Successfully starting insulin therapy in Primary Care

Transcription

1 Successfully starting insulin therapy in Primary Care May 2014 Lorna Bingham Nurse Practitioner Candidate Endocrine, Diabetes & Research Centre Capital and Coast District Health Board

2 Overview What is success? Background why start insulin in Primary Care? Who needs it & how? Self-efficacy tool Barriers to consider Practice, Health Professional, Person with diabetes Enhancing skills and knowledge Karori Medical Centre permission to share some insights from their work...

3 Success the accomplishment of an aim or purpose

4 Why start insulin in Primary Care? Better, sooner, more convenientgovernment health strategy (2011) Progressive nature of T2 DM & increasing No s Increase in specialist workload too - complexity & prevalence T1 T2 Gestational Diabetes Mellitus (GDM), Insulin pump service

5 Advantages of starting insulin in Primary Care Patient safer, less fragmented care, especially for complex patients with co-morbidities Practice continuity of care, less likely to fall through the gaps Population opportunistic care improves through enhanced team knowledge and skills in diabetes and insulin management.

6 Insulin Therapy How? Advance preparation of the patient is crucial Tell the person with diabetes its a progressive disease, 50% of beta cell mass lost at diagnosis 3-5% annual decline UKPDS Practicalities familiarity with the devices is one more appropriate than another? Disposable pens v s refillable Support for the person with diabetes - cultural role model buddy The Primary care team- from the Diabetes Specialist Team

7 Tool for assessing self-efficacy Importance Competence Confidence Scale of 1-10 Score <7 means work still needs to be done to address barriers (Lorig, Homan et al 2006 Living a health life with chronic conditions )

8 3 aspects to consider 1. Timing in the Practice setting Remember Importance Confidence Competence

9 3 aspects to consider 1. Timing in the Practice setting Remember Importance Competence Confidence

10 Considerations in the practice setting Practice buy-in Starting insulin is it part of the practice plan? Communication within the practice team Legal issues Standing Orders Support - in CCDHB Diabetes Nurse Practice Partnership model Follow-up for holiday/sickness cover 2 nurses/2 Drs

11 Other Practice considerations... Role clarity- who does what? Dr/Nurse/admin/priority targets/ titration/follow-up Time - if patient is known and uncomplicated, take 3 x 30 min sessions Lack of space you don t need a large clinical room Funding from DCIP bulk funding (old Get Checked $$) Opportunity to reorganize provide nurse led clinics

12 2. Health professional perspective Importance Confidence Competence

13 Knowledge and skills development (2009) Fundamental & Generalist Diabetes Nurse recommended in PHC

14 Knowledge development -free on line e-learning package from NZNO/NZSSD

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16 Consider Need for competent clinical champions MDT nurses/drs/allied health How do you learn - an opportunity to observe another competent health care professional Protected learning time- update skills and knowledge Time needed to reorganizing service? intro clinics

17 Tips 4 insulin initiation Clear goals - work in a defined time frame (3 months) to really get embedded in process Find supportive role model & mentor Identify (easier) appropriate patients Practice - do enough insulin starts to up skill e.g one a week over 6 weeks

18 Other considerations Work in a targeted way - from Query build or Dr Info e.g. to identify 10 patients to start HbA1c > 65 mmol/mol and on max oral meds Wagner s Chronic care Model is good when thinking about quality issues (Wagner E 1998) Key areas to consider Clinical information systems (IT), decision support, Delivery system design, self-management support

19 3. Patient Choice- importance, competence, confidence

20 Patient barriers psychological insulin resistance Khan 2008 Diabetic Medicine Family History family legacy effect Previous experience family/work colleagues Identify myths and misconceptions Needle phobia yours or theirs!!? true needle phobia is very rare

21 Know your patient- the need for a through assessment What skills and knowledge do they need- checklist Hypoglycaemia review Optimize lifestyle (diet/physical activity/medications) Self monitoring 3 day profile before you start, baseline weight, HbA1c, hyperglycaemia symptoms Demonstrate, repeat, supervise practice

22 Other insulin barriers... Insulin source copied from human insulin, not pigs or cattle NO risk of HIV/Hepatitis Loss of lifestyle injecting just before meals The end is nigh at the end of life expectancy when you start insulin Confidently sell the benefits improved energy levels, less disturbed sleep (< up to toilet o/night)

23 NZSSD / Education/ HbA1c as indicator of diabetes control

24 Education review & update If asymptomatic - does the patient really understand why they need insulin? Before starting ideally nurse/dietitian review Medication adherence- DART/MEMO study Baseline weight and diet review weight gain as they eat an extra meal Side effects - hypo s and weight gain Allergies rare to insulin, usually excipients

25 Education review & update Blood glucose profile what are documented/agreed targets? Educate on insulin management AFTER first injection Name, storage of insulin, time action profile, and need to take at consistent time, expiry date, contamination, site rotation, sharps disposal, keep orals going IMPORTANT - after hours contact, security blanket! For you For patients

26 Success - a prepared & focused team Clear goals are important for The practice Process, time and space The team Roles clear The patient Why would they start insulin when they feel fine I need to see the evidence Dr and Nurse!

27 What is stopping you and your team starting insulin?

28 Wagner s Chronic care model

29 Wagner s Chronic Care Model Clinical Information Systems Identify sub populations Pacific/Maori men in 40 S Timely reminders - Those not accessing follow-up? Annual review due Monitor performance of teams what will you use? Outcome measures e.g. reducing number not on insulin Process measures to do 1% or 14 insulin starts in next 3 months

30 Delivery System Design Define roles and tasks amongst team members Who will follow-up? How long for? Planned visits for key interventions - to start insulin Dr gets them to try a needle and addresses myths Nurse checks blood glucose monitoring and hypo knowledge, and discusses side effects (weight gain, hypos) Nurse covers insulin storage, injection technique, sites

31 Decision Support Evidence based guidelines NZ Primary Care Handbook 2012 NZSSD join free for first year, now have a study day Diagnostic information HbA1c chart great teaching tool E- learning for practice nurses Integrated specialist services Proven education methods - role modelling

32 Thank you for your attention, and lets continue to work together to provide quality health care for those whom we serve...