Table Of ContentIntegrated
Diabetes Care
A Multidisciplinary
Approach
David Simmons
Helmut Wenzel
Janice C. Zgibor
Editors
123
Integrated Diabetes Care
David Simmons
Helmut Wenzel (cid:129) J anice C. Zgibor
Editors
Integrated Diabetes
Care
A Multidisciplinary Approach
Editors
David Simmons Helmut Wenzel
School of Medicine Health Economist
Western Sydney University Konstanz , Germany
Sydney , NSW , Australia
Janice C. Zgibor
Department of Epidemiology
and Biostatistics, College
of Public Health
University of South Florida
Tampa , FL , USA
ISBN 978-3-319-13388-1 ISBN 978-3-319-13389-8 (eBook)
DOI 10.1007/978-3-319-13389-8
Library of Congress Control Number: 2016955045
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Foreword
I f one wished to choose a health condition that requires an integrated multi-
disciplinary approach to management, then you cannot go past diabetes. And
given the spectacular growth of diabetes over the last 20 years, the number of
people with diabetes worldwide has more than doubled. The International
Diabetes Federation (IDF) today estimates there are at least 415 million peo-
ple with diabetes. The IDF also estimates there will be over 620 million with
diabetes by 2040. Concerning features in relation to the current epidemic are
the increases in both type 1 and 2 diabetes, gestational diabetes, and the emer-
gence of type 2 diabetes in children and adolescents. This scenario poses
huge social, public health, and economic problems to most nations and
stretches their capacity for optimal diabetes care.
T he very nature of diabetes—with its issues relating to day-to-day man-
agement and the risk and burden of future complications such as cardiovascu-
lar disease, retinopathy, and kidney disease and comorbidities which include
liver disease and obstructive sleep apnoea—raises huge issues for an inte-
grated approach to management.
People with diabetes often have multiple comorbidities and see a number
of different health professionals across primary, community, and specialist
care services. This is where integrated care may have an important “game-
changing” role. It has been demonstrated that best-practice, high-quality dia-
betes care can only be achieved when healthcare professionals work
seamlessly. This involves partnerships across primary healthcare, community
care, and specialist care services delivering integrated diabetes care to the
consumer, the person with diabetes.
E stablishing an effective, integrated system will require a transformation
in the way care is delivered, making it more consumer focused and team
based. The person with diabetes may be looked after in primary, secondary,
and also tertiary care. Their healthcare team includes the general practitioner,
the diabetologist, diabetes educator, the dietician, and other healthcare pro-
viders. There is a requirement for coordination across the relevant agencies,
encompassing the whole diabetes care pathway. Consumer engagement, self-
management, and empowerment will be major contributing factors in achiev-
ing this goal.
U nless we embrace this approach to management of diabetes, health sys-
tems in both developed and developing countries will be swamped by the
numbers of people with diabetes. This will be associated with the increased
v
vi Foreword
direct cost of diabetes, and it also has indirect costs nationally in terms of
premature morbidity and impacts on the workforce.
So this brings us to this timely book Integrated Diabetes Care : A
Multidisciplinary Approach . It addresses integrated care and also the many
barriers for improving diabetes care across the globe. So, what do we really
need to understand about integrated care and how to overcome these hur-
dles? This excellent book edited by David Simmons, Helmut Wenzel, and
Janice C. Zgibor gives comprehensive coverage of these issues and provides
examples of approaches that could improve care while reducing costs.
Integrated Diabetes Care : A Multidisciplinary Approach collates worldwide
evidence of how integrated care works both across disciplines and across
organisations to improve diabetes care.
T he integrated approach prioritises the needs of the individual and recog-
nises the many interactions required between the person with diabetes, the
range of health professionals needed for their care, and the various levels of
the health system. Diabetes is for life, and this book provides guidance for all
those involved in diabetes to bring seamless and optimal care for the person
with diabetes.
Professor Paul Zimmet, AO MD PhD FRACP FRCP (London) FTSE
Honoris Causa Doctoris (Complutense University, Madrid)
Doctor of Laws Honoris Causa (Monash University, Melbourne)
Doctor Philosophiae Honoris Causa (Tel Aviv University, Tel Aviv)
Professor, Department of Medicine, Monash University
Honorary President of International Diabetes Federation
Formerly Director, International Diabetes Institute, and Director Emeritus,
Baker IDI Heart
Pref ace
Why a book on integrated diabetes care? Over the last 20–30 years, there
have been a plethora of projects and policies putatively designed to bring
together all the different health workers and health services for defi ned groups
of people with diabetes. Some have sat behind grandiose broader integrated
care initiatives. Others have sat within a single health service. Over this time,
there have been enormous improvements in the way we can manage type 1
and type 2 diabetes. There has been the growing recognition of the impor-
tance of personalised medicine including the ability to diagnose rare forms of
diabetes (such as monogenic diabetes). Behind this diabetes clinical evolu-
tion has been, perhaps, an even greater revolution in the work behind the
scenes, especially in the way we handle health data and clinical governance,
and in our understanding that there is a chasm behind what we can do and
what is actually happening. Why is care not as good as we know it can be?
Why do avoidable complications still happen? It is clear that there is much
more that can be done to facilitate and enable those with diabetes: right care,
right time, and right place.
This book came about to provide greater depth than possible in academic
publications on what worked and what did not from the clinicians’ and devel-
opers’ points of view. This in turn can inform future developers, managers,
and clinicians on how best to structure their next attempt to move towards a
more united and seamless approach to the way that those with diabetes
receive their care.
Sydney , Australia David Simmons
Konstanz , Germany Helmut Wenzel
Tampa , FL , USA Janice C. Zgibor
vii
Contents
1 An Introduction to Integrated Care and Diabetes
Integrated Care ........................................................................... 1
Helmut Wenzel and David Simmons
2 Integrating Outpatient Care the Toyota Way: An
Individualized Multidisciplinary Team-Care Model
for Diabetes Care Delivery ......................................................... 11
R. Harsha Rao and Peter Perreiah
3 Approaches to Integrated Diabetes Care: United States:
San Francisco .............................................................................. 31
David H. Thom and Thomas Bodenheimer
4 A Primary Health-Care System Approach to Improving
Quality of Care and Outcomes in People with Diabetes:
The University of Pittsburgh Medical Center Experience ...... 51
Janice C. Zgibor , Francis X. Solano Jr. , and Linda Siminerio
5 Integrated Diabetes Care in Hong Kong: From
Research to Practice to Policy .................................................... 65
Roseanne O. Yeung , Junmei Yin , and Juliana C. N. Chan
6 Approaches to Integrated Diabetes Care: A South
African Approach ........................................................................ 87
Larry A. Distiller and Michael A. J. Brown
7 English Approaches to Integrated Diabetes Care:
The East Cambridgeshire and Fenland Diabetes
Integrated Care Initiative: A Multiple Provider
Approach ...................................................................................... 107
David Simmons , Dahai Yu , and Helmut Wenzel
8 UK Approaches to Integrated Diabetes Care:
Derby—A Joint Venture Model Under the NHS ...................... 131
Paromita King
9 Integrated Diabetes Care: Coventry and Warwickshire
Approach ...................................................................................... 147
Ponnusamy Saravanan , Vinod Patel , Joseph Paul O’Hare ,
and Sudhesh Kumar
ix
x Contents
10 Integrated Diabetes Care in Germany: Triple Aim
in Gesundes Kinzigtal ................................................................. 169
Caroline Lang , Elisa A. M. Kern , Timo Schulte ,
and Helmut Hildebrandt
11 Approaches to Integrated Diabetes Care in the
Netherlands .................................................................................. 185
Harold W. de Valk and Helmut Wenzel
12 Integrated Diabetes Care in Sweden ......................................... 201
Helmut Wenzel , Stefan Jansson , and Mona Landin-Olsson
13 Integrated Diabetes Care for Adults with Diabetes:
A Patient Organisation Perspective ........................................... 215
Heather Bird and Bridget Turner
14 Training for Diabetes Integrated Care:
A Diabetes Specialist Physician Perspective
from the English NHS ................................................................. 227
Anne Dornhorst
15 Diabetes Integrated Care: Are We There Yet? ......................... 233
David Simmons , Helmut Wenzel , and Janice C. Zgibor
Index ..................................................................................................... 249
Contributors
Heather Bird Diabetes UK , London , UK
Thomas Bodenheimer Department of Family and Community Medicine ,
University of California, San Francisco School of Medicine and San Francisco
General Hospital , San Francisco , CA , USA
Michael A. J. Brown Centre for Diabetes and Endocrinology (Pty) Ltd ,
Johannesburg , South Africa
Juliana C. N. Chan D epartment of Medicine and Therapeutics, The Chinese
University of Hong Kong , Hong Kong , China
Hong Kong Institute of Diabetes and Obesity , The Chinese University of
Hong Kong , Hong Kong, China
I nternational Diabetes Centre of Education, The Chinese University of Hong
Kong, Prince of Wales Hospital, Satin, Hong Kong, China
Harold W. de Valk Internist-endocrinologist, Department of Internal
Medicine , University Medical Center Utrecht , Utrecht , The Netherlands
Larry A. Distiller Centre for Diabetes and Endocrinology (Pty) Ltd ,
Johannesburg , South Africa
Anne Dornhorst Department of Diabetes and Endocrinology , Imperial
College Healthcare NHS Trust, Hammersmith Hospital , London , UK
Helmut Hildebrandt OptiMedis AG , Hamburg , Germany
Stefan Jansson Department of Family Medicine , Brickebacken Primary
Health Care Center , Örebro , Sweden
Elisa A. M. Kern Gesundes Kinzigtal GmbH , Haslach , Germany
Paromita King Department of Diabetes and Endocrinology, Medical
Specialties , Derby Teaching Hospitals NHS Foundation Trust, Royal Derby
Hospital , Derby , UK
Sudhesh Kumar Warwick Medical School , The University of Warwick ,
Coventry , UK
University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
xi
