National Diabetes Work Programme 2014/15

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National Diabetes

Work Programme

2014/15

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Ministry of Health Work Programme for Diabetes 2014/15

OVERVIEW

This document outlines the Ministry of Health (the Ministry) diabetes team work programme for 2014/15,

including key priorities and the initiatives and objectives to achieve those priorities. This document also

shows the links across the Ministry’s various teams and work programmes and how those links contribute

to the diabetes team priorities.

The National Diabetes Work programme brings together the work of the Ministry, National Diabetes Service

Improvement Group (NDSIG), Health Quality Safety Commission (HQSC), District Health Boards (DHBs)

and Primary Health Organisations (PHOs) to implement the Government’s priorities for diabetes.

Non communicable diseases such as diabetes, cardiovascular disease and cancer are the leading causes

of mortality in New Zealand. The Ministry will work closely with the social sector and other sectors to

influence New Zealanders decisions about how to improve their own health. The Ministry continues to seek

to prevent the onset and impact of non-communicable diseases through more regular health checks

relating to diabetes and cardiovascular disease and their risk factors.

VISION

People living with diabetes are regarded as leading partners in their own care within systems that ensure

they can manage their own condition effectively with appropriate support.

Health services for people with diabetes in New Zealand will be high quality, patient focussed and

integrated across the health continuum from prevention to tertiary care thereby reducing the diabetes

burden and enabling optimum health outcomes.

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ROLE OF THE MINISTRY OF HEALTH

The MOH Diabetes team are the essential link between diabetes policy and frontline service improvements

for patients. Through our integrated work programmes across the Ministry and coordinating with other

government agencies, we are able to provide national leadership and direction and support local voices

working to champion good quality diabetes care.

Key Principles of the Diabetes Work Programme

The aim of the work programme is to focus service delivery on enhancing care and quality of life for

people with diabetes. The work programme assumes that the focal point of care remains in primary care

and the community setting, and this is supported by integrated primary health care teams and specialist

health services.

The work programme follows three key principles:

1. Prevention

2. Identification

3. Management

These key principles are underpinned by enablers and monitoring to support the implementation of the

work programme.

Work programme goals are to:

1. Prevent: Limit and reduce the risk of developing diabetes

2. Identify: Reduce the risk of developing complications for those New Zealanders with diabetes

3. Manage: Reduce the risk from complications of diabetes where they exist

4. Enable: Support and develop systems to provide high quality care for people with diabetes

5. Monitor: Continually improve diabetes services to ensure equity of access and quality care

The MOH diabetes team work with the National Diabetes Service Improvement Group (NDSIG), a Ministry

funded group of experts, including consumer representation.

The NDSIG currently have key work streams looking at:

 Prevention and prediabetes

 Complications of diabetes

 Patients with Type1 diabetes, Children and Young people

 Inpatients with diabetes

 Workforce requirements and development

 Health system performance

 Self-management

Prevention

Identification

Management

Enablers

Monitoring

SYSTEMS PEOPLE WITH DIABETES

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Being overweight significantly increases an individual’s chance of developing Type 2 diabetes. The Ministry

is coordinating several programmes of work looking at policies that influence lifestyle changes such as diet

and physical activity.

Initiatives Deliverables

More Heart and Diabetes Checks health target

 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years.

Evaluation of a prediabetes pilot at Albert Street Clinic

 Contract for the evaluation of the prediabetes programme at Albert St Medical Centre.

 Distribution of lessons learnt following completion of the evaluation.

 Development and distribution of options to make the model transferrable to other DHBs and their populations.

Prediabetes Pilots  Contract three prediabetes pilots, Health Hawkes Bay, Harbour Sport and Sport Bay of Plenty.

 Regular contract monitoring.

 Distribution of lessons learnt from pilots following completion of evaluation.

Māori Pilots  Conclude contract with the four Māori pilots.

 Evaluation of the Māori pilots.

 Distribution of lessons learnt following the evaluation. Green Prescription  Contract with providers to deliver Green Prescriptions. Healthy Families New Zealand  Commencement of 10 community pilot sites, which will reach

approximately 900,000 New Zealanders.

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Early identification of long term conditions such as diabetes allows people the opportunity to manage their

diabetes before it becomes out of control. This management also includes the early identification of

complications such as foot ulceration, kidney damage and eye disease. By detecting the early signs of

damage to feet, eyes, kidneys active treatment can be undertaken to reduce the risk of amputation, renal

failure, blindness, heart attack and stroke.

There are encouraging signs that the rates of these complications in people with diabetes has been falling

over recent years.

Similarly there are new guidelines for gestational diabetes aiming for improved and earlier detection of both

established and gestational diabetes.

Podiatry assessment tool  Disseminate podiatry assessment tool to health sector. Retinal screening  Update retinal guidance.

Chronic kidney assessment  Disseminate chronic kidney consensus statement to health sector. Gestational Diabetes  Implementation of the guidelines.

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Effective management of diabetes and its complications gives people with diabetes the opportunity to live

normal lives. Management of diabetes includes prevention and early identification of diabetes related

complications.

Diabetes Care Improvement Packages (DCIPs) were introduced in July 2012 to replace the

Get Checked

programme

. The introduction of DCIP meant a change from a universal funded annual review process to a

more tailored and individualised approach to diabetes care and management. This approach to diabetes

care aims to empower people with diabetes to take an active role in their own care planning, and to ensure

the delivery of patient centred care.

The Ministry is working closely with DHBs to ensure the continued implementation of the DCIPs and related

quality improvement in diabetes services.

Inpatients with diabetes

 National inpatient diabetes guidance.

 Guidance for care planning and discharge information.

 National Diabetes ketoacidosis guidance.

 Insulin safety in hospitals guidance, in conjunction with the Health Safety Quality Commission.

Self-management support/education

 Disseminate diabetes self-management support guidance to the sector and key stakeholders.

Pilot for new model of care promoting shared care

 Three pilots commenced in May 2014, looking at patient empowerment and change management in primary care for people with chronic disease.

 Evaluation due August 2015.

 Dissemination of lessons learnt following evaluation.

Podiatry

 Finalise the accreditation of training programme for community podiatrists and continue to work with Podiatry NZ on rolling this programme out nationally.

 Develop podiatry pathways.

 Develop podiatry models of care.

Retinal

 Revise retinal screening guidance.

 Develop a model of care for retinal screening.

Psychology

 Investigate the Diabetes Attitudes Wishes and Needs (DAWN) study to support people with diabetes and their whānau.

 Stocktake of assessment tools currently used to support psychological needs.

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Enablers such as service specifications provide the mechanism for changes in key priority areas of prevention, identification and management.

20 Quality of diabetes care standards

 Disseminate standards to sector. This will form part of DHB annual planning guidance and DHB service specifications.

Development of toolkit to support standards

 Develop toolkit to support the standards. This will include academic rationale, innovation and implementation advice.

Gap analysis

 A stocktake of current services against 20 quality standards to form a baseline.

Service specifications

 Review DHB service specifications and, in the long term, develop an overarching DCIP service specification.

Framework for diabetes contracting

 Develop monitoring framework to support standards and outcomes.

Virtual diabetes register (VDR)  Run the VDR for 2013 and 2014 then disseminate results to the sector. Development of a patient charter  Co-design a patient charter.

Development of case studies  Develop six case studies to highlight innovation and patient stories. Ministry of Health website  Update diabetes page.

Innovation and resource sharing centre

 Update diabetes page on HIIRC.

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Monitoring of the health system provides the Ministry with a clear understanding of services being provided to people with diabetes. This gives us the opportunity to provide support for quality improvements and to share lessons learnt from stories of success across the sector.

There is currently inconsistency and inequity in the access to, availability of and quality of diabetes services between DHBs and PHOs. These will be addressed using the following tools and frameworks.

DHB Annual plans  Review and agree timeframes and deliverables against advice provided.

DHB Annual Planning Advice  Develop annual planning advice for 2015/16.

Quarterly reporting  Monitor progress of DHBs against annual plan deliverables. DHB visits  Visit DHBs 6 monthly.

Health Safety Quality

Commission - Diabetes Atlas of Variation

 The Atlas, shortly to be published, shows many diabetes metrics by individual DHB.

 The Atlas will be used as a quality improvement tool to measure progress in quarters 2 and 4.

World Health Organisation and OECD reporting

 Collate diabetes related data to inform reporting to the World Health Organisation and OECD.

Ambulatory sensitive

Hospitalisation (ASH) rates for diabetes

 Collate rates and trends of ASH rates and report back to DHBs as a quality improvement measure.

Clinical governance  Identify and disseminate examples/models of successful local clinical governance.

Coding of prediabetes  Share advice with health sector.

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Appendix 1: Diabetes Work Programme 2014/15

Prevention

•MoreHeart and Diabetes

Checks

•NDSIG prevention sub

group

•Green Prescription

prediabetes contracts

•Three prediabetes pilots

•Albert Street Evaluation

•Māori pilots

•Healthy Families New

Zealand

•Green Prescription

Identification

•More Heart and Diabetes

Checks

•Screening at admission to

hospital

•Early Identification of

complications

•Podiatry assessment tool

•Retinal screeing

•Gestational Diabetes

guidelines

Management

•DCIP Implementation

•Inpatients

•Podiatry

•Chronic Kidney disease

•Psychology and

depression

•Cardiovascular risk

management

•Self-management and

education

•Dietetics and nutritional

support

Enablers

•20 Standards of Diabetes

care and toolkit

•Virtual Diabetes Register

•Systematic audit

•IT infrastructure

•Service Specifications

•NDSIG

•DHB visits

•Innovation and sharing to

support quality

improvement

Monitoring

•More Heart and Diabetes

Checks

•World Health

Organisation

•OECD reporting

•Quarterly reporting

(PP20)

•Annual planning

•ASH rates

•Health Safety Quality

Comission -Diabetes Atlas

of Variation

•Gap analysis of quality

standards

SYSTEMS

PEOPLE WITH DIABETES

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Appendix 2: Quality standards for diabetes care

For revision end-2016

These standards should be considered when planning your local service delivery. They provide guidance for clinical quality service planning and implementation of equitable and comprehensive patient-centred care - scaled to local diabetes prevalence. They should be read alongside the NZGG and other guidelines which highlight specific clinical expectations. These standards are specific to people with diabetes - those identified with prediabetes should be managed in accordance with the prediabetes advice provided by the Ministry of Health (2013).

Basic care, self-management and education

1. People with diabetes should receive high quality structured self-management education that is tailored to their individual and cultural needs. They and their families/whanau should be informed of, and provided with, support services and resources that are appropriate and locally available.

2. People with diabetes should receive personalised advice on nutrition and physical activity together with smoking cessation advice and support if required.

3. They should be offered, as a minimum, an annual assessment for the risk and presence of diabetes-related complications and for cardiovascular risk. They should participate in making their own care plans, and set agreed and documented goals/targets with their healthcare team.

4. They should be assessed for the presence of psychological problems with expert help provided if required. Management of diabetes and cardiovascular risk (extensive guidelines available)

5. People with diabetes should agree with their health care professionals to start, review and stop medication as appropriate to manage their cardiovascular risk, blood glucose and other health issues. They should have access to glucose monitoring devices appropriate to their needs.

6. They should be offered blood pressure, blood lipid and anti-platelet therapy to lower cardiovascular risk when required in accordance with current recommendations.

7. When insulin is required it should be initiated by trained healthcare professionals within a structured programme that, whenever possible, includes education in dose titration by the person with diabetes.

8. Those who do not achieve their agreed targets should have access to appropriate expert help. Management of diabetes complications (extensive guidelines available)

9. All people with diabetes should have access to regular retinal photography or an eye examination, with subsequent specialist treatment if necessary.

10. They should have regular checks of renal function (eGFR) and proteinuria (ACR) with appropriate management and/or referral if abnormal.

11. They should be assessed for the risk of foot ulceration and, if required, receive regular review. Those with active foot problems should be referred to and treated by a multidisciplinary foot care team within recommended timeframes.

12. Those with serious or progressive complications should have timely access to expert/specialist help. While in hospital...

13. People with diabetes admitted to hospital for any reason should be cared for by appropriately trained staff, and provided access to an expert diabetes team when necessary. They should be given the choice of

self-monitoring and encouraged to manage their own insulin whenever clinically appropriate.

14. Those admitted as a result of uncontrolled diabetes or with diabetic ketoacidosis should receive educational support before discharge and follow-up arranged by their GP and/or a specialist diabetes team.

15. Those who have experienced severe hypoglycaemia requiring ED attendance or admission should be actively followed up and managed to reduce the risk of recurrence and readmission.

Special groups

16. Young people with diabetes should have access to an experienced multidisciplinary team including developmental expertise, youth health, health psychology and dietetics.

17. All patients with type 1 diabetes should have access to an experienced multidisciplinary team, including expertise in insulin pumps and CGMS when required.

18. Vulnerable patients, including those in residential facilities and those with mental health or cognitive problems, should have access to all aspects of care, tailored to their individual needs.

19. Those with uncommon causes of diabetes (e.g. cystic fibrosis, monogenic, post-pancreatectomy) should have access to specialist expertise with experience in these conditions.

20. Pregnant women with established diabetes and those developing gestational diabetes (GDM) should have access to prompt expert advice and management, with follow-up after pregnancy. Those with diabetes of child-bearing age should be advised of optimal planning of pregnancy including the benefits of preconception

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Appendix 3: Additional information on Quality Standards for Diabetes Care

The Ministry Diabetes Team, working in conjunction with clinical leaders and the National Diabetes Service

Improvement Group (NDSIG), have developed 20 Standards of Diabetes Care (the Standards). These standards have been developed to assist DHB planning and funding in delivering their diabetes services and to ensure high quality and equitable service provision across New Zealand. The Standards are attached to this work programme as Appendix 2.

The Standards are separated into five categories.

1. Basic care, self-management and education

2. Management of diabetes and cardiovascular risk

3. Management of diabetes complications

4. While in hospital…

5. Special groups

The Diabetes Team will continue to work with the NDSIG to develop a toolkit to support the implementation of the standards.

While the majority of the Standards address the management of diabetes care they do fit into the various work streams of the Diabetes Team work programme as illustrated in the diagram below:

PREVENTION

IDENTIFICATION

MANAGEMENT

Relevant Standards:

 Special Groups -Standard 20

Relevant Standards:

 Basic Care, self-management and education – Standard 3  Management of diabetes

and cardiovascular risk – Standards 5 & 7  Management of complications – Standards 9, 10, 11 & 12 Relevant Standards:

 Basic Care, self-management and education – Standards 1 - 4  Management of diabetes and cardiovascular risk – Standards 5 - 8  Management of diabetes complications – Standards 9 - 13  While in hospital – Standards 14 - 16  Special Groups – Standards 17 - 19

Enablers and Monitoring: Work coordinated by the Ministry Diabetes Team to implement the 20 Standards of Diabetes Care.

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Appendix 4: Prediabetes Advice

Prediabetes advice

August 2013

1. Identification of people with Type 2 diabetes or prediabetes.

Screening for hyperglycaemia is undertaken as part of cardiovascular risk assessment according to national guidelines (see Table 1, page 4 in New Zealand Guidelines Group. New Zealand Primary Care Handbook 2012. 3rd ed).

In addition, the New Zealand Society for the Study of Diabetes (NZSSD) has endorsed the need for opportunistic screening amongst younger adults (those over 25 years) who are known to be at especially high risk of developing diabetes.

The following groups are included:



Those with known ischaemic heart, cerebrovascular or peripheral vascular disease



Those on long-term steroid or anti-psychotic treatment



Obese individuals (BMI ≥ 30 - or ≥ 27 kg/m

2

_{for Indo-Asian people)}



People with a family history of early age onset of Type 2 diabetes in more than one first

degree relative



Women with a past personal history of gestational diabetes mellitus



In addition, obese children and young adults (BMI ≥ 30 kg/m

2

_{or ≥27 kg/m}

2

_{in Indo-Asian)}

should be screened if there is a family history of early onset Type 2 diabetes, or if they are of

Māori, Pacific or Indo-Asian ethnicity.



Women with Polycystic Ovarian Syndrome (PCOS)

Haemoglobin A1c (HbA1c) is the recommended screening test for diabetes and prediabetes. While acknowledging that increasing levels of HbA1c are associated with a continuous gradient of risk of progressing to diabetes, those with HbA1c levels in the range 41–49 mmol/mol are considered to have prediabetes1_{, otherwise known as ‘intermediate}

hyperglycaemia’.

Impressive evidence from many randomised controlled trials (RCT) indicates that the risk of progression from prediabetes to diabetes can be substantially reduced through lifestyle modification or, to a lesser extent, with drug treatment. Additionally, the fact that cardiovascular risk rises with increasing levels of HbA1c further justifies intervention in people with prediabetes.

Rates of prediabetes in New Zealand vary according to age, sex and ethnicity but the overall prevalence amongst New Zealand residents aged 15 years and over is about 25 percent.

2. Lifestyle management of people with prediabetes

RCTs have confirmed the potential of lifestyle modification to approximately halve the risk of progression from prediabetes to Type 2 diabetes over a prolonged period. The following principles can help in providing advice to individuals:

Principles of initiating change

 Changing eating and activity patterns and life-long habits is not easy

 Assess willingness to change

 Encourage people to make one change at a time

 Start with small achievable goals, especially those which might be expected to give the greatest benefit

 Ensure that people know what foods contain ‘sugar’ and hidden fat

 Encourage and congratulate even the smallest success

 Ensure that there is an agreed plan with the individual that includes follow up

Reducing weight

 Weight reduction is the most important target for most people with prediabetes.

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 Assuming the patient is overweight or obese, aim for a weight loss of 0.5–1kg per week and a long-term loss of at least 5 per cent of initial weight - but acknowledge any degree of loss as a success

 Staying the same weight may be a meaningful achievement for some individuals

Follow the healthy eating guidelines

 Eat three meals a day including 5+ serves of fruit and vegetables

 Reduce sugary foods and drinks by:

a) substituting cakes, biscuits and snack foods with fruit b) drinking water instead of fizzy or sugary drinks

 Reduce fat by:

a) using low-fat dairy products (e.g., skimmed or calci-trim milk, low fat yoghurts) b) limiting fried foods and takeaways to once a week or less

c) avoiding food with hidden fat (e.g., pies, pastries, chippies)

 Have smaller portion sizes – use a smaller plate

Increase exercise

 Consider a ’Green Prescription’

 Aim for 30 minutes of moderate intensity exercise such as brisk walking on most days - when possible increase exercise time to 60 minutes per day

 Snacks of exercise may be a good alternative, for example 3 x 10 minutes during the day

 Help the individual find an activity that fits in with their lifestyle and is sustainable. Undertaking exercise with others is often more enjoyable

 Any increase in activity, however small, is a positive step

 Reduce inactivity – avoid sitting for extended periods e.g., TV watching (even standing uses more energy)

Follow-up

Follow up needs to reflect the goals and plan agreed with the person, particularly with lifestyle interventions.

Initial HbA1c should be repeated after three months of ‘lifestyle therapy’ and thereafter at 6–12 monthly intervals, as should measures of weight, dietary and exercise changes.

Treatment with metformin should be considered after 6–12 months for those whose HbA1c levels continue to rise despite attempts to make lifestyle changes, or when levels are close to the cut-off level for diabetes and are not falling (i.e 46–49 mmol/mol).

Self-monitored blood glucose (SMBG) measurement and retinal screening are not indicated for people with prediabetes.

Drug treatment

Metformin is the only drug currently recommended for the routine management of prediabetes. It is an adjunct, not an alternative, and is less effective alone than lifestyle change. It is important to consider this in the context of CVR. It is usually best to start with a low dose (500mg daily or twice daily with food) and increase gradually as tolerated, if required, to 1500–2000g/day in divided doses. Metformin should always be taken with food and, if patients are intolerant, can be initiated at a dose of 250mg/day.

Support to achieve lifestyle and weight loss goals should continue.

3. Cardiovascular risk management

Cardiovascular risk assessment and active management should still be carried out as per the NZ guidelines - CV risk is the greatest threat to the patient’s short and medium-term health, irrespective of progression or not to Type 2 diabetes.

These interim recommendations were written by Professor Jim Mann and Dr Kirsten Coppell with input from Dr Paul Drury, Dr Helen Rodenburg and Ann Gregory on behalf of the National Diabetes Services Improvement Group (NDSIG).

Where this advice is being used in systematic prediabetes programmes in practices, PHOs and DHBs it is strongly recommended that contact is made with the Ministry of Health to ensure data collection and outcome measures/evaluations are compatible with other such projects.

National Diabetes Work Programme 2014/15