evaluate
• effectiveness of the care provided
• signs of complications

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Early Detection and Management
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Strategic Priorities

• DEVELOPMENT AND IMPLEMENTATION OF EVIDENCE BASED
  GUIDELINES TO DIRECT DIABETES RELATED SERVICE
  PLANNING AND DELIVERY

• Screening activities
• Development and implementation of clinical care
  pathways in hospital
• Management
• Implementation of education guidelines
• development of guidelines for
• impotence among males
• urinary incontinence among females
• Human resources for implementation

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Strategic Priorities

• Role delineation
• Provider recall of patients
• Patient access to services as per guidelines
• The collection of minimum data set across
  providers
• Implementation of collaborative service models
  for the management of diabetic retinopathy
  (local diabetes network groups)

• REDESIGN OF SERVICES TO BE COLLABORATIVELY
  PLANNED AND DELIVERED AND WHICH ENSURE ACCESS TO
  PEOPLE AT NEED

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Strategic Priorities

• Social, behavioural and environmental
  determinants of health
• Raise community awareness of diabetes
• Incentives for people with diabetes
• Investigate the effectiveness of brief
  interventions in promoting optimal management and
  healthy lifestyle choices

• SERVICE PLANNING AND DELIVERY FOCUSSED ON
  ENHANCING THE CAPACITY OF PEOPLE TO PREVENT
  DIABETES OR OPTIMALLY MANAGE THE DISEASE IF
  PRESENT

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Strategic Priorities

• Training for health professionals
• Indigenous health workers trained in diabetes
  education
• Support service providers in implementing
  clinical management guidelines by automating care
  plans

• INFORMED AND NETWORKED DIABETES SERVICE PROVIDERS

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Strategic Priorities

• Diabetes - mandatory field on hospital admission
  form
• NDOQRIN minimum data set
• Access to healthy, affordable food
• Incidence and prevalence of diabetes and its risk
  factors
• Adverse outcomes of management

• INFORMATION SYSTEMS IN PLACE TO DIRECT EVIDENCE
  BASED CLIENT MANAGEMENT

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Strategic Priorities

• RESEARCH INFORMS SERVICE PLANNING AND DELIVERY

• Progressing knowledge of effective diabetes
  prevention and management interventions,
  particularly among high risk groups

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Outcome Performance Indicators

• Reduced mortality associated with Diabetes
• Reduced prevalence of Diabetes related
  complications
• Enhanced quality of life for people with Diabetes
  
• Reduced prevalence of risk factors for
  complications in people with Diabetes

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Best Practice Guidelines For the Management of
Type 2 Diabetes
Podiatry
Dietetics
Diabetes Education
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Diabetes Educator

• Membership of the Australian Diabetes Educators
  Association

• Working towards or fulfilled the requirements of
  the Australian Diabetes Educators Association to
  be considered a diabetes educator
• Qualifications

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Diabetes Resource Person

• Has undertaken an appropriate level of education
  
• Role is to support the person with diabetes and
  the Diabetes Educator to achieve optimal health
  outcomes.

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Referrals

• Patient rights
• Self referrals
• Consistency
• Accessibility
• Patient autonomy
• Deterioration of presenting health problems

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When to Refer to a Diabetes Educator?

• Initial diagnosis of diabetes
• Diagnosis of impaired glucose tolerance
• Change in the management of diabetes
• Change in physical status
• Psychological changes
• Social changes
• Annual review of clients
• People at high risk for developing diabetes
• Gestational Diabetes Mellitus

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Optimal Level of Education

• Refer to flow Chart - Appendix 2

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Priority Patients

• Newly diagnosed
• Changes to management/treatment
• Development of complications
• Assistance with blood glucose monitoring
  technique
• Review/assessment of those that do not access the
  service on a regular basis
• Knowledge and educational needs
• Assessment of complications
• Clinical indicators outside normal parameters for
  psychological wellbeing reasons
• For social wellbeing reasons

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Group Education

• Criteria that would restrict group education
  sessions
• Criteria limiting the benefits to the individual
  within group education sessions

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Other Considerations

• Standards of professional practice
• Indigenous health workers
• Flexible competencies
• Education Elements

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Guidelines Workshop Diabetes Education
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Best Practice Guidelines For the Management of
Type 2 Diabetes
Podiatry
Diabetes Education
Dietetics
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Dietitians Aims

• Achieve and maintain optimal nutritional status
  for clients
• Minimize the risk of short and long term
  complications and
• Promote optimal patient wellbeing.

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Interventions

• Outcome focused
• Consistent with evidence based approaches
• Both treatment and prevention of disease
• Professional standards and best practice
  guidelines
• Promote a self-management philosophy.

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Qualifications

• Mandatory
• Highly Desirable

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When to Refer to a Dietitian?

• Initial diagnosis or impaired glucose tolerance
• Recent change in management HbA1c ? 8
• Episodes of uncontrolled glycaemia
• Dyslipidaemia
• Obesity BMI gt 30kg/m2
• Pregnancy / Intention to become pregnant
• Gestational Diabetes
• Renal complications / Nephropathy
• Active comorbidities e.g. recent MI, worsening
  CVD
• Concurrent medical conditions
• Sudden unexplained weight loss or weight gain
• People with recognised risk of developing
  diabetes23
• Annual review of client if not seen within 1 year

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Individual vs Group Consultation

• Non English speaking requiring interpreter
• Impaired vision or hearing
• Episodes of uncontrolled glycaemia
• HbA1c ?8
• Obesity - BMI ?30Kg/m2
• Nephropathy
• Gestational Diabetes
• Behaviour not conducive to group learning
• Any patient with type 2 diabetes who requires
  insulin and is experiencing difficulty in
  controlling BGL
• Active comorbidities
• Concurrent medical conditions

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Lifestyle and Nutrition Interventions Outcomes
and Objectives

• Achieve And Maintain Body Fat Loss In People With
  A BMI ? 27 Kg/M2 Or Waist gt102cm (Male) Or gt88cm
  (Female)25
• Achieve and Maintain Positive Lifestyle Behaviour
  Changes
• Nutrition
• Physical Activity
• Psychosocial factors

• To achieve and maintain optimal nutritional
  status
• To minimise the risk of short-term and long-term
  complications
• To promote optimal client well-being
• Metabolic Control
• Blood Glucose Control
• Blood Lipids
• Blood Pressure

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Priority Patients for Dietary Care

• HbA1c ? 8
• Newly diagnosed diabetes or impaired glucose
  tolerance
• Obesity BMI gt 30kg/m2
• Episodes unsafe hypoglycaemia or hyperglycaemia
• Active comorbidities e.g. recent MI or worsening
  CVD (unstable angina, dyslipidaemia (ongoing, not
  improving))
• Nephropathy
• Any patient with Type 2 Diabetes who requires
  insulin and is experiencing difficulty in
  controlling BGLs
• Gestational Diabetes

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Other Considerations

• Standards of professional practice
• Level of care
• How to use the guidelines
• Select the elements
• Evaluates results
• Negotiates goals
• Implements intervention/education strategy
• Tables of Elements
• Flexible competencies

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Guidelines Workshop Dietitics
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Best Practice Guidelines For the Management of
Type 2 Diabetes
Diabetes Education
Dietetics
Podiatry
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The Role of the Podiatrist

• Maintenance of foot health
• Maintenance of mobility
• Prevention of complications to the feet
• Decrease the level of morbidity and amputations

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Qualifications

• Mandatory
• Highly Desirable

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Clinical Management Guidelines

• Lower Limb Assessment and Referral Pathway (Page
  6)

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Referrals

• Annual Foot Assessment
• Foot Care and Health Promotion
• Requires Podiatry Referral

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When to Refer to a Podiatrist?

• Clinical Signs of
• Foot ulcer
• Foot abnormality
• Skin pathology
• Warm oedematous foot
• Peripheral neuropathy
• Peripheral vascular disease
• Gait abnormalities, unsteadiness or change of
  gait
• Muscle wastage in the lower limb
• Restricted joint range of motion

• History of
• Previous foot ulceration
• Previous partial or total foot amputation
• Poor ability to heal injured skin within normal
  time frame
• Intermittent claudication
• Rest pain
• Neuroarthropathy
• Neuropathic symptoms

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Annual Basic Foot Screening by Non-Podiatrists

• Who?
• What?
• When?
• Why?

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Comprehensive Foot Assessmnet by Podiatrists

• Dermatological
• Wound classification and management
• Nail management
• Vascular
• Neurological

• Biomechanical
• Morphological
• Footwear
• Education
• Individual or group

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Other Considerations

• Standards of professional practice
• Risk categorisation
• Level of service delivery
• Assessments and managements
• Flexible competencies

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Guidelines Workshop
Podiatry
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Resource Scenario Workshop