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JA-CHRODIS

WorkPackage7

Diabetes:acasestudyonstrengtheninghealthcareforpeoplewithchronicdiseases

ExamplesofpotentialGoodPractices

forpreventionandmanagementofdiabetes


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Table of Contents

Acknowledgements

Introduction

Descriptionofpotentialgoodpractices

Austria

TherapieAktiv–educationprogrammeforpersonswithdiabetes 6AktivtreffDiabetes-Effectivenessofapeersupportprogramme 8TrainingforDiabeticsType2Carinthia 10NationalActionPlanMotionNAP.b 12AustrianNationalNutritionActionPlan(NAP.e) 14Generalscreening 16Continuousdiabetescounseling 18DiabetesEducationforDietitians 20UniversitycourseonDiabetesCare 22

Croatia

ProgrammeofHealthCareforPersonswithDiabetes-Education 23ProgrammeofHealthCareforPersonswithDiabetes–HealthPromotion 25ProgrammeofHealthCareforPersonswithDiabetes-Management 27ProgrammeofHealthCareforPersonswithDiabetes-Prevention 29ProgrammeofHealthCareforPersonswithDiabetes-Training 31

Finland

RegionalNetworkofdiabetologistsanddiabetesnurses 33

France

Asalée-Generalhealthresponseteam 35Sophia-Remotecoachingprogrammeforpatientswithdiabetes 38

Germany

TheSaxonianDiabetesManagementProgramme 40AOKCheckUpPlus 43SMS.Besmart.Joinin.Befit. 45MEDIAS2programme 47


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TrainingsoftheGermanDiabetesSociety 51

Greece

IPIONI-NationalPilotProjectonPreventionandHealthPromotionforOlderPeople 55

Italy

C.U.R.I.A.M.O.-HealthyLifestyleInstitute’sModel 58C.U.R.I.A.M.O-Innovativemultidisciplinaryinterventionforchangingthelifestylesofpersonswithtype2diabetesmellitusand/orobesity 60DiabeticRetinopathyCentre 63MasterCourseonEndocrinologyandDiabetesfornursingpersonnel 67GroupCareModel:TheTurinexperience 69SINERGIA-Chroniccaremodelforthemanagementofdiabetes 73Patient-centeredapproachforthepreventionandtreatmentofpatients

withdiabetesmellitus 75ScreeningDiabetesPalermo 77IGEA 79

Norway

Diabetesnursingspeciality 82

TheNationalGuidelinesforprevention,diagnosisandtreatmentofdiabetes 84

NCD-strategy:Prevention,diagnosis,treatmentandrehabilitationofnon-communicable

diseases-cardiovasculardisease,diabetes,COPDandcancer 86

PatientEducationandHealthMastery 88

Slovenia

DiabetesPreventionandCareDevelopmentProgramme2010-2020 90TrainingofRegisteredNursesforcarecoordinatorsinhealthpromotionandcareforselectedchronicdiseasesinprimarycare–courseondiabetes 93Nationalprogrammefordiabeticretinopathyscreening 96

Spain

CompetentPatientinDiabetes 98

Table1-PotentialGoodpracticesbyTypeandCountry 100


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AcknowledgementsThisreportderivesfromWorkPackage7oftheEUJointActiononChronicDiseasesandHealthyAgeingAcrosstheLifeCycle(JA-CHRODIS).

WP7leader: MarinaMaggini,NationalInstituteofHealth(ISS)ItalyWP7co-leaderandTask5leader:JelkaZaletel,NationalInstituteofPublicHealth(NIJZ)SloveniaTask1leader:JaanaLindström,THLFinlandTask2leader:UlrikeRothe,TechnischeUniversitätDresden(TUD)GermanyTask3leader:MonicaSørensen,TheNorwegianDirectorateofHealth(HDir)NorwayTask4leader:AndreaIcks,HeinrichHeineUniversityDüsseldorf(HHU)Germany

Thefollowingpartnerscontributedtothecollectionofpotentialgoodpractices

AustriaBrigitteDomittner,SabineHöfler(GÖG)CroatiaJosipCulig,MarcelLeppée(STAMPAR)FinlandJaanaLindström,KatjaWikström(THL)FranceAlainBrunot(MoH)GermanyUlrikeRothe(TUD),AndreaIcks,SilkeKuske(HHU)GreeceTheodoreVontetsianos,PanagiotouThemistoklis(YPE)ItalyMarinaMaggini,BrunoCaffari,MarikaVilla(ISS)NorwayMonicaSørensen(HOD)SloveniaJelkaZaletel(NIJZ)SpainManuelAntonioBotana(SERGAS)

Wewouldfurtherliketothankallthehealthprofessionalswhoacceptedtosharetheirexperience,andcontributedtothedescriptionofpractices.


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IntroductionThisReport is an integralpartof the surveyonpractices forpreventionandmanagementofdiabetes conducted by the WP7 of the European Joint Action on Chronic Diseases andPromotingHealthyAgeingacrosstheLifeCycle(JA-CHRODIS).

The surveywas organized in two phases: the first had the objective to provide a structuredoverviewaboutcurrentprogrammes(interventions,initiatives,approachesorequivalents)thatfocusonaspectsofprimarypreventionofdiabetes, identificationofpeopleathighrisk,earlydiagnosis, prevention of complications of diabetes, comprehensive multifactorial care,education programmes for persons with diabetes and training for professionals; the secondphasewasdevotedtothedescriptionoftheprogrammesidentifiedinthefirstone.

The survey was not intended to provide an exhaustive description of all the activities ondiabetes in the participating countries, in fact the partners were asked to report plans,programs,interventions,strategies,experiencesthattheyfeltworthtobereportedandshared.

Theresultsof the firstphaseareavailableonthe JA-CHRODISwebsite:http://chrodis.eu/wp-content/uploads/2016/01/Report-prevention-and-management-diabetes-Final.pdf.

All the partners and experts who reported programmeswere requested to further describethem,usingaspecifictextformat,tomakethemavailableforthescientificcommunityandallthestakeholders.

TheprogrammesdescribedinthisReportmaybeconsideredaspotentialgoodpracticesuntiltheywillbeevaluatedusingasetofqualitycriteria.Tothispurpose,theWP7togetherwiththecolleaguesof theAragonHealthScience Institute (WP4 leaders)definedacore setofqualitycriteriathatmaybeappliedtovariousdomains:prevention,care,healthpromotion,education,andtraining.AnextensiveprocesswascarriedouttoidentifythequalitycriteriainvolvingtheWP7community,andexpertsfromawidenumberoforganizationsacrossEuropeandfromavarietyofprofessionalbackgrounds.TheconsultationwiththeexpertpanelfollowedtheRANDmodifiedDelphimethodology.Theprocessledtotheagreementon9qualitycriteria,madeupof 39 categories ranked and weighted, to assess whether an intervention, policy, strategy,programme, aswell as processes and practices, can be regarded as a "goodpractice" in thefield of diabetes prevention and care (https://drive.google.com/file/d/0B8Xu4R_n0-nzT3R4RVRDSnZ1UGc/view).


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TherapieAktiv-educationprogrammeforpersonswithdiabetes

Austria

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge,preventionofdiabetescomplications,managementofstressandcopingwitheverydaylivingactivities.Thetargetgroupsareallthepersonswithdiabetesmellitustype2.Thefollowingcriteriaaredefinedintheeducationprogramme:goals,rationale,setting,schedulingoftheeducationsessions,numberofparticipantsandqualificationofthetrainers/educators.TherapieAktivisadiseasemanagementprogramme(DMP)forpatientswithdiabetesmellitustype2.Themainaimsoftheprogrammeare:

• Improvementofdiabetescare• Preventionoflongtermdiabetescomplications(e.g.amputations,heartattacks,strokes)

Structurededucationprogrammeforpersonswithdiabetesmellitustype2inthecontextoftheDiseaseManagementProgrammeTherapieAktivDiabeticscantakepartincourses/trainingsrelatingtodiabetesmellitustype2(non-insulin-dependentorinsulin-dependent).Inthediabetestrainingdiabeticslearneverythingtheyneedtoknowaboutdiabetes,enablingthemtotakechargeoftheirownhealth.Peoplewithtype2diabetesattendtheworkshopingroupsonceaweekfor4or5weeks,relativesareallowedtoattend.Thediabetesself-managementworkshopscantakeplaceinmedicalsurgeries,healthcarecentersorAustriansocialsecurityinstitutions.(Afteratrainingprogrammeforhealthprofessionalsgeneralpractitionersandspecialistsininternalmedicinearequalifiedtoorganizetrainingsfordiabeticsintheirownpractices/surgeries).Yearofimplementation,levelofimplementation,fundingTheDiseaseManagementProgramme(DMP)TherapieAktivwas introduced2007 inAustria inordertoimprovehealth caredelivery fordiabetics via thepromotionof treatmentaccording toguidelines. TheprogrammeisbasedonanagreementbetweenAustriansocialsecurity institutions,medicalassociationandfederalpublichealthfunds.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Outcome criteria: metabolic control (HbA1c values or incidence of hypoglycaemia) and diabetesknowledge,qualityoflife,empowerment/self-efficacy.Evidence criteria: international evaluated structured education programme (e.g. Düsseldorfer Modell,Medias2).


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Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Type2diabeticsgetmoreknowledgeaboutthedisease.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Diabetics learn interesting facts about the symptoms of diabetes, healthy eating, physical activity,hyper/hypoglycemia, management of stress, appropriate use of medication, prevention of diabetescomplications,footexaminationandselfcare,methodsofself-monitoring,regularcheck-ups,etc.Howdoesthisprogramme/experiencehelpindrivingthechangetowardpreventionandimprovementthequalityofcareforpeoplewithdiabetes?Adoctor,adiabetesadviser/educatorandadietitianhelpeachparticipanttolaydownmeasuresforbetterdealingwiththediseaseindailylife.Participantsshareexperiencesandhelpeachothersolveproblemstheyencounterincreatingandcarryingouttheirself-management.Leadingorganizationoftheprogramme/experienceMainAssociationofAustrianSocialSecurityInstitutions(HauptverbandderösterreichischenSozialversicherungsträger).ContactpersonSonjaReitbauer([email protected])Websitewww.therapie-aktiv.atReferences


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AktivtreffDiabetesEffectivenessofapeersupportprogrammeversususualcarein

diseasemanagementofdiabetesmellitustype2regardingimprovementofmetaboliccontrol

Austria

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge,preventionofdiabetescomplications,managementofstressandcopingwitheverydaylivingactivities.Thetargetgroupsare:allthepersonswithdiabetes,personswithdiabeteswithco-morbiditiesandpersonswithanewdiagnosisofdiabetes.Theeducationprogrammetakesintoaccountlowsocio-economicgroupsandgenderdifferences.The following criteria are defined in the education programme: goals, rationale, target group,setting,schedulingoftheeducationsessions,numberofparticipants,environmentalrequirements,qualificationofthetrainers/educators,corecomponentsoftheeducator/trainer'srole,monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.Yearofimplementation,levelofimplementation,funding2011-2013Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Outcomecriteria:metaboliccontrol(HbA1cvaluesorincidenceofhypoglycaemia),diabetesknowledge,qualityoflifeandEmpowerment/self-efficacy.Evidencecriteria:theprogrammeisbasedonrandomisedtrial.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Positive evaluation by the participants; reduction in costs in health economic evaluation (not yetpublished).Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?There was no improvement in glycemic control due to low initial values. The programme should betargetedspecificallyatpatientswithunsufficientglycemiccontrol.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Theprogrammeimprovesknowledgeondiabetesandstrengthensselfmanagementskills.


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Leadingorganizationoftheprogramme/experienceParacelsusMedicalUniversitySalzburgContactpersonProf.Dr.AndreasSönnichsen([email protected])Websitehttp://www.egms.de/static/en/meetings/ebm2014/14ebm115.shtmlReferences


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TrainingforDiabeticsType2CarinthiaAustria

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge,preventionofdiabetescomplicationsandcopingwitheverydaylivingactivities.Thetargetgroupsareallthepersonswithdiabetes,relativesandcaregivers.Theeducationprogrammetakesintoaccountethnicminoritiesandlowsocio-economicgroups.Thefollowingcriteriaaredefinedintheeducationprogramme:goals,rationale,setting,schedulingof the education sessions, number of participants, qualification of the trainers/educators, corecomponents of the educator/trainer's role, monitoring of the effectiveness and quality of theprogrammeandsourceoffunding.Yearofimplementation,levelofimplementation,funding2007Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Outcomecriteria:qualityoflifeandempowerment/self-efficacy.Evidencecriteria:theprogrammeisbasedonDüsseldorferModell.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?ItisplannedtocomplementtheexistingDiabetikerschulungTypIIKärntenwiththeparticipationoftheKGKK in theDMPTherapieAktivproject.Thisnextstepshould improvethecareof type IIdiabetics inCarinthiasignificantly.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?By improving theunderstandingof the illness, the complianceof thepatient increases.Unfortunately,thereliabilityofthepatientsregardingtheattendanceofthecoursesisoccasionallyinsufficient.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Leadingorganizationoftheprogramme/experienceKärntnerGebietskrankenkasse+beteiligteSV-Träger+ÄrztekammerfürKärnten


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ContactpersonMagChristianeDabernig([email protected])Dr.RenateHammerschlag([email protected])ChristineMastalier([email protected])Websitehttp://www.kgkk.at/portal27/portal/kgkkportal/content/contentWindow?contentid=10007.698234&action=2&viewmode=contentReferences


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NationalActionPlanMotionNAP.bAustria

Shortdescriptionoftheprogramme/experienceThe programme is on the institutional and national level. A theoretical basis of the programmeincludesdescriptionofthemethod.Transparency:theconceptincludesaspecificationoftheprojectaimsandobjectives.The following elements of the programme are described and theoretically justified: frequency,durationandselectionandrecruitmentmethodlocation.Thetargetpopulationisdefinedonthebasisofneedsassessment.The followingdimensionsare taken into consideration: socioeconomic status, ethnicity and culturalfactors,genderdifferences,rural-urbanareaandvulnerablegroups.Theinterventionaimstopromotethetargetgroup(s)self-managementskills.Potential burdens of the intervention are addressed and the benefit-burden balance are fairlybalanced.The intervention creates ownership among the target group and several stakeholders considering:multidisciplinary,multi-/inter-sectorialandpartnershipsandalliances.Yearofimplementation,levelofimplementation,funding2013Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)There ismonitoringsystem(only for selectedparts) inplace todeliverdataalignedwithevaluationandreportingneeds.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Becauseitcoversallareasoflifeandallaffectedtargetgroups.Whichare the reasons for success (positive lessons learned)and failure (negative lessons learned) ifany?Theholisticapproachisparamountforsuccess.Ariskforfailureislackingcooperationandmotivation.Howdoesthisprogramme/experiencehelpindrivingthechangetowardpreventionandimprovementthequalityofcareforpeoplewithdiabetes?HEPA (ie. The WHO / EU programmefor Health Enhancing Physical Activity) can support bothpreventioneffortsandthetreatmentofdiabetes.


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Leadingorganizationoftheprogramme/experienceCollaborationbetweentheFederalMinistryofHealthandtheFederalMinistryofDefenceandSports.The Federal Ministry of Defence and Sports implements the plan in cooperation with mainstakeholders.ContactpersonRobertMoschitz([email protected])WebsiteFederalMinistryofHealthhttp://www.bmg.gv.at/home/Nationaler_Aktionsplan_BewegungFederalMinistryofDefenceandSportshttps://www.sportministerium.at/de/themen/nationaler-aktionsplan-bewegungReferences


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AustrianNationalNutritionActionPlan(NAP.e)Austria

Shortdescriptionoftheprogramme/experienceTheNAP.e,was launchedin2011andfollowsahorizontal“health inallpolicies“-strategy. ItcombinesAustria's nutrition policies and strategies for the first time. The primary goals of the NAP.e are areductionofover-,under-andmalnutritionaswellasthereductionoftherisingratesofoverweightandobesity by 2020. The healthier choicemust become the easier. NAP.e isn´t a static document but arolling strategy and catalogue of measures – its aims and subjects are adapted regularly, measuresalreadyestablishedarereviewedandifnecessaryupdated.Thepreventionofdiet-andlifestylerelateddiseasesstartsinearlyinfancy.ThereforeNAP.eaddressesdifferent target groups in all life stages. It focuses on the primary prevention of non-communicablediseases (NCD) in general on thebehavioural and situational prevention level.NAP.edoesn´t addressspecific diseases. Secondary preventionmeasures like interventions in diabetes are not the primarilyaddressed ones of NAP.e and are mainly implemented by organizations like the Austrian DiabetesAssociation. Institutions implementing interventions in diabetes are represented in the NationalNutritionCommission(NEC).TheNEC,consistingofallrelevantinstitutionsandorganizationsinAustria,is an interdisciplinary nutrition advisory body for theMinister ofHealth and is themain panel in thestrategicdevelopmentofAustriannutritionpolicy.Yearofimplementation,levelofimplementation,funding2011-Theprogrammeisonthenationallevel.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Anationalnutritionstrategy iscrucial forconcertedaction in the fieldofnutrition.TheNAP.edefinescommon goals, agreed objectives and describes fields of action. It was adopted by the council ofministers in 2011 what forms the basis for intersectional and interdisciplinary cooperation andenforcement.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive:commonintersectionalapproach,enhancednetworking,concertedaction.Negative:constraintsduetobudgetarycutssince2011.


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Howdoes thisprogramme/experiencehelp indriving thechange towardpreventionand improvementthequalityofcareforpeoplewithdiabetes?Leadingorganizationoftheprogramme/experienceAustrianFederalMinistryofHealthContactpersonMag.aJudithBenedics,Mag.aPetraLehnerWebsitehttp://www.bmg.gv.at/cms/home/attachments/6/5/8/CH1046/CMS1378816554856/nap.e_20130909.pdfhttp://www.bmg.gv.at/References


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GeneralscreeningAustria

Shortdescriptionoftheprogramme/experienceThe “Allgemeine Vorsorgeuntersuchung” is the Austrian yearly medical check-up. The followingdata/statistics are available for the target population: prevalence of diabetes, percentage of thepopulationphysicallyinactive,prevalenceofoverweight,obesityandabdominalobesityandpercentageofpopulationfollowingnationalrecommendationsonnutrition.Individual’sriskfactorprofileisassessed.Individual’smotivationforbehaviouralchangesisdiscussed.Yearofimplementation,levelofimplementation,funding1974Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Whyshouldthisprogramme/experiencebeconsideredagoodpractice?The medical check-up (once in 12 months) is free for the whole population in Austria; preventingdiabetesisoneofthegoalsforthemedicalcheck-upprogramme.Around12%ofthepopulationtakepartinthisprogramme.Itisoneofthewaystofindpeoplewithdiabetesandpeoplewithriskfactorsfordiabetes.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Earlydetectionfordiabetesanditsriskfactorsis important–themedicalcheck-uptriestofindpeoplewithriskfactorsfordiabetes.Leadingorganizationoftheprogramme/experienceÖsterreichischeSozialversicherung(AustriansocialsecurityOrganisation)ContactpersonStephanieStürzenbecher([email protected])


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Websitehttps://www.sozialversicherung.at/portal27/sec/portal/esvportal/content/contentWindow?contentid=10007.683727&action=2&viewmode=contentReferences


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ContinuousdiabetescounselingAustria

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogrammefordiabetesconsultants:healthpromotioninterventions, diabetes knowledge, prevention of diabetes complications, management of stress andcopingwitheverydaylivingactivities.The following criteria are defined in the education programme: goals, rationale, target group,setting,schedulingoftheeducationsessions,numberofparticipants,environmentalrequirements,qualification of the trainers/educators, core components of the educator/trainer's role andmonitoringoftheeffectivenessandqualityoftheprogramme.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Monitoringcriteria:structureindicatorsandprocessindicators.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Thetrainershavepracticalexperienceorareeducated/traineddiabetesconsultants.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?The programme is approved by the Österreische Diabetesgesellschaft – ÖDG (Austrian DiabetesAssociation), the content complies the ÖDG guidelines. Also there is a cooperationwith the VerbandÖsterreichischerDiabetesberaterInnen(AustrianAssociationofDiabetesdiabetesconsultants).Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Leadingorganizationoftheprogramme/experienceAZW(AusbidlungszentrumWestfürGesundheitsberufe)ContactpersonHaraldTamerl([email protected])


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Websitehttps://www.azw.ac.at/page.cfm?vpath=pflegeausbildungen/weiterbildungen/diabetesberatungReferences


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DiabetesEducationforDietitiansAustria

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge, prevention of diabetes complications, management of stress and coping with everydaylivingactivities.The following criteria are defined in the education programme: goals, rationale, target group,setting, scheduling of the education sessions, number of participants, environmentalrequirements,qualificationofthetrainers/educators,corecomponentsoftheeducator/trainer'sroleandsourceoffunding.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Monitoringcriteria:intermediateoutcomeindicators.Evidencecriteria:theprogrammeisbasedonsatisfactionenquiryquestionnaire.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?TheDiabetes trainingcourse forDietitians isan important tool to transformscientific knowledge intopracticefordietitians.Theaimistoputthewell-basedtheoreticalknowledgeofdiabetesmellitusintobest practice and therapy so that the diabetics can benefit from the dietitians in the trainingprogrammes.Thedietitianslearnabouttheaimsofthetrainingprogrammesforthediabeticsandworkwithpatientempowerment.Dietitians learn the structure and content of education programmes for personswith diabetes. Afteraccomplishingthetrainingprogramme,Dietitiansarecapableofteachingthecontentstheylearnedtodiabetics, based on the knowledge they acquired from each lesson (choice of food, physical activity,diabetesknowledge,preventionofdiabetescomplication,managementofstress,copingwitheverydaylivingactivities).Dietitians gain knowledge, which they then communicate to patients with diabetes. The educationprogrammeoffersthespecificcontentsneededtocommunicateprofessionallywithdiabetics.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?-hightransferofknowledgeaboutDiabetesMellitus(causeofdisease,aims,symptoms,..)-Practicalorientationbyobservingandparticipatingwithaprofessionaldieteticinstructorspecializedindiabetics.-Participantshavetorepresentadieticianprocessaboutdiabetics-discussingdiabeticscasestudies


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-learningaboutpatientempowerment-assessmentoftheoreticalknowledgebyamultiplechoicetestHowdoes thisprogramme/experiencehelp indriving thechange towardpreventionand improvementthequalityofcareforpeoplewithdiabetes?The programme supports patient empowerment, change of lifestyle, encourages and requirescompliance,improvesthetreatmentadherence,ithelpstopreventhealthconsequences.Leadingorganizationoftheprogramme/experienceAustrianAssociationofDietitians,Grüngasse9/Top20,1050WienContactpersonBettinaKnabl,educationprojectsmanager([email protected])Websitewww.diaetologen.atReferences


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UniversitycourseonDiabetesCareAustria

Shortdescriptionoftheprogramme/experienceThe following items are included in the educationprogramme:healthpromotion interventions, diabetesknowledge,preventionofdiabetescomplications,managementof stressandcopingwitheveryday livingactivities. The following criteria are defined in the education programme: goals, rationale, target group,setting, scheduling of the education sessions, number of participants, environmental requirements,qualificationofthetrainers/educators,corecomponentsoftheeducator/trainer'srole,monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.Yearofimplementation,levelofimplementation,funding2014Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Whyshouldthisprogramme/experiencebeconsideredagoodpractice?TrainingprogrammesforHealthProfessionalsoffersaninteractivelearningenvironmentthatsupportsparticipantstodeveloptheirskillsineffectivediabetesmanagement.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Howdoesthisprogramme/experiencehelpindrivingthechangetowardpreventionandimprovementthequalityofcareforpeoplewithdiabetes?Leadingorganizationoftheprogramme/experienceDiabetesCare/DiabetesEducatorContactpersonDGKSGertraudSadilekMSc,Graz,DGKSBarbaraSemlitsch,MSc,LKH-Uniklinikum,UKIM,EndokrinologieundStoffwechsel,GrazWebsitewww.medunigraz.at/diabReferences


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ProgrammeofHealthCareforPersonswithDiabetesinCroatia-Education

Croatia

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions(choiceof food,physicalactivity),diabetesknowledge,preventionofdiabetescomplicationsandcopingwitheverydaylivingactivities.The target groups are: all the persons with diabetes, persons with diabetes with comorbidities,personswithanewdiagnosisofdiabetes,relativesandcaregivers.Theeducationprogrammetakesintoaccountgenderdifferences.The following criteria are defined in the education programme: goals, rationale, target group(inclusionandexclusioncriteria),setting(e.g.primarycare),schedulingoftheeducationsessions,number of participants, core components of the educator/trainer's role (e.g. clinical practice,health promotion, counselling and behavioural change techniques) and monitoring of theeffectivenessandqualityoftheprogramme.The programme is based on observational study, non-analytic studies (case reports, case series)andexpertopinion.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The following outcome criteria are measured: metabolic control (HbA1c values or incidence ofhypoglycemia)anddiabetesknowledge(ideallymeasuredusingstandard,validated,questionnaires).Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Thisstructureddiabeteseducationprogrammecoveringallmajoraspectsofdiabetesself-careandthereasonsforitshouldbemadeavailabletoalladultswithtype2diabetesinthemonthsafterdiagnosis,andrepeatedaccordingtoagreedneedanditwillbeconsideredagoodpractice.Which are the reasons for success (positive lessons learned) and failure (negative lessons learned) ifany?Implementation of national clinical guidelines is an essential part of clinical governance and is thereason for success. Mechanisms should be in place to review care provided against the guidelinerecommendations. The reasons for any differences should be assessed and addressed where


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appropriate.Localarrangementsshouldbemadetoimplementthenationalguidelineinhospitals,unitsandpractices.Howdoesthisprogramme/experiencehelp indrivingthechangetowardpreventionand improvementthequalityofcareforpeoplewithdiabetes?ThisEducationprogrammehelps indrivingthechangeby itspotentialbenefitsofaneffectivepatienteducation programme for people with type 2 diabetes which include: improving knowledge, healthbeliefs, and lifestyle changes; improving patient outcomes (weight, haemoglobin A1c (HbA1c), lipidlevels, smoking, and psychosocial changes such as quality of life and levels of depression; improvinglevelsofphysicalactivityandreducingtheneedfor,andpotentiallybettertargetingof,medicationandotheritemssuchasbloodtestingstrips.Leadingorganizationoftheprogramme/experienceAndrijaStampar,InstituteofPublicHealthContactpersonJosipCulig([email protected])Websitehttp://www.zadi.hr/doc/NacionalniProgram2015-2020.pdfReferences


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ProgrammeofHealthCareforPersonswithDiabetesinCroatia–HealthPromotion

Croatia

Shortdescriptionoftheprogramme/experienceTheprogramme ison the institutional, local andnational level. The concept includes an adequateestimation of: human resources, material and non-material requirements and budgetrequirements.A theoretical basis of the programme includes: description of the method, description ofactivities in a chain of causation and time frame and description of interactions between keystakeholdersandprocesses.The following elements of the programme are described and theoretically justified: frequency,duration, selection and recruitment method, location. The target population is defined on thebasisofneedsassessment.Thefollowingdimensionsaretakenintoconsideration:rural-urbanareaandvulnerablegroups.Theinterventionaimstopromotethetargetgroup(s)self-managementskills.The intervention creates ownership among the target group and several stakeholdersconsidering:multidisciplinary,multi-/inter-sectorialandpartnershipsandalliances.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Thereisadefinedevaluationframework,assessingstructure,processandoutcome.Theevaluationmethodsand/ortoolsarevalidated.Thereismonitoringsystemsinplacetodeliverdataalignedwithevaluationandreportingneeds.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Thisprogrammeisaddressingkeyareasrelevantforpreventingtype2diabetes.Itisbasedontype2diabetesriskquestionnaires,designandimplementaprogrammeoftargetedhealthchecks.ThechallengeistomakediabetesthemostimportantissueincreatingCroatianhealthcarepolicy.CrucialtothisinitiativehasbeenthejointinvolvementofkeyleadersindiabetesissuesinCroatia.Thecollaborationisbasedoncommongoals,commitment,respectandtrust.Partneringwithothermajorstakeholdershasfacilitatedmoreeffectivecommunicationwiththediabeticcommunity,andontheirbehalftoawideraudienceincludingthemediaandgeneralpublic.


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Which are the reasons for success (positive lessons learned) and failure (negative lessons learned) ifany?Reasons for success: According to the programme recommendations, lifestylemodificationmay benecessary. Patients should be advised that success will depend upon their agreeing to follow theprescribed treatment to lower their different risks, especially risk of CVD. They should also becomeawareofanypotentialsideeffectsofdrugs.Howdoesthisprogramme/experiencehelpindrivingthechangetowardpreventionandimprovementthequalityofcareforpeoplewithdiabetes?Implement prevention initiatives in vulnerable and high-risk populations; improve the health ofpregnantwomen,infantsandchildren.Diabetesisaninterdisciplinaryproblemwithprofoundimplicationsforsocietyandforindividuals,andgeneralpublichastopayattentiontodiabetes.Strongmediainteresthelpsraisediabetesawarenessindirectlyinthetargetaudience.Leadingorganizationoftheprogramme/experienceAndrijaStamparInstituteofPublicHealthContactpersonJosipCulig([email protected])Websitehttp://www.zadi.hr/doc/NacionalniProgram2015-2020.pdfReferences


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ProgrammeofHealthCareforPersonswithDiabetesinCroatia-Management

Croatia

Shortdescriptionoftheprogramme/experienceThe programme was initiated by: governmental body, hospitals, primary care organization/scientificassociation, diabetologist-endocrinologists/scientific association, home care organization, patientorganization/associationandinsurer.The key components of the programme are: self-management support, delivery system design,decisionsupporttools,integratedcaredeliverysystem,interdisciplinaryworkingpracticeteamandclinicalinformationsystemsupportinginterdisciplinaryworkingpracticeandmonitoring.Thedecisionsupporttoolsinvolveguidelinesfordiabetestype2andcomplexguidelinesforpersonswithdiabetestype2andmultiplechronicconditions.The integrated caredelivery system involves general practitioners, diabetes specialists inhospital,specialized nurses, cardiologist, ophthalmologist, neurologist, angiologist, nephrologist andpodologist.The patient centered approach is based on risk assessment for complications, defined clinicalpathways to deal with individuals at different risk for complications, individualized targets forinterventions,shareddecisionmakingandplanforfollow-upisdefined.Themainobjectivesare:preventingorreducinginappropriatehealthcare,improvingintegrationofdifferent organizations/care providers, increasing multi-disciplinary/multi-professionalcollaboration, improving patient involvement/centeredness, improving quality of care for personswith diabetes, improving early detection of co-morbidities, decreasing/delaying complications,decreasing morbidity, decreasing mortality, reducing hospitalizations, reducing inequalities inaccesstocareandreducing(public)costs.Yearofimplementation,levelofimplementation,fundingIncentivepaymentforperformanceandforoutcome.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Process indicators: proportionofpersonswithdiabetesenrolled in theprogramme(70%)anddroppingout of programme(10%), proportion of planned visits completed (50%), proportion of persons withdiabetes with regular education (40%), proportion of persons with diabetes who regularly self-check(blood glucose) (70%) and regularly checked (50%) up on: HbA1c (60%), body weight (40%), bloodpressure(50%),lipidparameters(40%),uricacid(30%),creatinine(30%),Albumini.U(30%),footpulsesandvibrationsensationtest(orfilamenttest)(20%),ECG+24RRprofile(25%),ocularfundus(30%)andfootinspection(20%).Intermediate outcome indicators:HbA1c (40%), BMI (50%),waist circumference (50%), blood pressure


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(50%),HDL-C(50%),LDL-CHDL-C(50%),TG(50%),qualityoflife(50%)andsmokingpeople(50%).Longtermoutcomeindicators:majorlimbamputationratereducing,myocardialinfarctionratereducing,stroke rate reducing, cardiovascular mortality rate reducing, microangiopathy rates reducing,nephropathyordialysis,retinopathyorblindnessandneuropathyordiabeticfootsyndrome.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?This can be considered a good practice because of its success in terms of participation and achievedtargets.CroDiab surveyoffer a good indicationof thedistributionanddiversityofdiabetes inCroatia,providingclinicianswithhelpfuldatathattheycanusetomakeassessmentexercises.Ensure that intervention is providedas soonas appropriate, deliver coordinatedandhigh-quality careresponsestoaddresstheneedsofpeoplelivingwithdiabetes.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Thereasonsforsuccess:Earlydetection,screening,simplediagnosticsprocedures,patienteducation.Thereasonsforfailure:Limitedfinancialresources,healthprioritiesarenotclarified.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Empower patients through people-centred chronic care models, capture data to inform and drivedecisionmaking.Applicability for thewider population. Participation in theproject helps to sharebest practices acrossCroatiainpracticalandtangibleways.The creation of an electronic diabetes register is setting the agenda for the definition of a CroatianNationalDiabetesRegister.Leadingorganizationoftheprogramme/experienceAndrijaStampar,InstituteofPublicHealthContactpersonJosipCulig([email protected])Websitehttp://www.zadi.hr/doc/NacionalniProgram2015-2020.pdfReferences


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ProgrammeofHealthCareforPersonswithDiabetesinCroatia-Prevention

Croatia

Shortdescriptionoftheprogramme/experienceActivitiesofdiabetespreventiontakeintoaccountgenderdifferences.The following data/statistics are available for the target population: prevalence of diabetes andprevalenceofoverweight,obesityandabdominalobesity.Screening for high risk: screening protocols to identify high-risk persons have been evaluated atnational level, validated diabetes risk assessment tools are available to health care providers andinformationtechnologysystemssupportingtheimplementationofscreeningareavailableathealthcareproviderlevel.The following data are available: proportion of the population screened (by health care provider)peryearandpercentageofidentifiedhigh-riskindividualsremittedtodiagnosticprocedures.Interventionsforhighrisk individuals:high-riskpreventionstrategiesare includedintheeducationofthehealthcareprofessionals;definedclinicalpathwaysexistforthehealthcareprovidertodealwithindividualsatriskfordiabetes;multidisciplinaryapproachforinterventionsissupportedbythehealth care provider; health care providers are collaborating with other players in healthpromotion; medical record system supports interventions for chronic disease prevention;individual’s risk factor profile is assessed; individual’s motivation for behavioural changes isdiscussed; structure and content of the interventions have been defined at individual level;individualizedtargetsforinterventionshavebeenestablished.Planforfollow-upisdefined.The followingdata are available: proportionof individuals droppingoutof interventions, diabetesincidence rate among high-risk individuals in interventions at health care provider, proportion ofplanned intervention visits completed over 1 year, weight change over 1 year, change in waistcircumferenceover1year,changeinglucoselevelover1year.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Whyshouldthisprogramme/experiencebeconsideredagoodpractice?This programme is health care programme for population at increased risk: positive family history,previously established glucose intolerance, gestational diabetes, those older than 45, obese, patientswithhypertensionand/orhyperlipidemia,personswhohadincreasedglycemicvaluesmeasuredinstresssituations (myocardial infarction, burns, traumas, infections, operations), andotherpersons suspected


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for diabetes. Individual counseling and group work (about 20 patients) are aimed at changing life-threateninghabitsandadoptinghealthierlifestyle.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Thereasonsforsuccess:earlydetection,screening,simplediagnosticsprocedures,patienteducation.Thereasonsforfailure:limitedfinancialresources,healthprioritiesarenotclarified.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Applicabilityforthewiderpopulation(DiabetesPatientsForums).Leadingorganizationoftheprogramme/experienceAndrijaStampar,InstituteofPublicHealthContactpersonJosipCulig([email protected])Websitehttp://www.zadi.hr/doc/NacionalniProgram2015-2020.pdfReferences


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ProgrammeofHealthCareforPersonswithDiabetesinCroatia-Training

Croatia

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions(choiceoffood,physicalactivity),diabetesknowledge,preventionofdiabetescomplications,copingwitheverydaylivingactivities.The following criteria are defined in the education programme: goals, rationale, target group(inclusionandexclusion criteria), setting (e.g. primary care), schedulingof theeducation sessions,numberofparticipants,monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.Theprogrammeisbasedonobservationalstudy.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Indicators used to monitor the training programme: structure indicators (e.g. account of the ongoingtrainingprocess)andprocessindicators(e.g.numberofinterventions,numberofprofessionalstrained).Whyshouldthisprogramme/experiencebeconsideredagoodpractice?In our Training programme there are some training elements which will make this programmeconsidered a good practice: physical fitness is composed of several components, includingcardiorespiratory endurance, body composition, muscular endurance, muscular strength or power,flexibility,andbalance/coordination.Eachcomponentoffitnesshasauniqueroleinthepreservationofhealth.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Implementationofnationalclinicalguidelinesisanessentialpartofclinicalgovernanceandisthereasonfor success. Mechanisms should be in place to review care provided against the guidelinerecommendations. The reasons for any differences should be assessed and addressed whereappropriate.Localarrangementsshouldthenbemadetoimplementthenationalguidelineinindividualhospitals,unitsandpractices.


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Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Training programme provides to understand the complexities relating to lifestyle that a person withdiabetesfaceseachday.Thisprogrammewillgiveattendeesknowledgeandconfidencewhenworkingwithpeoplewithdiabetes.Diabetesprogramme’sexperienceandexpertiseensurethatthosecomplyingtheprogrammereceivethemostup-to-dateandcomprehensiveinformationavailable.Leadingorganizationoftheprogramme/experienceAndrijaStampar,InstituteofPublicHealthContactpersonJosipCulig([email protected])Websitehttp://www.zadi.hr/doc/NacionalniProgram2015-2020.pdfReferences


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RegionalNetworkofdiabetologistsanddiabetesnurses

Finland

Shortdescriptionoftheprogramme/experienceNorth Karelia is one the 18 regions in Finland. There are 13municipalities inNorth Karelia and thepopulationisapproximately175000.Healthservicesareprovidedbyonecentralhospital(specializedcare)and13healthcentres (primarycare).Diabetescare isorganizedwithsharedresponsibilitiesofspecialized care and primary health care and both specialists, GPs, nurses and many otherprofessionals are involved in the work. In North Karelia, there is a special network of theseprofessionalscoordinatedbyasmallkeyteamconsistingofprofessionalsfromthehospitalandfromsomehealth centres. Themain aimof thenetwork is to harmonize the treatment and follow-upofdiabetes patients in the region and to improve the quality of care. The network is responsible forplanning,development,implementationandfollow-upofclinicalpathwaysindiabetescare.Commonprocesses that are based on national Current Care Guidelines are agreed within the network. Thenetworkalsoagreesthemeasuresoffollowinguptheprocessesandoutcomesandrelatedindicators.Thenetworkorganizesregulartrainingandcontinuouseducationfortheprofessionalsandcarriesoutseminarsandworkshopstodevelopthework.Thenetworkhasactivelybeeninvolvedintheregionalwork developing electronic patient records and reporting systems. At themoment all professionalsinvolvedinthecareofdiabetespatientscaneasilyproduceonlinereportingrelatedtotheoutcomesofcareoftheirownpatients.Yearofimplementation,levelofimplementation,fundingTheworkofthenetworkhasbeenstartedalreadyinthebeginningof1980sandgraduallydevelopedtocurrentform.Thenetworkhasallthetimebeenimplementedregionallyandallthekeyexpertsinthe region have been actively involved. There is no separate funding to run the network, but it isembeddedintheregionalhealthcaredevelopmentandcontinuouseducationsystem.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The network has developed a joined recommendation for clinical pathways of diabetes patientsincludingtheindicatorsforfollow-upoftheprocessandthetreatmentoutcomes.Eachhealthcentreisrequiredtoprovidetheseindicatorsonaregularbasis.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?In Finland, each municipality is responsible for providing the health and social services for theirpopulation.TheregionalnetworkofphysiciansandnursestreatingdiabetesintheHospitalDistrictofNorthKarelia (neworganization from thebeginningof2017will be called “Siun sote”) and inall 13


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municipalities helps to develope equal services in all municipalities, improves the collaborationbetween the primary health care and the specialized care, provides health professionals theopportunitytoexchangeideas,achieveeducationandtobenchmarktheirperformance.Thenetworkhasalsobeenabletocontributetothedevelopmentofregionalelectronicpatientrecordstosupporttheassessmentofthequalityofcare.Which are the reasons for success (positive lessons learned) and failure (negative lessons learned) ifany?The network has always had enthusiastic leadership (both from hospital and from primary healthcare).Municipalitieshavegivenpermissionforthehealthprofessionalstoallocatesomeworkingtimeforthecollaboration.Howdoesthisprogramme/experiencehelpindrivingthechangetowardpreventionandimprovementthequalityofcareforpeoplewithdiabetes?The network improves the regional clinical pathways, increases the professional knowledge ofphysiciansandnurses,affectstothedevelopmentofregionalelectronicpatientrecordsandreportingsystems, improves the collaboration and information change between primary health care andspecializedcare.Leadingorganizationoftheprogramme/experienceTheHospitalDistrictofNorthKareliaContactpersonEndocrinologist Päivi Rautiainen, [email protected], diabetologist Hilkka Tirkkonen,[email protected]


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AsaléeGeneralHealthResponseTeam

France

Shortdescriptionoftheprogramme/experienceThe programme was initiated by primary care organization/scientific association, and generalpractitioners, with support of government bodies. The key components of the programme are:decisionsupporttools,integratedcaredeliverysystem,interdisciplinaryworkingpracticeteamandclinical information system, supporting interdisciplinary practice and monitoring. It aims atmanagement of patients with type 2 diabetes (and also: patients with high cardio-vascular risk,screening for COPD and Alzheimer). The integrated care delivery system involves generalpractitionersandspecializednurses.Theprogrammesfundspart-timepositionandtrainingof thenurses in voluntary GP practices, supervision of the health professional involved, informationsystem.The patient-centered approach relies on risk assessment for complications, defined clinicalpathways according to the patient’s risk level for complications, individualized targets forinterventions,shareddecisionmaking,andpatienteducation.Planforfollow-upisdefined.Theprogrammetakesintoaccountsocio-economicstatusandgender.The main objectives are: preventing or reducing inappropriate healthcare, increasingmulti-disciplinary/multi-professional collaboration, improving patient involvement/centeredness,improving quality of care for diabetic people, improving early detection of co-morbidities,decreasing/delaying complications, decreasingmorbidity andmortality, reducing hospitalizations,reducinginequalitiesinaccesstocareandreducing(public)costs.Yearofimplementation,levelofimplementation,fundingTheproject started in2004. It is still anexperimental scheme,but it hasbeenextended toanationallevelsince2012.Itisfundedthroughthenationalhealthinsurancesystem.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Processindicators:proportionofpersonswithdiabetesenrolledintheprogramme(80%),proportionofpersonswithdiabeteswhith regular education (80%), proportionof personswithdiabeteswhowereregularlycheckedforHbA1c(90%),bodyweight(90%),bloodpressure(90%),lipidparameters(90%),creatinine(90%),albumini.U(90%),footpulsesandvibrationsensationtest(orfilamenttest)(90%),ECG+24RRprofile(90%),ocularfundus(90%),footinspection(90%)andmicroalbuminuria.Intermediate outcome indicators: HbA1c (target: < 7 %), BMI, waist circumference, blood pressure(target:140/90),HDL-C, LDL-CHDL-C,TG,qualityof life (ideallymeasured throughQALY)andsmokingpeople(target:cessation).


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Whyshouldthisprogramme/experiencebeconsideredagoodpractice?The ASALEE experiment improves quality and effeciency in healthcare: improvement of the mainoutcomeindicatorsfordiabeticpatients(2.8timesimprovementforHgA1C(HbA1C)targetcomparedtodiabeticpatientsnotfollowedbyASALEE; IRDES,2008)andreducedhealthcarecosts(by10%;CNAM,2010).Thesewerethecoreobjectives.Theprogrammewas developedby healthcare providers in accordancewith standardpractice of care,validated by the French National Authority for Health (Haute Autorité de Santé), including evidence-basedguidelines,self-assessmentandexternalevaluationsforthepast10years.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Fromthehealthcareproviderpointofview,akeyfactorinASALEEisateamworkrelationshipinplaceofaverticaldoctor-patientrelationship.Thistakesintoaccountboththebiomedicalandenvironmentalaspects of patients. Healthcare professionals have complementary therapeutic approaches: screening,education,anddiagnosis.ASALEEputtheinterpersonalface-to-faceprovider/patientrelationshipatthecenteroftheprocess.Technologyisinvolvedassoonasitsinputispertinent,andisusedwiththehelpoftheover-archingprovider/patientrelationship.Asaprogramme,ASALEEhasnot noticedfailureperse.However, it isfacingtwoinherentlimitations:One is the logistical difficulties for GPs to accomodate an additional professional in their own clinic;second is a paradox: although ASALEE is an answer to the lack of family doctors, ASALEE needs asufficientcriticalmassoffamilydoctorsintheregioninordertodevelop.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Wearedealingwithamultidisciplinarychallenge:tobringthepopulationofType2diabeticpatientsacomprehensive care in the context of a family practice. Making prevention and patient educationpossible there and encouraging patients to consult their family practitioner, ASALEE is inherently aprogramme that promotes and develops prevention. Moreover, this programme may contribute torethinkingofprimaryhealthcareby focusingmoreonpreventionandpatienteducation, knowing thatType2diabeteisamodelforchronicillness.Inthecourseofitsfirst7yearsofexistence,ASALEEgrewatanextremelyrapidpace(+1000%).Inthepast3years,thatsamegrowthratehascontinued(+1000%).However,sinceASALEErequiresprofoundchangesintermsofcurrentdeliveryhealthcare,timeisneededforeachhealthcareprofessionaltotakeownershipofthisadvancement.Leadingorganizationoftheprogramme/experienceAssociationAsaléeContactpersonDr.JeanGautier([email protected])


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Websitehttps://www.asalee.frhttps://www.youtube.com/watch?v=NUy_2zEZKHIReferences


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SophiaRemoteCoachingProgrammeforPatientswith

DiabetesFrance

Shortdescriptionoftheprogramme/experienceSophia is a remote coaching programme for patients with diabetes, providing: phone call support bytrainednursesbasedincallcenters,andalsoonlineandwrittenresources.The key components of the programme are: self-management support, delivery system design anddecisionsupporttoolstopeoplewithdiabetes.Registrationisofferedtoalladultinsuredpatients.Registrationisvoluntary(opt-in)andfreeofcharges.GPsmayalsoproceedtotheregistration.Amoreactivecoachingistargetinghighriskpatients.Thepatientcenteredapproachisbasedonriskassessmentforcomplications.Theprogrammetakesintoaccountlowsocio-economicgroups.The main objectives are: improving patient involvement/centeredness, improving early detection ofco-morbidities, decreasing/delaying complications, reducing hospitalizations, reducing inequalities inaccesstocareandreducing(public)costs.Yearofimplementation,levelofimplementation,fundingGeneralizationatthenationallevelin2012.Funding:Nationalhealthinsurer.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Process indicator:proportionofpersonswithdiabetesenrolled in theprogramme(30%),proportionofpersonswithdiabetesdroppingoutofprogramme(<1%),proportionofpersonswithdiabeteswhowereregularly checkeduponHbA1c,bloodpressure, lipidparameters, creatinine, albumin i.U,ECG+24RRprofile,ocularfundusandfootinspection.Intermediateoutcomeindicators:smokingpeople.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Aphonesupport fora largepopulationofpeoplewithchronicdisease (diabetes thenasthma).Apilotintervention was experimented between 2008 and 2011 before generalization in 2012. Externalevaluationwasperformed.


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Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?With 700 000members with diabetes, the programme has a very high level of satisfaction (>90% ofpeople). It’s highly supported by patients’ association. It’s a free service. You can enter or exit theprogrammewheneveryouwant.Failure-Lowerenrollmentformorevulnerablepatients:HaveattentiontolowinvolvementofGPs.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?This programme helps to empower people with diabetes by giving them disease basic information,testimony of patients and health professionals and having phone support with nurses to help themchangetheirbehaviors.Leadingorganizationoftheprogramme/experienceCNAMTS(Nationalhealthinsurer)ContactpersonWebsitehttps://www.ameli-sophia.fr/References


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TheSaxonianDiabetesManagementProgrammeGermany

ShortdescriptionoftheprogrammeThe Saxon DiabetesManagement Programme (SDMP) based on integrated practice guidelines, sharedcare and an integrated intersectoral quality management system. The SDMP was implemented intodiabetescontractsbetweenhealth insurances,GPsanddiabetesspecialisedpractitioners(DSPs)unifiedintheSaxonassociationofStatutoryHealthInsurancePhysicians.The evaluation of the SDMP inGermany represents a realworld study by using clinical data collectedfrom participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxonyparticipated.Finally291,771patientswereincludedintheSDMP.Cross-sectionaldatawereevaluatedatthebeginningof2000(groupA1)andattheendof2002(groupA2).Asubcohortof105,204patientswasfollowedupoveraperiodofthreeyears(groupB).Results–Thestate-wideimplementationoftheSDMPresultedinachangeoftherapeuticpracticeandinbettercooperation.ThemedianHbA1catthetimeofreferraltoDSPsdecreasedfrom8.5%to7.5%andsotheoverallmeandid.Attheend,78%and61%ofgroupBachievedthetargetsforHbA1candBP,respectivelyrecommendedbytheguidelinescomparedto 69% and 50% at baseline. Poorly controlled patients benefited the most. Pre-existing regionaldifferenceswerealigned.Conclusions–Inconclusion,wefoundthatacoordinated,interdisciplinaryandintegratedcaresettingwaseffectiveandefficienttoreducemeanHbA1candBPcontinuouslyovertimethroughoutacountry.Therefore,itcanbeconcludedthatanintegratedcarediseasemanagement,basedon integrated practice guidelines implemented into an integrated care structure and a practicableintegrated quality management is an innovative way to improve diabetes care continuously andunselectedthroughoutacountry.Yearofimplementation,levelofimplementation,funding1999,implementationatallcarelevels(GPs,Diabetesspecializedpractitionersaswellasdiabetologistsinhospitals), funding by health insurers as well as statutory health insurance physicians, pay forperformanceaswellaspayforoutcomeIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Ithasbeenevaluatedbetween2000and2002(resultss.aboveandinDiabetesCare2008).Structure indicators: integratedcare,GPs forprimarycareanddiabetes specialists inownpractices forsecondary care, diabetes nurses, integrated practice guidelines with criteria for timely refer todiabetologistsandthenextcarelevel,respectively,integratedintersectoralqualitymanagementsystem,patientcenteredandpopulationbasedintersectoralapproachetc.Process indicators: HbA1c, blood pressure, lipids, Creatinin, Microalbuminuria, education, hospitaladmissions as well as accounting data from the Association of Statutory Health Insurance Physicians(“KassenärztlicheVereinigung”),timelyrefertospecialistsetc.Outcomeindicators:HbA1c,bloodpressure


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Whyshouldthisprogramme/experiencebeconsideredagoodpractice?TheintegratedSaxonianHealthCareModel(SDMP)wasveryinnovativeandimplementedevery-where(statewide) in Saxony with a coverage of nearly 90% of all patients with diabetes, of all diabetesspecialistsinownpracticesandofabout80%ofallGP’sinSaxonyandwaspositiveevaluated.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?SUCCESS:TheSDMPwasabottom-upmodelwithgoodadaptions toregionalconditionsandwasverysimple,especially thevalidshortdocumentation,andwithoutanybureaucracy (withoutadministrativeworkloadandwithoutsigning inofpatients).Thedocumenteddatabyphysiciansfortheevaluationaswellas for thequarterly feedback reportswereverysmall,butcovered themulti-morbidity,andwereselectedfromthere,wheretheywerealreadyregistered(e.g.fromtheregionalAssociationsofStatutoryHealthInsurancePhysiciansàsecondarydatawereincluded).Allparticipatingphysiciansreceivedtheirvalid feedback reportsquarterly in time todiscuss it in thequality circles:aboutmore than50%ofallGP’s took part in peer-review-methods, e.g. in cross-sectoral quality-circles, organized by the regionaldiabetesspecialist.Therefore, theSDMPwaswidelyacceptedbynearlyallphysicians (andalsoby thepatients). Also the scientific basis – the Saxonian practice guidelines – was statewide accepted. Theguidelines basiswas the natural history of themultifactorial disease, and they included concrete (riskadjusted)targetsandstandardsforcooperation,e.g.forintimerefertothenexthealthcarelevel.Thus,theGP’s cooperatedwith the diabetes specialists outstanding and referredmost of the patientswithparaclinicalparametersabove the targetsorwithdiabetes-specific complications in time.Additionally,thepayforperformanceandespeciallythealreadypreparedpayforoutcomecontributedtothegreatsuccess of the SDMP. And thus, the effectiveness (the outcome) aswell as the efficiency of the caremodelimprovedsignificantlywhiletheobservationperiod(of3years).FAILURE:Nothing.Unfortunately,becauseofthenationwideimplementationofthetop-down-DMP’sinGermany,in2003theverysuccessfulSDMPwascancelled.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?The SDMP could be a model for implementation into other European countries, because of theoutstanding cross-sectoral cooperation, the good feasibility with a small documentation and using ofsecondary data, the high acceptance rate and the significant improvement of the outcome. And, itcontainedalreadysomecomponentsofaChronicCareModelformulti-morbidpatientswithDMT2andcouldbefurtherdevelopedtoacomprehensivediseaseindependentChronicCareModel.Leadingorganizationoftheprogramme/experienceTheRegionalHealthInsuranceFunds,theRegionalAssociationsofStatutoryHealthInsurancePhysicians(KVS),theRegionalChamberofPhysicians(SLÄK),theRegionalMinistryofHealth(SMS).ContactpersonPDDr.med.UlrikeRothe,[email protected]


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WebsiteFachkommissionDiabetes:http://www.slaek.de/de/05/kommissionen.phpReferencesRotheUetal.Evaluationofadiabetesmanagementsystembasedonpracticeguidelines,integratedcareandcontinuousqualitymanagementinafederalstateofGermany:apopulation-basedapproachtohealthcareresearch.DiabetesCare31(2008)863-868


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AOKCheckUpPlusGermany

Shortdescriptionoftheprogramme/experienceDependingonthediabetesrisk(accordingtoFINDRISKquestionnaire)diagnosticsandprimary/secondaryprevention offerings, respectively are provided. If an unknown diabetes case has been detected byCheckUpPlus,registrationandcarefollowsintothediseasemanagementprogramme(DMP).Yearofimplementation,levelofimplementation,funding2014,atGPsprimarycarelevel,insurerAOKplusIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)NotyetWhyshouldthisprogramme/experiencebeconsideredagoodpractice?TheprogrammeCheckUpPlus isavery innovativeearlydetectionprogrammeofpersonsathighriskofdiabetes (among other tools and findings by means of the evidence based FINDRISK sheet/tool) andfollowing active prevention. AOKplus insured persons (age 35-65) who still have no diabetes arescreened by means of the CheckUpPlus programme in Saxony instead of the insufficient statutorilyregulatedCheckUp35.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive lessons learned: Each participant will be individual managed and guided according to hisindividualriskoranexistingcondition.Thisprocedureoftheprogrammeisuniquesofar.Negative lessons learned:Theprogrammehasn’tbeenevaluatedyet.Nevertheless,GPshastousetheprogramme better andmore. The transition to prevention offeringsmust be improved. Furthermore,GPs recommend the insured persons often several interventions, but the insured person doesn´t usethem.ItwouldbeimportanttoappealtogetherwiththeGPsmoretothehealthawarenessofaninsuredperson.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?CheckUpPlusprogrammecan identify persons at high risk for diabetesmellitus anddiagnosediabetesmellitus at an early stage, respectively. Early identification of high risk groups can lead to earlypreventionandeducationofpatientsathighriskaswellastoearlydetectionofaconditionandanearlyandeffectivecare,whichisadjustedtoindividualpatientneeds.


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Leadingorganizationoftheprogramme/experienceAOKplus(insurer)ofSaxonyandThueringiaContactpersonYvonneLehnertandMr.MildeWebsitewww.aokplus-online.de,Referenceswww.aokplus-online.de/leistungen-services/vorsorge/check-up-plus.html


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“SMS.Besmart.Joinin.Befit."Germany

Shortdescriptionoftheprogramme/experience“SMS.Seischlau.Machmit.Seifit."(engl.“SMS.Besmart.Joinin.Befit."),aninitiativeledbyProfessorMüssiginDüsseldorfandCologneprimaryschools,seekstocounteractobesityandotherlifestyle-relateddiseasesinchildhoodandadolescence,payingspecialattentiontochildrenwithamigrationbackground.Theparticipatingchildrenreceiveextra lessonsonnutrition incooperationwiththeEducationalCenterfor Dietary Assistants of the Kaiserswerther Diakonie, and take part in the exercise programme forprimaryschools“FitnessforKids”developedbysportsscientistProf.Dr.KerstinKetelhut.ThetwohealthinsurancecompaniesIKKclassicandKKH,theorganizationdiabetesDE-GermanDiabetesAid,theSportsDepartmentofDüsseldorfandotherrenownedpartnersandprominentpeoplesupporttheprojectandprovidetheparticipatingschoolchildrenwithadditionalattractivevenuesforlearningoutsideofschool.ThepatronoftheinitiativeisThomasGeisel,mayorofthestatecapitalDüsseldorf.Yearofimplementation,levelofimplementation,funding2012Funding by the two health insurance companies IKK classic and KKH, the organization diabetesDE -GermanDiabetesAid,andtheSportsDepartmentofDüsseldorf,thecapitalcityoftheGermanstateofNorthRhine-Westphalia.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Outcome: Tests on physical fitness and motor skills and questionnaires on dietary behavior andknowledgebeforeandaftertheinterventionStructure&process:Theprogramme is regularlyadaptedaccording to theexperiencesof theheadsofthe schools, teachers, children and their families, trainers, and dieticians within a school year and ispermanentlybroadenedbynovelvenuesforlearningoutsideofschool.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Theprogrammecomprises impartingknowledge to school children regardingbalanceddiet, aswell asregular physical activity. The parents are involved in the programme by joint activities, such asparticipation in sports event. The teachers are trained to become multiplicators of the programmecontents.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?The nutrition and sports lessons were specifically developed for school children and are given verypractically. Therefore, the children follow the programme very enthustically. In particular, the


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participatingchildrenappreciatetheveryattractivevenuesforlearningoutsideofschool,suchasbakingbreadinabakery.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Bystartinginearlychildhood,theprogrammeaimsatavoidingthedevelopmentofconsequencesofanunhealthylifestyleand,consequently,atreducingtheriskfactorsforobesityandtype2diabetes.Leadingorganizationoftheprogramme/experienceDüsseldorferKidsmitPFIFFe.V.(supportassociation)GermanDiabetesCenter(scientificevaluation)ContactpersonProf.Dr.KarstenMüssigDepartment of Endocrinology and Diabetology, Faculty of Medicine, Heinrich Heine University,Düsseldorf, Germany; Institute for Clinical Diabetology, German Diabetes Center at Heinrich HeineUniversity, Leibniz Center for Diabetes Research, Düsseldorf, Germany; German Center for DiabetesResearch(DZD),München-Neuherberg,GermanyAuf’mHennekamp65,40225Düsseldorf,Germany,phone:+49-(0)211/3382-218,fax:+49-(0)211/3382-690,email:[email protected]://www.sms-mach-mit.de/ReferencesThefirstresultsontheimpactoftheinterventiononphysicalfitnessandmotorskillsoftheparticipatimgchildrenhavebeensubmittedtoaninternationalscientificjournal.


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MEDIAS2programme

Germany

Shortdescriptionoftheprogramme/experienceMEDIAS2wasdevelopedbytheworkgroupattheDiabetes-AkademieBadMergentheimandUniversitätBamberg (Bundesärztekammer et al. 2013). The programme is based on recommendation of theEuropean Diabetes Policy Group, the International Diabetes Federation and Deutsche DiabetesGesellschaft(Kulzeretal.2008a).Itprovidesthreedifferenteducationprogrammes:

- MEDIAS2BASIS- MEDIASICT- MEDIAS2BOT+SIT+CT

“MEDIAS2Basis”isacertified(DeutscheDiabetesGesellschaft)groupeducationprogrammeforpeople(40-65years)withnon-insulindependenttype2diabetesandisbasedonaself-managementapproach.Theprogrammedurationis8or12h,byagroupsizeof6-8participants. It isbasedonacriteriabasedcurriculum,worksheets,diabetesdiariesetc.Diabeteseducatorsare,e.g., specialdiabetes consultants,physicians,andpsychologists(Bundesärztekammeretal.2013,Kulzeretal.2008a).The MEDIAS 2 Basis for patient education aims to stimulate to think about lifestyle and attitude,consciousofbehavior(Bundesärztekammeretal.2013), improveeverydaylifewithdiabetes,developalong-termplanandenableactivedecision-making(Kulzer&Hermanns2001).Thecurriculumcontainsprinciplesofdiabetes,treatmentoptions,self-observation,individualaims,acutecomplications,latecomplications,nutrition,physicalactivity,riskfactors,QualityofLife,diabetesrelatedfootproblems,socialaspects,handlingoffailure,andcheckups(Kulzer&Hermanns2001).“MEDIAS 2 ICT” is also a certified (Deutsche Diabetes Gesellschaft) group education programme forpeople (40-65years)with insulindependent type2diabeteswithan intensive insulin therapyand it isbasedonaself-managementapproach.Theprogrammeduration is12units(à90minutes),byagroupsizeof4-8participants. It isbasedonacriteriabasedcurriculum,worksheetsanddiabetesdiaries.TheprogrammeisextendedthesametopicsthatexistinMEDIAS2BASIS.Itaimstostimulateself-managementregardingintensiveinsulintherapyineverydaysituations,qualityoflife,theunderstandinginsulintherapy,andformulatingindividualgoals.Italsoincludesrelativesininsulintherapy,andhandlingdifficultiesinordertoimprovebloodsugarlevel,bloodpressureandbloodlipids.MEDIAS 2 ICT exercise especially focused on flexible insulin dosage in everyday situations(Bundesärztekammeretal.2013,Kulzeretal.2008b).“MEDIAS2BOT+SIT+CT”isanewconstructedgroupeducationprogrammeforpeople(40-65years)withbasalsupportedoraltherapy(BOT),supplemental insulintherapy(SIT)andconventional insulintherapyand is based on a self-management approach. MEDIAS 2 BOT+SIT+CT was designed to close the gapbetweenthetwootherprogrammes.Theprogrammedurationissixunits(à90minutes),byagroupsizeof4-8participants.Itisbasedoncardssets,worksheets,self-controlbookletetc.(Kulzeretal.2008c).


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Itaims tohelppeoplemanage their insulin therapy ineverydaysituations. Italso includesexchangeofexperiences,increaseQualityofLife,stimulatecopingstrategies,supportandinformationtransfer(Kulzeretal.2008c).Yearofimplementation,levelofimplementation,fundingThe results from“MEDIAS2BASIS”were firstpresented in1996at31.DeutscheDiabetesGesellschaftJahrestagung(Kulzeretal.2008d).ThefifthEditionwasreleasedin2011.Thefirsteditionof“MEDIAS2ICT”wasreleasedin2012(Bundesärztekammeretal.2013).“MEDIAS2BOT+SIT+CT”startedinautumn2015(ForschungsinstitutDiabetes).Theeducationprogrammeis implementedonregionalandnationallevel(ForschungsinstitutDiabetes2016).Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)MEDIAS2Basishasbeenevaluatedbymeansofafive-yearrandomisedcontrolledtrialincluding193(181participants 15months afterbaseline)overweightpeoplewithnon- insulindependent type2diabetes(Kulzeretal.2007,Kulzer&Hermanns2001).Quality criteria on sructure level are: Defined goals, defined target group (inclusion and exclusioncriteria),definedsetting(e.g.inpatient,outpatient),descriptionofthenumberoftheeducationunits(45minutes), description of the scheduling of the education units (45 minutes) per programme: (type 1diabetes -24 education units; type 2 diabetes -20 education units; type 2 diabetes and a low risk ofsecondary diseases - 8 education units), limitation of the number of participants (6-11 participants),defined settings (e.g., group setting, inclusion of relatives), description of the environmentalrequirements, provided education material for patient information, evaluated curricula, definedqualification of the trainers, individualized educational plan of care based on assessment andbehavioural goal, description of information exchange between all stakeholders incl. Physicians,description of the inclusion of relatives, description of appropriate media, description of specificdidactics(whatto learnandwhy),descriptionofspecificmethods(howtogive lessons),descriptionoftheevaluation/measurementof theeducationprogramme,provisionof theevaluation resultsan fiveyearevaluationoftheeducationinstitutionregularaudit(Bundesärztekammeretal.2013).Outcome level criteria are: HbA1c values, diabetes knowledge, eating behavior, anxiety, depression,Qualityoflife,self-treatment,empowerment/self-efficacy(Bundesärztekammeretal.2013,Kulzeretal.2007,Kulzer&Hermanns2001).Whyshouldthisprogramme/experiencebeconsideredagoodpractice?MEDIAS 2 meets requirements of a modern criteria based patient education, including the self-managementapproach.Thiscorrespondstothereccommendationsofleadingprofessionalssocietiesforpatienteducation.Additionally, theprogramme is involved inDiseaseManagementProgrammes since2014inGermany(Kulzeretal.2008d).MEDIAS 2 ICT is the first education programme in Germany, which considered all diabetes-relatedmetabolicriskfactors(Kulzeretal.2008b).


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MEDIAS2BOT-SIT-CTbasedonnational guidelines (NationaleVersorgungsLeitlinie Typ-2-Diabetes, S3)andalsooninternationalguidelines(IDF,ADA,NICE)(Kulzeretal.2008c).Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?-Itisapatientorientatedprogramme:thecontentsarepresentedvividly.-thecoursewillfocusonpersonalcontactconsideringillnesanddifficulties-practiceeverydaysituationsincourses(e.g.buyingfood,gotocelebrations)(Kulzeretal.2008a)Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Self-management training had a significantly higher medium-term efficacy than didactic diabeteseducation. The group sessionsweremore effective than amore individualized approach (Kulzer et al.2007). The best effects are evaluated when the education programme starts shortly after diagnosis(Kulzeretal.2008a).Theeffectsare:1. Thepatientsloseweightafter15months(mean2,4kg)2. Bettercontrolofeatingbehaviour3. Significantincreaseindiabetesknowledge4. Morepsychicalwell-being5. Improveregularcontrol(footcare,bloodsugarmeasurement)(Bundesärztekammer2013,Kulzeretal.2007,Kulzer&Hermanns2001)Leadingorganizationoftheprogramme/experienceFIDAM-ForschungsinstitutderDiabetes-AkademieBadMergentheimContactpersonPDDr.phil.BernhardKulzer,[email protected]ärztekammer,KassenärztlicheBundesvereinigung,ArbeitsgemeinschaftderWissenschaftlichenMedizinischenFachgesellschaften.NationaleVersorgungsLeitlinieDiabetes–StrukturierteSchulungsprogramme–Langfassung,1.Auflage.Version3;2013.Availablefrom:www.awmf.org/uploads/tx_szleitlinien/nvl-001fl_S3_NVL_Diabetes_Schulung_2013-07(22.03.2016).ForschungsinstitutDiabetes.SeminarinformationenundSeminartermine2016.2016.Availablefrom:


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http://www.diabetes-schulungsprogramme.de/templates/main.php?recordID=283(23.03.2016).ForschungsinstitutDiabetes.Startseite.Availablefrom:http://www.diabetes-schulungsprogramme.de/templates/main.php?recordID=20(23.03.2016).KulzerB,HermannsN.“MehrDiabetesSelbstmanagementTyp2”:EinneuesSchulungs-undBehandlungsprogrammfürMenschenmitnicht-insulinpflichtigemTyp-2-Diabetes.PraxisKlinischeVerhaltensmedizinundRehabilitation54,129-136,2001.KulzerB,HermannsN,MaierB,HaakT.WasistMEDIAS2BASIS?2008a.Availabefrom:http://www.medias2.de/templates/main.php?recordID=113(23.03.2016).KulzerB,HermannsN,MaierB,HaakT.InhaltevonMEDIAS2ICT.2008b.Availabefrom:http://www.medias2.de/templates/main.php?recordID=321(23.03.2016).KulzerB,HermannsN,MaierB,HaakT.WasistMEDIAS2BOT+SIT+CT.2008c.Availabefrom:http://www.medias2.de/templates/main.php?recordID=319(23.03.2016).KulzerB,HermannsN,MaierB,HaakT.AnerkennungdesMEDIAS2Schulungsprogramms.2008d.Availabefrom:http://www.medias2.de/templates/main.php?recordID=238(23.03.2016).KulzerB,HermannsN,MaierB,HaakT.MEDIAS2BASISSeminarefürAnwender.2008e.Availabefrom:http://www.medias2.de/templates/main.php?recordID=270(23.04.2016).KulzerB,HermannsN,MaierB,HaakT.VerhaltensmedizinischePräventionundTherapiedesTyp-2-Diabetes.2008d.Availabefrom:http://www.medias2.de/templates/main.php?recordID=148(23.03.2016).KulzerB,HermannsN,ReineckerH,HaakT.Effectsofself-managementtraininginType2diabetes:arandomized,prospectivetrial.DiabeticMed24(4),415-423,2007.


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TrainingsoftheGermanDiabetesSocietyGermany

Shortdescriptionoftheprogramme/experienceSpecialized professions in diabetology, established for the Deutsche Diabetes Gesellschaft. Exemplarytraining programmes: Diabetologist DDG(Diabetologe DDG), Psychological Specialist DDG(Fachpsychologe DDG), Diabetes Advisor DD (Diabetesberaterin DDG), Diabetes Assistant DDG(Diabetesassistentin DDG), DiabetesWound Care Nurse DDG (Wundassistentin DDG), Clinical DiabetesNurse DDG (Diabetes-Pflegefachkraft DDG (Klinik)), Long Term Diabetes Nurse DDG (Diabetes-PflegefachkraftDDG(Langzeit)).Kombination: seminar, hospitation, work in diabetes practice (Deutsche Diabetes Gesellschaft [DDG]2014a).DiabetologistDDG(DiabetologeDDG)TheaimformedicalprofessionalstobecomesanexpertwithskillsofoptimaltreatmentforthepatientwithType1andType2diabetesofallages.(DDG2014b).TargetGroup/Requirement:Qualifiedmedicalprofessionals,whomight have todealwithdiabetes patients in their field. Theyhave to go through aperiod of 2-years evidence of practicalwork in an accepted diabetes specialistmedical institution, ofwhichone year has to beon anmedialward. Participation in training courses part 1 andpart 2 (DDG2014b).Training courses part 1: 80-hours (10 days) of clinical diabetology focussing on theoretical basicknowledge and clinical diabetology (e.g. pediatric diabetology, metabolic syndrome, complications...)(DDG2016a,DDG2016b).Trainingcoursepart2of2:32-hours (4days) considers communicationandpatient-centred consultations inmedical practise. Learning units in course 2. focus on communicationbetweenpatient andphysician, self reflection in interactions, dealingwith non-compliant patients andsupportofpatientinstressfulsituations(DDG2013).PsychologicalSpezialistDDG(Fachpsychologe/inDiabetesDDG)Aim:Theprofessionalbecomesanexpertforpsychologicalandsocialaspectsofdiabetesandwillacquireskills for diagnosis, education and treatment of people with diabetes and mental problems.Target Group/Requirement: Psychologist with specialist qualification, 2-years evidence of practicalwork in an accepted diabetes specialized medical institution and participation in training courses.Contentofcourses:6trainingcourses(80hours)focusedonpsychodiabetology,behavioralandmentalaspectsofdiabetes,socialproblems,qualitymanagement,10dayshospitation,5casereportsDiabetesAssistantDDG(DiabetesassistentinDDG)Aim: To aquire skills and knowledge regarding diabetes to teach patients self-management and socialcompetence.Focusondiseasespecific,medical,educationalandpsychosocialbasiswiththeaimtolearnhowtoadvice,guideandeducatepeoplewithType2diabetes.TargetGroup:QualifiedspecialiststaffinmedicalprofessionsTrainingcourse:Thetrainingisdesignedfor3-8months:160-hourstrainigcourses(2x2weeks)andahospitation(40hours).(DDG2015)


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DiabetesAdvisorDDG(DiabetesberaterinDDG)Aim:Careandcounsellingofpatientsofallages(includingchildren)withdiabetesmellitustype1,type2and pregnant women suffering from diabetes or gestational diabetes. The focus is the analysis andassessmentofthepatient´scondition,aswellasplanning, implementation,reflectionandevaluationofconsulting,trainingandsupportforpatientsandtheirrelatives.TargetGroup:Qualifiedspecialiststaffinmedicalprofessions.Trainingcourse:Thetrainingisdesignedfor12-14months,duringthistimethestudentshavetoproduceevidence of having completed 520 hours of training (5 x 2-3weeks) and 584 hours of practical work.ThereistheoptionoftheshortercoursefortheDiabetesAssistants(336hourstraining(4x2weeks),362hourspractical).(DDG2014c,DDG2014d)In 2011 this training to become a diabetes advisor was awarded the Innovation Prize of the FederalInstituteforVocationalTraining(BIBB)inthedivision:ContinuingEducationClinicalDiabetesNurseDDG(Diabetes-PflegekraftDDG(clinic))Aim: To manage inpatients with diabetes: this includes monitoring, documentation and care (e.g.woundmanagement),guidanceandeducationbothpatientsandrelativesandtoreducediabetes-relatedemergencies.TargetGroup:AllqualifiednursingstaffTrainingcourses:80hours(2x1week)trainingcourses,physiologicalandpathologicalbasis,treatmentofdiabetesmellitus,diabetes-relatedhealthcaremanagement(DDG2014e).LongTermDiabetesNurseDDG(Diabetes-PflegekraftDDG(longterm))Aim:Recognizediabetologicalcareriksandconsiderandavoidthisrisksinnursingservicesandlongtermcare,whoareworkinginoutpatientclinicorinhomecare.Target:qualifiedstaffnurses,e.g.districtnursesandelderlycarenursesTrainingcourses:10daysandpracticalwork(DDG2014f).DiabetesWoundCareNurseDDG(WundassistentinDDG)Aim:Totreatandmonitorthepatients’woundsandpromotehealthmanagementtoavoidrelapses.Requirement:Qualifiedspecialiststaffinmedicalprofessions.Training course: The training is designed for 6months: during this time the students have to provideevidenceofhavingcompleted40-hourstrainigcourse(1week)andahospitation(24hours).(DDG2015).Yearofimplementation,levelofimplementation,fundingLevelofimplementation:national(DeutscheDiabetesGesellschaft2014).Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Evaluationinprogress.Whyshouldthismeme/experiencebeconsideredagoodpractice?Beststandardscomparedtointernationalstandards,qualityassurance:QSW(DeutscheDiabetesGesellschaft2014).AccordingtoEuropeanStandardEQRandDQRoflifelonglearning'


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Whatarethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Quality assurance by applying quality standards under supervision of the German Diabetes Society(DeutscheDiabetesGesellschaft2014).In2011theFederalInstituteforVocationalEducationandTraining(BIBB)hashonouredthe"ContinuingEducation Innovation Prize" (WIP) to the innovative and trend-setting project and idea in vocationaleducationandtrainingtothequalification:DiabetesAdvisor(DiabetesberaterinDDG)Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Qualitativetrainingprogramme(evaluationinprogress).Leadingorganizationoftheprogramme/experienceDeutscheDiabetesGesellschaft(DDG),GermanyContactpersonMartinaWallmeier,[email protected],[email protected],[email protected]://www.deutsche-diabetes-gesellschaft.de/weiterbildung.htmlReferencesDeutscheDiabetesGesellschaft.DieWeiterbildungenimÜberblick.2014a.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Weiterbildung/Übersicht_Weiterbildungen_DDG_Auszug_GB_2014.pdf(23.03.2016).DeutscheDiabetesGesellschaft.DiabetologieDDG.2014b.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/weiterbildung/diabetologe-ddg.html/fileadmin/Redakteur/Weiterbildung/Übersicht_Weiterbildungen_DDG_Auszug_GB_2014.pdf(23.03.2016).DeutscheDiabetesGesellschaft.78.Fortbildungskurs“KlinischeDiabetologie(80Stunden-Kurs)PROGRAMM.2016b.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Weiterbildung/Diabetologe_DDG/2-Programm-DDG-Kurs-Freiburg_2016-April.pdf(26.04.2016).DeutscheDiabetesGesellschaft.Seminare:KommunikationundpatientenzentrierteGesprächsführungin


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derDiabetologie.2013.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Weiterbildung/Diabetologe_DDG/-Ziele_und_Inhalte_der_Kurse_sowie_Qualifikation_der_Seminarleiter.pdfDeutscheDiabetesGesellschaft.WeiterbildungzurDiabetesberaterinDDG.2014c.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/weiterbildung/diabetesberaterin-ddg.html(26.01.2016.)DeutscheDiabetesGesellschaft.InformationenzurWeiterbildung.2014d.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/weiterbildung/diabetesberaterin-ddg/informationen-zur-weiterbildung.html(26.04.2016).DeutscheDiabetesGesellschaft.Weiterbildungsinformationen.2014e.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/weiterbildung/diabetes-pflegefachkraft-ddg-klinik/informationen-zur-weiterbildung.html(26.04.2016).DeutscheDiabetesGesellschaft.WeiterbildungzurDiabetes-PflegefachkraftDDG(Langzeit).2014f.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/weiterbildung/diabetes-pflegefachkraft-ddg-langzeit/informationen-zur-fortbildung.html(26.04.2016).DeutscheDiabetesGesellschaft.Weiterbildungs-undPrüfungsordnung(WPO)Diabetesassistent/inDDG.2015.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Weiterbildung/-Diabetesassistent_DDG/201500225_WPO_DiAss_inkl._Anlage_1-3_final.pdf(26.04.2016).DeutscheDiabetesGesellschaft.78.Fortbildungskurs“KlinischeDiabetologie(80Stunden-Kurs)2016Freiburg.2016a.Availablefrom:http://www.deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Weiterbildung/Diabetologe_DDG/1-Programm-DDG-Kurs-Freiburg_2016-Februar.pdf(26.04.2016).


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IPIONI-NationalPilotProjectonPreventionandHealthPromotionforOlderPeople

Greece

Shortdescriptionoftheprogramme/experienceTheproposalwaspreparedandsubmitted to theDepartmentofPimaryHealthCareof theMinistryofHealth by the Hellenic Association of Gerontology & Geriatrics, and it was approved in Spring 2015.HavinginmindthatinGreecetherewasnotageneralframeworkforhealthpropmotionandpreventionforolderpeople theproposalaimed to sensitize the responsibleauthoritieson thenecessityof it. Theproposal includeddemographicdata(EuropeanHealthforAlldatabase)aswellasepidemiologicaldataonspecificforolderpeoplemorbidityandmortality(http://www.worldlifeexpectancy.com/country-health-profile/greece).DuringameetinginJuly2015itwasdecidedthatthefirstpilotwillfocusonthepreventionofDiabetestypeII.Followingthis,allrelevantscientificbodieswereinvitedtoprovideinformationinordertodesignthe first implementation. In subsequentmeetings, professional bodies and patient orgnaisations werealsoinvolvedaswellastheNationalInter-MunicipalNetworkofHealthyCities.Thetargetpopulationwereallpeopleover55,healthyandthosewithchronic ill-healthincludingthosewithknowndiabetes.Yearofimplementation,levelofimplementation,funding• Runfromthe1stofOctobertothe31stofDecember2015–itwasannouncedonthe1stofOctober–

OlderPeople’sDay-duringadayseminarsorganizedbyHAGGintheMunicipalTheatreofPiraeusandtheMunicipalityofMaroussi.

• Informationwasdistributedtoallprimaryhealthcarefacilities- thoserunbytheNHSandthe localauthorities-inGreeceelectronically.

• Materialwasbasedon current and valid scientific data. It included a standardprotocol, a standardhistory,themostcurrentinformationofdiabetespreventionandrelevantwebsites.

• Additionalinformationwasavailablethroughtheinternet.• Therewere organized health promotion activities in Open Care Centres (KAPI) and Health Centres.

Theseincluded: -provisionofinformation -preventivetestson-site -riskassessment -managementandreferralofdiabeticstodiabetesreferencecentres• Therewasalsoprovisionofelectronicprescribingofadditionalexaminationswhenneeded.• Fundingwasbasedonexistingcoveragebysocialsecurityandalargepartoftheimplementationwas

alsovolunteering.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)


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Thisfirstpilotdidnotaimatformalevaluation.Itwasdecidedfromthebeginningthatevaluationwillbedescriptive and that all stakeholders involvedwill provide a report describingwhat they did. During ameeting at the ministry of health in the beginning of June 2016 most of the participating bodiespresentedtheirfindings.Theseincluded:• Allparticipatingbodiesprovidedinformationthroughtheirwebsites.• Regional health authorities provideddescriptive evaluationof the implementation activities in their

areaofresponsibility.• Manymunicipalitiesactivelycollaboratedandprovidededucationalsessionsandbloodsugartestsin

theopencarecentres(KAPIs).Thiswasevidentthroughawebsearch.• Manyhealthprofessionalsvolunteeredtoprovideinformationinorganizedactivitiesbyhealthcentres

andKAPIs.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Itisthefirstnationalproject-althoughapilot-aimedatthisspecificpopulation.Inadditionisaimedatimprovingservicesprovidedtoolderpeoplethroughcooperationofscientificorganisations,professionalbodies,primaryhealthcareservices,localauthoritiesunderthecoordinationoftheministryofhealth.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Theevaluationofthispilotwaspositiveasparticipantorganisationsreported.Asthiswasthefirstpilotanditsimplementationwasnationalitwasfoundoutthatcollaborationamongthedifferentstakeholderswasnotalwayssuccessful.Thiswillbetakenintoaccountinthe2ndpilotthatwillrunautumn2016withfocusonadifferenttopic.Duringthis2ndpilot,theprojectonDiabetesTypeIIwillcontinueandtherewillbeanefforttoevaluateitformally.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?As of today prevention and health promotion for older people was fragmented. This project tried toimprovecooperationamongthedifferentstakeholdersandprovideappropriateservicesinanorganisedmannerandavoidingduplication.Leadingorganizationoftheprogramme/experienceMinistryofHealth,DepartmentofPrimaryHealthCare,CoordinatorHellenicAssociationofGerontologyandGeriatrics-HAGG,ScientificcoordinatorContactpersonP.Sourtzi,[email protected],[email protected]://www.gerontology.gr/


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ReferencesOECD(2013),OECDEconomicSurveys:Greece2013,OECDPublishing.http://dx.doi.org/10.1787/eco_surveys-grc-2013-enU.S.PreventiveServicesTaskForce(USPSTF):FocusonOlderAdults,http://www.uspreventiveservicestaskforce.org/uspstopics.htmWΗΟ(2012),http://www.who.int/countries/grc/en/


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C.U.R.I.A.M.O.HealthyLifestyleInstitute’sModelItaly

Shortdescriptionoftheprogramme/experienceTheconceptincludesaspecificationoftheprojectaimsandobjectives,anadequateestimationofhumanresources,materialandnon-materialrequirementsandbudgetrequirements.A theoretical basis of the programme exists and includes description of the method, description ofactivitiesinachainofcausationandtimeframeanddescriptionofinteractionsbetweenkeystakeholdersandprocesses.Thefollowingelementsoftheprogrammearedescribedandtheoreticallyjustified:frequency,intensity,duration,selectionandrecruitmentmethodlocation.The target population is defined on the basis of needs assessment, taking into consideration:socioeconomicstatus,ethnicityandculturalfactors,genderdifferencesandvulnerablegroups.The intervention,designed inconsultationwith the targetgroups,aims topromote the targetgroup(s)self-managementskills.Potentialburdensoftheinterventionareaddressedandthebenefit-burdenbalanceisfairlybalanced.The intervention creates ownership among the target group and several stakeholders considering:multidisciplinary,multi-/inter-sectorial,partnershipsandalliances.Yearofimplementation,levelofimplementation,fundingTheprogrammeisontheInstitutionalandlocallevel.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Thereisadefinedevaluationframework,assessingstructure,processandoutcome.Theevaluationmethodsand/ortoolsarevalidated.Thereismonitoringsystemsinplacetodeliverdataalignedwithevaluationandreportingneeds.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?The C.U.R.I.A.MO. model is an innovative multidisciplinary methodological approach that hastheoreticalstructure based on the review of the literature, on the experience in the treatment withlifestyle intervention of obese adults and on the pilot experience in the treatment of obese children,adolescentsandtheirparents.Themostrelevantaspectcharacterizingthismodelisthemultidisciplinaryapproach that aims to improve, at the same time, three key aspects of healthy lifestyles: nutrition,exercise and psychologicalmotivation, and the adoption of a family-based approachwith the relatedinterventions:psychological,nutritional,physicalexercising forchildren,adolescentsandtheirparents.The model of intervention is described in detail in the publication of De Feo et al. 2011. Thismethodology,asclinicalinterventionhasbeenrecentlyimplementedbyEUROBIS(EpodeUmbriaRegionObesity Intervention Study). The project (www.eurobis.it) is one of EPODE programme, it is acoordinated,capacitybuildingapproach,acommunitybaseprogramme,thataimstoreducechildhoods


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obesity through a social process in which local environment, childhood setting and family norms aredirected and encouraged to facilitate the adoption of a healthy lifestyle in children based on acombinationofpreventiveandcurativestrategiesaimingatovercomingthedivisionbetweenpreventionandheathcare.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?The reasons for the success are 1) the multidisciplinary approach, through which physical activity,healthynutritionandmotivationtoacorrectstyleoflifeareenhancing,and2)thepatientcenteredcare.Wehave reported indetail theopinionof thepatients (seepublication: PianaNetal., 2013) and thepsychologicaldeterminantsofthefinalsuccessofthe intervention(seepublication:MazzeschiCetal.,2012).Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Theinterventionprogrammebyimprovingthethreekeyaspectsofhealthylifestyles:nutrition,exerciseand psychologicalmotivation increases the quality of life of patients either affected by obesity or bydiabetes(seepublication:MazzeschiCetal.,2012).Leadingorganizationoftheprogramme/experienceHealthyLifestyleInstituteC.U.R.I.A.MO.-UniversityofPerugiaContactpersonProf.PierpaoloDeFeo([email protected])Websitehttp://curiamo.unipg.it/ReferencesDeFeoP,FatoneC,BuraniP,PianaN,PazzagliC,BattistiniD,CapezzaliD,PippiR,ChipiB,MazzeschiC.Aninnovativemodelforchangingthelifestylesofpersonswithobesityand/ortype2diabetesmellitus.JEndocrinolInvest2011;34:e349-e354.

Piana N, Battistini D, Urbani L, Romani G, Fatone C, Pazzagli C, Laghezza L, Mazzeschi C, De Feo P.Multidisciplinary lifestyle intervention in the obese: its impact on patients' perception of the disease,food and physical exercise. Nutr Metab Cardiovasc Dis. 2013 Apr;23(4):337-43. doi:10.1016/j.numecd.2011.12.008.Epub2012Apr11.

MazzeschiC,PazzagliC,BurattaL,ReboldiGP,BattistiniD,PianaN,PippiR,FatoneC,DeFeoP.Mutualinteractionsbetweendepression/qualityoflifeandadherencetoamultidisciplinarylifestyleinterventioninobesity.JClinEndocrinolMetab2012;97:E2261-E2265.


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C.U.R.I.A.M.O.Innovativemultidisciplinaryinterventionforchangingthelifestylesof

personswithtype2diabetesmellitusand/orobesity

Italy

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge, prevention of diabetes complications, management of stress and coping with everydaylivingactivities.Thetargetgroupsareallthepersonswithdiabetes,personswithdiabeteswithcomorbidities,personswithanewdiagnosisofdiabetes,relativesandcaregivers.Theeducationprogrammetakesintoaccountgenderdifferences.The followingcriteriaaredefined in theeducationprogramme:goals, rationale, targetgroup, setting,schedulingoftheeducationsessions,numberofparticipants,environmentalrequirements,qualificationof the trainers/educators, core components of the educator/trainer's role, monitoring of theeffectivenessandqualityoftheprogrammeandsourceoffunding.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The following outcome criteria are measured: metabolic control (HbA1c values or incidence ofhypoglycemia)andqualityoflife(empowerment/self-efficacy).The programme is based on the following evidence: randomised trial, observational study andqualitativestudybasedonnarratives.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Theeffectivenessofthemodelisitsmultidisciplinaryapproachwhoisabletofacethecomplexityofthechronicdiseaseandofhumanbeinginalongtermstablelifestylechange.TheCURIAMOmodelinvolvesthe following health care professionals: medical doctors with specialties in endocrinology, sportmedicine or cardiology, psychologists, dieticians, educators, nurses, exercise physiologists, and amanager of outside leisure time activities. The philosophy of the CURIAMO model is the activeinvolvementofthepatientwhoisconsideredtheactorofchange.Theintensivelifestyleinterventionofthefirstthreemonthsincludesthefollowing7steps:1)Visitwithaspecialistinendocrinology,2)Visitwith a specialist of nutrition, 3) visitwith a specialist of psychology, 4) visitwith a specialist of sport


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medicine, 5) supervised programme of 2 sessions per week of structured indoor exercise with anexercisephysiologist,6)educationalsessionswithotherpatients(15/20foreachgroup)organizedbyaneducator (doctorofpedagogicsciencesandanurse) tosupportmotivation for lifestylechangeand7)dailyNordicwalkingactivitycombinedwithwalkingexcursionsduringweekendsplannedbyamanagerfor outside leisure time activities. Steps 1-4 will serve to both clinical judgment and to promotebehavioralchange.Steps5-7arefinalizedtoimprovephysicalfitnessandtousegrouppowertosupportlong-termlifestylechange.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Thismodelistheoreticallygroundedonsocio-cognitiveandgroupempowerment.Themainaimofthemultidisciplinary approach is to actively involve the patient, who is considered the main actor inachievingchange.Forthisreasontheintervention(afour-monthintensiveprogramme)ischaracterizedbycounselingcenteredoneachpatient’sneed,bypromotingtheinvolvementofpatientsineducationalgroup session, nutritional education and exercises session tailored on each patient. The model isdesigned topromoteparticipant’sgrowth in threeparallel fields:exercise,nutritionandpsychologicalwell-being. Motivation to change is based on promoting decisional balance and auto-efficacy,motivation to long-term stable lifestyle improvement is based on several group empowermentstrategies: educational group session for nutrition and for motivation to change, indoor exercisesessionsandoutdoorexcursionsandactivities.Howdoes thisprogramme/experiencehelp indriving thechange towardpreventionand improvementthequalityofcareforpeoplewithdiabetes?Thepresentmodeloflifestyleinterventionrepresentanadvancementofourpreviousphysicalactivitycounselingstrategybecauseutilizesastructuredmultidisciplinaryapproach.Patientsperceivetheeffortand the support of a group of health care professionals finalized to improve their psychological andclinical conditions and for this reason theyare stronglymotivated. Theweeklymeetingsofoperatorsconfirm that also health care professionals, thanks to the model that emphasizes their specificcompetencesandtothepositivefeedbacksreceivedbypatients,reinforcetheirattitudeandmotivationtocare.Leadingorganizationoftheprogramme/experienceHEALTHY LIFESTYLE INSTITUTE of Perugia University - C.U.R.I.A.M.O. – Centro Universitario RicercaInterdipartimentaleAttivitàMotoria.ContactpersonProf.PierpaoloDeFeo([email protected])Websitewww.curiamo.unipg.it


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ReferencesMazzeschiC,PianaN,CapezzaliD,MommiA,AielloC,GattiM,RomaniG,BurattaL,BattistiniD,NasiniG,ReginatoE,UrbaniL,PazzagliC,FerriC,AmbrosioG,DeFeoP.Theimpactofstrenuousgroupphysicalactivityonmoodstates.,personalviews,bodycomposition,andmarkersofmyocardialdamageinoverweight/obeseadults:the"Step-by-StepItaly'sCoasttoCoast"trek.BioMedResearchInternational,ArticleID854129,Volume2014.PazzagliC,MazzeschiC,LaghezzaL,ReboldiGP,DeFeoP.Effectsofamultidisciplinarylifestyleinterventionforobesityonmentalandphysicalcomponentsofqualityoflife:themediatoryroleofdepression.PsycholRep.2013;112:33-46.N.Piana,C.Pazzagli,D.Battistini,D.Capezzali,R.Pippi,B.Chipi,C.Mazzeschi,“Aninnovativemodelforchanginglifestylesofpersonswithobesityand/orType2diabetesmellitus”,JournalofEndocrinologicalInvestigationdoi:0.3275/7857,published:12.07.2011PianaN.PhD,BattistiniD.MD,UrbaniL.PhD,RomaniG.PhD,FatoneC.MD,PazzagliC.PhD,LaghezzaL.PhD,MazzeschiC.PhD,DeFeoP.MD.,"Multidisciplinarylifestyleinterventionintheobese:itsimpactonpatients’perceptionofthedisease,foodandphysicalexercise”Nutrition,Metabolism&CardiovascularDiseases,2012.doi:10.1016/j.numecd.2011.12.008MazzeschiC.,PazzagliC.,BurattaL.,ReboldiG.P.,BattistiniD.,PianaN.,PippiR.,FatoneC.,DeFeoP.,“MutualInteractionsbetweenDepression/QualityofLifeandAdherencetoaMultidisciplinaryLifestyleInterventioninObesity”JClinEndocrinolMetab,2012,97(12):E2261–E2265


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DiabeticRetinopathyCentreItaly

Shortdescriptionoftheprogramme/experienceThe key components of the programme are: integrated care delivery system, interdisciplinaryworkingpractice team and clinical information system supporting interdisciplinary working practice andmonitoring. The integrated care delivery system involves diabetes specialists in hospital, specializednursesandophthalmologist.The programme was initiated by diabetologist-internists. The patient centered approach is based ondefinedclinicalpathwaystodealwithindividualsatdifferentriskforcomplicationsandplanforfollow-upisdefined.Theprogrammetakesintoaccountethnicminoritiesandlowsocio-economicgroups.Themainobjectivesare:increasingmulti-disciplinary/multi-professionalcollaboration,improvingqualityofcareforpersonswithdiabetes,decreasing/delayingcomplications,decreasingmorbidityandreducinginequalitiesinaccesstocare.Yearofimplementation,levelofimplementation,fundingYearofimplementation:1991(officiallyopenedin1998).Levelofimplementation:TertiarycarereferralcentreIncentivepaymentforperformance.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Process indicator: proportion of persons with diabetes with regular check of ocular fundus (schedule100%)Longtermoutcomeindicator:reducingratesofvisuallossorblindness.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?The Centre offers screening for sight-threatening diabetic retinopathy to patients with type 1 and 2diabetes followed in the general out patient diabetes clinic of the major teaching hospital in Turin,togetherwithshorttermfurtherassessmentand,ifnecessary,treatmentbylaserphotocoagulation.Byincludingallpassageswithinthesamepremises,weareoftenabletoconsiderablyreducewaitingtimesanddeliverappropriatecareasneeded,alsominimizingtheilleffectsofreducedaccesstocareduetosocio-economicproblems.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive lessons: dedicated nursing and specialist (diabetologist and ophthalmologists) staff. Supportfromexternal fundingsource.Negative lessons:dryingupofexternal fundingandconsequentpossiblewearingofstaffinvolved.


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Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Byearlydetectionofsight-threateninglesionsweareabletodelivertimelytreatment,thusmanagingtopreventdeteriorationofvision.Datacollectedoveralmost25yearsofactivityshowthatvisualacuityisindeedpreservedovertime(5years)inthepatientswhoareinvolvedinthescreeningprogramme.Leadingorganizationoftheprogramme/experienceDepartmentofMedicalSciences,UniversityofTurin,ItalyContactpersonProf.MassimoPorta([email protected])WebsiteDepartmentofMedicalSciences,UniversityofTurin,ItalyCittàdellaSaluteedellaScienzadiTorinohttp://www.cittadellasalute.to.it/index.php?option=com_content&view=article&id=4400:medicina-interna-1-ReferencesPortaM,ToppilaI,SandholmN,HosseiniSM,ForsblomC,HietalaK,BorioL,HarjutsaloV,KleinBE,KleinR,PatersonAD;DCCT/EDICResearchGroup,GroopPH;FinnDianeStudyGroup.VariationinSLC19A3andProtectionfromMicrovascularDamageinType1Diabetes.Diabetes.2015Dec30.pii:db151247.[Epubaheadofprint]PMID:26718501

LasagniA,GiordanoP,LacillaM,RavioloA,TrentoM,CamussiE,GrassiG,CharrierL,CavalloF,AlberaR,Porta M, Zanone MM. Cochlear, auditory brainstem responses in Type 1 diabetes: relationship withmetabolic variables and diabetic complications. Diabet Med. 2015 Nov 25. doi: 10.1111/dme.13039.[Epubaheadofprint]PMID:26605750

Salardi S,PortaM,MaltoniG,Cerutti F,RovereS, IafuscoD,Tumini S,CauvinV, Zucchini S,CadarioF,dʾAnnunzio G, Toni S, Salvatoni A, ZeddaMA, Schiaffini R, for the Diabetes StudyGroup of the ItalianSocietyofPediatricEndocrinologyandDiabetology(ISPED).Ketoacidosisatdiagnosisinchildhood-onsetdiabetes and the risk of retinopathy 20 years later. Journal of Diabetes and Its Complications (2015),http://dx.doi.org/10.1016/j.jdiacomp.2015.10.009

MazzeoA,BeltramoE,IavelloA,CarpanettoA,PortaM.Molecularmechanismsofextracellularvesicle-inducedvesseldestabilizationindiabeticretinopathy.ActaDiabetologica52,1113-1119,2015

BeltramoE,LopatinaT,BerroneE,MazzeoA,IavelloA,CamussiG,PortaM.Extracellularvesiclesderivedfrommesenchymal stem cells induce features of diabetic retinopathy in vitro. Acta Diabetologica 51,1055-1064,2014.

PortaM,SchellinoF,MontanaroM,BaltatescuA,BorioL,LopatinaT,TrentoM,DalmassoP,CavalloF.Prevalence of retinopathy in patients with type 1 diabetes diagnosed before and after puberty. Acta


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Diabetologica51,1049-1054,2014.

FavaroE,CarpanettoA,LamorteS,FuscoA,CaorsiC,DeregibusMC,BrunoS,AmorosoA,GiovarelliM,Porta M, Cavallo Perin P, Tetta C, Camussi G, Zanone MM. Human mesenchymal stem cell-derivedmicrovesiclesmodulateTcellresponsetoisletantigenglutamicaciddecarboxylaseinpatientswithtype1diabetes.Diabetologia57,1664-1673,2014

LopatinaT,BrunoS,TettaC,KalininaN,PortaM,CamussiG.Platelet-derivedgrowthfactorregulatesthesecretion of extracellular vesicles by adipose mesenchymal stem cells and enhance their angiogenicpotential.CellCommunicationandSignaling2014,12,26-38

PortaM, Schellino F,MontanaroM, Baltatescu A, Borio L, Lopatina T, TrentoM, Dalmasso P, CavalloF.Prevalence of retinopathy in patientswith type 1 diabetes diagnosedbefore and after puberty. ActaDiabetologica51,1049-1054,2014.

IafuscoD, Salardi S, ChiariG, Toni S, Rabbone I, PesaventoR, PasquinoB, de Benedictis A,MaltoniG,ColomboC,RussoL,MassaO,SudanoM,CadarioF,PortaM,BarbettiF,and theEarlyOnsetDiabetesStudy Group of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED). No Sign ofProliferative Retinopathy in 15 Patients With Permanent Neonatal Diabetes With a Median DiabetesDurationof24Years.DiabetesCare37,e181–e182,2014.

PortaM,CurlettoG, CipulloD, Rigault de la Longrais R, TrentoM, PasseraP, TaulaigoAV,DiMiceli S,CenciA,DalmassoP,CavalloF.Estimatingthedelaybetweenonsetanddiagnosisoftype2diabetesfromthetimecourseofretinopathyprevalence.DiabetesCare37,1668-74,2014

Porta M, Taulaigo AV. The changing role of the endocrinologist in the care of patients with diabeticretinopathy.Endocrine.46,199-208,2014.

TrentoM, Passera P, TrevisanM, Schellino F, Sitia E, Albani S,MontanaroM, Bandello F, Scoccianti L,CharrierL,CavalloF,PortaM.Qualityof life, impairedvisionandsocial role inpeoplewithdiabetes:amulticenterobservationalstudy.ActaDiabetol50,873-7,2013.

KiireCA,PortaM,ChongV.Medicalmanagementforthepreventionandtreatmentofdiabeticmacularedema.SurvOphthalmol58,459-465,2013.

Porta M, Maurino M, Severini S, Lamarmora E, Trento M, Sitia E, Coppo E, Raviolo A, Carbonari S,MontanaroM,PalanzaL,DalmassoP,CavalloF.Clinicalcharacteristics influencescreening intervals fordiabeticretinopathy.Diabetologia56,2147-2152,2013.

Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, Chen SJ, Dekker JM, Fletcher A,GrauslundJ,HaffnerS,HammanRF,IkramMK,KayamaT,KleinBE,KleinR,KrishnaiahS,MayurasakornK,O'HareJP,OrchardTJ,PortaM,RemaM,RoyMS,SharmaT,ShawJ,TaylorH,TielschJM,VarmaR,WangJJ,WangN,WestS,XuL,YasudaM,ZhangX,MitchellP,WongTY;onbehalfoftheMeta-AnalysisforEyeDisease (META-EYE) Study Group. Global Prevalence and Major Risk Factors of Diabetic Retinopathy.DiabetesCare.35,556-564,2012.

BandelloF,Cunha-Vaz J,ChongNV,LangGE,MassinP,MitchellP,PortaM,PrünteC,SchlingemannR,Schmidt-ErfurthU.Newapproachesforthetreatmentofdiabeticmacularoedema:recommendationsbyanexpertpanel.Eye(Lond).26,485-493,2012.

SalardiS,PortaM,MaltoniG,RubbiF,RovereS,CeruttiF, IafuscoD,TuminiS,Cauvin,onbehalfoftheDiabetesStudyGroupof the ItalianSocietyofPaediatricEndocrinologyandDiabetology (ISPED). InfantandtoddlerType1diabetesmellitus:complicationsafter20years’duration.DiabetesCare35,829-833,


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2012.

PortaM,Maldari P, Mazzaglia F. New approaches to the treatment of diabetic retinopathy. DiabetesObesityandMetabolism13,784-790,2011.

SjølieAK,KleinR,PortaM,OrchardT,Fuller J,ParvingHH,BilousR,AldingtonS,ChaturvediN.Retinalmicroaneurysmcountpredictsprogressionandregressionofdiabeticretinopathy.Post-hocresultsfromtheDIRECTmeme.Diabet.Med.28,345–351,2011.


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MasterCourseonEndocrinologyandDiabetesfornursingpersonnel

Italy

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge,preventionofdiabetescomplications,managementofstressandcopingwitheverydaylivingactivities.Yearofimplementation,levelofimplementation,funding2007.UniversityofTurin.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The following quality criteria are defined in the education programme: goals, rationale, target group,setting, scheduling of the education sessions, number of participants, environmental requirements,qualificationofthetrainers/educators,corecomponentsoftheeducator/trainer'srole,monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.The following indicators are used to monitor the training programme: structure indicators, processindicatorsandintermediateoutcomeindicators.Theprogrammeisbasedonthefollowingevidencecriteria:randomisedtrialandobservationalstudy.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Thetraininghelpsworkers toacquireskillsandknowledge in themanagementofchronicdisease.Thetraining programme incorporated developmental and learning theory, longitudinal interactions withindividual with diabetes, reflective learning and discussions to explore the experience of illness. Weexamined thewrittenworkof studentswhohadbeenasked toanalyse theactivitiesobservedand torelateontheirpersonalexperience.We observed in this pedagogical training that the students had learned to perceive emotional andrelationalaspectsinthepatients.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?In recent years, sharing the training with doctors, nutritionists, psychologists, educators, nurses havenoted theusefulnessof the trainingand the fatigueofdailywork inchronicdisease.The trainingalsohelpstoovercomethestressthatcomesfromworkingwithpatientswithchronicdiseases.


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Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?In educational planning much depends both on the way of understanding education and the way ofunderstandingthepersonandthepossibilitiesofhumanaction.Thehumanpersonisthefirstandmostimportantvalueineducation.Leadingorganizationoftheprogramme/experienceDepartmentofMedicalSciences,UniversityofTurinContactpersonProf.MauroMaccario([email protected])Prof.MassimoPorta([email protected])Prof.EzioGhigo([email protected])Websitehttp://www.dsm.unito.it/do/home.plReferencesDurandoO,MerloS.TrentoM.Gestieazionidicuraeducativa.Laprogettazioneeducativanell’ambitodellemalattiecroniche.GiornaleItalianodiDiabetologiaeMetabolismo.35,308-311,2015

TrentoM, Borio L,Merlo S. Lamalattia cronica e laQualità di vita.Giornale Italiano di Diabetologia eMetabolismo.35,85-89,2015

Trento M, Porta M. The Role of Group Care in the Management of Type 2 Diabetes. EuropeanEndocrinology.5,61-67,2010

Trento M, Borgo E, Semperboni L, Cirio L. Dimonte, V, Porta M. La narrazione e la rilettura delleesperienzepersonalicomestrumentodiformazioneinambitosanitario.GiornaleItalianodiDiabetologiaeMetabolismo,29,2009


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GroupCareModel:TheTurinexperienceItaly

Shortdescriptionoftheprogramme/experienceThefollowingitemsareincludedintheeducationprogramme:healthpromotioninterventions,diabetesknowledge,preventionofdiabetescomplications,managementofstressandcopingwitheverydaylivingactivities.Thetargetgroupsare:allthepersonswithdiabetes,relativesandcaregivers.The education programme takes into account ethnic minorities, low socio-economic groups andgenderdifferences.Yearofimplementation,levelofimplementation,fundingYearofimplementation:1996.This pilot experience evolved into the ROMEO trial. T2DM patients (n=815) were randomized to befollowedbyeitherGroupCareortheusualunidirectionalprovider-patientapproachfor4years.2002:ROMEOwassupportedbya3-yeargrantfromtheEuropeanFoundationfortheStudyofDiabetesEASD/EFSD(EFSD-NovoNordiskprogrammeforType2diabetes).2008and2012:supportedbygrantsoftheItalianMinistryofHealth.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The following quality criteria are defined in the education programme: goals, rationale, target group,setting, scheduling of the education sessions, number of participants, environmental requirements,qualificationofthetrainers/educators,corecomponentsoftheeducator/trainer'srole,monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.The following outcome criteria are measured: quality of life, knowledge of diabetes and healthbehaviours.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Theprogrammeisbasedonthefollowingevidencecriteria:randomisedtrialandobservationalstudy.WefirstdemonstratedthefeasibilityandefficacyofGroupCarefromcognitive,qualityoflifeandclinicalpoints of view by a 5-year pilot randomised, controlled clinical trial. Patients followed by Group CarereducedtheirbodyweightandimprovedHbA1c,ameasureoflong-termbloodglucosecontrol,andHDLcholesterolwithout increasingdrugprescriptions. Knowledgeof diabetes andproblem-solving abilitiesimproved steadily and were still getting better at year 5 among patients followed by Group Care,althoughmostofthemwereelderlyandhadpoororevennoformalschooling.Qualityoflifestartedtoimproveatyear2. Incontrast,all thesepsychologicalandcognitivevariablesworsenedamongcontrolpatientsfollowedbythetraditionalone-to-onedoctor-patientrelationship.ThispilotexperienceevolvedintotheROMEOtrial.T2DMpatients(n=815)wererandomizedtobefollowedbyeitherGroupCareortheusualunidirectionalprovider-patientapproachfor4years.Attheendofthetrial,patientsonGroup


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Care had lower body mass index, HbA1c, total cholesterol, LDL cholesterol, triglyceride, systolic anddiastolic bloodpressure and serum creatinine, andhigherHDL cholesterol (p<0.001, all) than controlsreceivingusualcare,despitesimilarpharmacologicalprescriptions.Alsohealthbehaviours,qualityoflifeandknowledgeofdiabeteshadimprovedinGroupCarepatientsbutnotamongcontrols(p<0.001,all).Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?TheGroupCareModelsuggestthatpatientswithDiabetesType1andType2haveamoreinternallocusofcontrolandempowerment.Patientscan formulatetheirownpersonalstrategytoadoptan internallocusofcontrolandmakethechangesnecessarytoalterlifecircumstancesandreachpersonalgoals.In group care, the focus is on health rather than disease, prevention and education rather than cure,makingpeopleawareoftheirchoicesinrelationtohealth.Experiencesharingmayhelpmodifythelocusof control by promoting the development of a sense of responsibility toward one’s own healthybehaviors.Traditional visits, on the other hand, are centered onmedical information and prescriptions aimed atavoidingthefearedconsequencesof incorrectbehaviors,butthesemessagesoftenfailtocomeacrossbecausetheyareremovedfromthepatients’perceptionsoftheirdisease.Inconclusion, thegroupCareModel reinforcescommunicationandpeer identificationandthat itmayachieveitsclinicalresultsbypromotingawareness,self-efficacy,positiveattitudestowarddiabetesandthesettingofcare,aninternallocusofcontrol,and,ultimately,empowermentinthepatients.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Patientswithchronicdiseasesarenormallyprescribedmultipledrugtherapies(it isnotuncommonforelderlypeoplewithmultiplepathologies tohave to take10-15pillsaday)but thenareusually leftontheirowntofacethechallengesandhealthrisksposedbydailylifesituations.Asaconsequence,diseaseprogression and onset of complications are accelerated because of inappropriate/wrong choices withregard to food, physical activity and all other daily threats to preserving health. These patients needcontinuouslifestyletrainingtolearnthebestsurvivalstrategies.GroupCareisagroupeducationmodelwhichimprovesclinicalandpsycho-cognitivevariablesinpeoplewithdiabetes.Itisfeasibleindailypracticeandwasrepeatedlyprovenclinicallyeffective,cost-effectiveand transferable to other health care settings. It should nowbe tested in patientswith other chronicdiseases.Ourdatasuggestthattheimprovementsobservedarenotentirelyexplainedbyweightlossorhealthierbehaviours.Theysuggestarole forcentralnervoussystem(CNS)mechanisms,activatedbythegroup-based educational activities, which might interact with the metabolic milieu sustaining diabetes.Understanding someof thesemechanismswill help elucidate the possible connections betweenmindandhealth.Leadingorganizationoftheprogramme/experienceLaboratoryofClinicalPedagogy,DepartmentofMedicalScience,UniversityofTurinhttp://www.dsm.unito.it/do/gruppi.pl/Show?_id=7yax


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ContactpersonMarinaTrento([email protected])MassimoPorta([email protected])WebsiteROMEOPaper(http://www.ncbi.nlm.nih.gov/pubmed/20103547)ReferencesSicuro J, Charrier L, Berchialla P, Cavallo F, Merlo S. Mazzeo A, Porta M, Trento M. SelfmanagementEducation by Group Care reduces Cardiovascular risk in patients with type 2 diabetes: analysis of theROMEOclinicaltrial.DiabetesCare,37,e1-e2,2014

SicuroJ,BondonioP,CharrierL,BerchiallaP,CavalloF,PortaM,TrentoM,fortheROMEOinvestigators.CostanalysisofGroupCareversususualcareinpatientswithtype2diabetesintheROMEOclinicaltrial.Nutrition,Metabolism&CardiovascularDiseases,23(2):e13-4.2013

Trento M, Porta M. Structured and persistently reinforced patient education can work. BMJ.21;345:e5100,2012

Raballo M, Trevisan M, Trinetta A, Charrier L, Cavallo F, Porta M, Trento M. A study of patients’perceptions of diabetes care delivery and diabetes. Propositional analysis in peoplewith type 1 and 2diabetesmanagedbygrouporusualcare.DiabetesCare,35,242-247,2012

PortaM,TrentoM.Timeofexposureandtypeofdiabetesmaydeterminetreatmentoutcomeofgroupclinics.AnnalsofInternalMedicine.483,2010

TrentoM,KucichC,TibaldiP,GennariS,TedescoS,BalboM,ArvatE,CavalloF,GhigoEandPortaM.Astudyof central serotoninergicactivity inhealth subjectsandpatientseigth type2diabetes treatedbytraditionalone-to-onecareorGroupcare.JournalofEndocrinologicalInvestigation,33,624-628,2010

TrentoM,GambaS,GentileL,GrassiG,MiselliV,MoroneG,PasseraP,TonuttiL,TomalinoM,BondonioP,CavalloF,PortaM;fortheROMEOinvestigators.Romeo:RethinkOrganizationToImproveEducationAndOutcomes.AMulticentreRandomisedTrialOfLifestyleInterventionByGroupCareToManageType2Diabetes.DiabetesCare.33,745-747,2010

TrentoM,BorgoE,KucichC,PasseraP,TrinettaA,CharrierL,CavalloF,PortaM.Qualityof life,copingability and metabolic control in patients with Type 1 Diabetes managed by Group Care and acarbohydratecountingprogramme.DiabetesCare,32,e134,2009

TrentoM, Basile M, Borgo E, Grassi G, Scuntero P, Trinetta A, Cavallo F and PortaM. A randomisedcontrolledclinicaltrialofnurse-,dietitian-andpedagogist-ledGroupCareforthemanagementoftype2diabetes.JournalofEndocrinologicalInvestigation.31,1038-1042,2008IF=1.654

TrentoM,M.Tomelini,M.Basile,EBorgo,PPassera,VMiselli,MTomalino,FCavallo,MPorta.Thelocusofcontrol inpatientswith type1and type2diabetesmanagedby individualandGroupCare.DiabeticMedicine,25,86-90,2008

Trento M, P Passera, V Miselli , M Bajardi , E Borgo, M Tomelini, M Tomalino, F Cavallo, M Porta,Evaluation of the Locus of Control in Patients with Type 2 Diabetes after Long-TermManagement by


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GroupCare.Diabetes&Metabolism,32,77-81,2006

MTrento,PPassera,EBorgo,MTomalino,MBajardi,FCavallo,MPorta.A5-yearrandomizedcontrolledstudyoflearning,problemsolvingabilityandqualityoflifemodificationsinpeoplewithtype2diabetesmanagedbygroupcare.DiabetesCare,27,670-675,2004.

TrentoM,PasseraP,BajardiM,TomalinoM,GrassiG,BorgoE,DonnolaC,CavalloF,BondonioPV,PortaM.Lifestyle interventionbygroupcarepreventsdeteriorationof type2diabetes:a4-year randomizedcontrolledclinicaltrial.Diabetologia45,1231-1239,2002

TrentoM, Passera P, TomalinoM, BajardiM, Pomero F, Allione A, Vaccari P,Molinatti GM. PortaM.Groupvisitsimprovemetaboliccontrolintype2diabetes.atwo-yearfollow-up.DiabetesCare,24,995-1000,2001.


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SINERGIA-Chroniccaremodelforthemanagementofdiabetes

Italy

Shortdescriptionoftheprogramme/experienceThekeycomponentsoftheprogrammeare:self-managementsupport,deliverysystemdesign,decisionsupport tools, integrated care delivery system interdisciplinary working practice team and clinicalinformation system supporting interdisciplinaryworking practice andmonitoring. The decision supporttools are guidelines for diabetes type 2; the integrated care delivery system involves generalpractitioners,diabetesspecialists,specializednurses,dietitiansandpatientassociations.The programme was initiated by diabetologists. The patient centered approach is based on riskassessment for complications, defined clinical pathways to deal with individuals at different risk forcomplications, individualizedtargets for interventions,shareddecisionmakingandplanfor follow-up isdefined.Theprogrammetakesintoaccountlowsocio-economicgroupsandgenderdifferences.The main objectives are: preventing or reducing inappropriate health care, improving integration ofdifferent organizations/care providers, increasing multi-disciplinary/multi-professional collaboration,improving patient involvement/centeredness, improving quality of care for persons with diabetes,improving early detection of co-morbidities, decreasing/delaying complications, decreasing morbidity,decreasingmortality,reducinghospitalizations,reducinginequalitiesinaccesstocareandreducingpubliccosts.Yearofimplementation,levelofimplementation,funding2006,diabetesoutpatientclinic,usualfundfromNationalhealthsystemIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Process indicator:proportionofpersonswithdiabetesenrolled in theprogrammeanddroppingoutofprogramme, proportion of personswith diabeteswith regular education, self-check blood glucose andcheckofHbA1c,bodyweight,bloodpressure,lipidparameters,uricacid,creatinine,albumin,footpulsesandvibrationsensationtest(orfilamenttest),ECG+24RRprofile,ocularfundus,footinspection.Intermediateoutcomeindicators:HbA1c,BMI,bloodpressure,HDL-C,LDL-CHDL-C,TG,smokingpeople.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Itisbasedonwellestablishedmodelofcare(Chroniccaremodel)anditworksinthereallife.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Theorganizationofcareispatientcentred.Information:leafletswithbasicinformationonthe“programme”areavailable.


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Goodcommunicationwithpatients:asynthesisofeachvisitiswrittenwiththepatientinaclinicaldiarythatissharedwithotherprofessionals.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Itincreasesawarenessofhealthprofessionalsontheessentialelementsforabetterqualityofcare.Leadingorganizationoftheprogramme/experienceAzienda Ospedaliera 'Istituti Clinici di Perfezionamento' di Milano - Diabetesclinic,CusanoMilanino,Italy ContactpersonAnnalisaGiancaterini([email protected])NicolettaMusacchio([email protected])WebsiteReferencesMusacchioN,CogliatiS,ErrichelliC,GiancateriniA,LovagniniScherA,LovisariM,PessinaL,PuggioniR,SalisG,SangiorgioV,SchivalocchiF,GendusoG.Centrodiintegrazioneterritoriale:daUOSdidiabetologiaacentroperlagestionedellacronicità.GItDiabetolMetab2008;28:104-112.MusacchioN,GiancateriniA,LovagniniScherA,ErrichelliC,PessinaL,SalisG,SchivalocchiF,NicolucciA,PellegriniF,RossiMC.Impattodiunmodellodicuradellepatologiecronichebasatosulpatientempowermentperilcontrollodeldiabeteditipo2:effettidelprogrammaSINERGIA.GItDiabetolMetab2010;30:58-64.MusacchioN,LovagniniScherA,GiancateriniA,PessinaL,SalisG,SchivalocchiF,NicolucciA,PellegriniF,RossiMC.ImpactofachroniccaremodelbasedonpatientempowermentonthemanagementofType2diabetes:effectsoftheSINERGIAprogramme.DiabetMed2011,28:724-30.


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Patient-centeredapproachforthepreventionandtreatmentofpatientswithdiabetesmellitus

Italy

Shortdescriptionoftheprogramme/experienceThe key components of the programme are: integrated care delivery system and clinicalinformationsystemsupportinginterdisciplinaryworkingpracticeandmonitoring.Theintegratedcare delivery system involves diabetes specialists in hospital, specialized nurses, cardiologists,ophthalmologistsandnephrologists.Theprogrammewasinitiatedbydiabetologist-endocrinologists.The patient centered approach is based on risk assessment for complications, individualizedtargets for interventions, shared decision making and plan for follow-up is defined. Theprogrammetakesintoaccountgenderdifferences.The main objectives are: improving early detection of co-morbidities, decreasing/delayingcomplications, decreasing morbidity, decreasing mortality, reducing hospitalizations andsemplificationadministrativeprocedures.Yearofimplementation,levelofimplementation,funding2008-OutpatientclinicwithnofundingfromNHS.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Processindicators:proportionofpersonswithdiabeteswithregulareducation,self-checkbloodglucoseandcheckofHbA1c,bodyweight,bloodpressure,lipidparameters,uricacid,creatinine,albumin, footpulsesandvibrationsensation test (or filament test),ECG+24RRprofile,ocularfundus,footinspectionandperipheralnerveassessment.Intermediateoutcomeindicators:HbA1c,BMI,waistcircumference,bloodpressure,HDL-C,LDL-CHDL-C,TG,smokingpeople,glomerularfiltration,microalbuminuriaandcreatinine.Longterm outcome indicator: reducing rates ofmajor limb amputation,myocardial infarction,stroke, cardiovascular mortality, nephropathy or dialysis, retinopathy or blindness andneuropathyordiabeticfootsyndrome.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?


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Theprogrammeisbasedonamultidisciplinaryapproach.Itsmainobjectivesare:identificationof patients at high risk of complications; early identification of complications; decreasingincidenceofcomplicationsanddecreasingmortality.Which are the reasons for success (positive lessons learned) and failure (negative lessonslearned)ifany?Positive-Empowermentofpatients,whicharefollowedbyamultidisciplinaryteam.Negative-Organizationalproblems.Shortageofdedicatedprofessionals.Lowbudget.How does this programme/experience help in driving the change toward prevention andimprovementthequalityofcareforpeoplewithdiabetes?Theaimofthisprogrammeistoreversetheconsolidatedconceptthatthepatientmustreacheachsinglespecialistinvolvedinher/hiscure.Thisprogrammeputthepatientatthecentreofthe health system so that each specialist and nurses move toward her/him. This approachmakes the health system toward patients with diabetes more efficient, and humanizes thehealthsystemitself.Leadingorganizationoftheprogramme/experienceAziendaOspedalieradiPadovaContactpersonProf.AngeloAvogaro([email protected])Websitehttp://www.sanita.padova.it/sez,2722References


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ScreeningDiabetesPalermoItaly

Shortdescriptionoftheprogramme/experienceActivitiesofdiabetesprevention take intoaccountgenderdifferences.The followingdata/statisticsareavailable for the target population: prevalence of diabetes and prevalence of overweight, obesity andabdominalobesity.Validateddiabetes riskassessment toolsareavailable tohealthcareproviders. Information technologysystems supporting the implementation of screening are available at health care provider level. Thefollowingdataareavailable:proportionofthepopulationscreened(byhealthcareprovider)peryearandpercentageofidentifiedhigh-riskindividualsremittedtodiagnosticprocedures.High-risk prevention strategies are included in the education of the health care professionals. Definedclinicalpathwaysexist forthehealthcareprovidertodealwith individualsatrisk fordiabetes.Medicalrecord system supports interventions for chronic disease prevention. Individual’s risk factor profile isassessed.Planforfollow-upisdefined.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Whyshouldthisprogramme/experiencebeconsideredagoodpractice?An observational study “Screening Diabetes Palermo” was conducted, in primary care, in Italy. Thescreening programme is divided into two phases. Phase 1: identification of patients at high risk ofdiabetes, through theanalysis of databasesof general practitioners. Phase2: screening tests for earlydetectionofDMT2or,ofothersdisordersofglucosemetabolism(ImpairedfastingglucoseIFG,impairedglucose tolerance IGT and HbA1c 42-48 mmol/mol). The OGTT is a central point of the screeningprogramme,infact,asignificantproportionofindividuals,withimpairedfastingglucose(IFG),hasbloodglucose levels, afterglucose load, compatiblewith thediagnosisofT2DMor IGT.The totalpopulationwas composed of 25801 subjects, of which 12918, equal to 50.07%, was at high risk of T2DM. The39,86%ofhigh-riskindividualshadanimpairedfastingglucose"IFG".Asampleof815subjectswithIFG,wasthensubjectedto"OGTT",onthebasisofwhichhavebeenidentified123subjects,equalto15.9%with IGT and 66 subjects, equal to 10.8%,with a response toOGTT compatiblewith the diagnosis ofT2DM.Ifthemodelofscreeningexperiencedwastransferred,throughajointaction,betweentheItalianregionsorEuropeancountries,theresultcouldonlybeadrasticreductionofundiagnoseddiabetesandtheidentificationofalargepopulationofpatientswithotherdisordersofglucosemetabolismrequiringpreventive interventions. Starting from the results of the study “ScreeningDiabetes Palermo”,we aredeveloping a prevention programme aimed at high-risk individuals, especially with IFG and IGT. Ourpreventionprogrammeisbeingimplementedanditwillbethenextphaseofourproject.


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Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive lessons learned: The information systems, through a process of clinical audit, lead to bettermanagement of the screening programme. The general practitioners, have special electronicinstruments, used to select the diabetes risk population, but also to proactively manage the entirescreeningprogramme,includingmonitoringovertimeofpatientswithdisordersofglucosemetabolism,andthepreventionprogramme.Negativelessonslearned:Thecostofspecialelectronicinstrumentsweighsonthegeneralpractitioner.Theabsenceofsupportstaff,particularlynursingfiguresformedanddedicatedtodelegatepartofthewelfareactivities.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Inprimarycare,aproactiveapproachtowardsdiabetesscreeningpermit,throughtheuseofelectronicinstruments,theidentificationofindividualsathighriskofdiabetesand,subsequently,earlydetectionofundiagnoseddiabetesandtheotherdisordersofglucosemetabolism,predictingthefuturedevelopmentof the disease. Randomized controlled trial have shown that individuals with disorders o glucosemetabolism(IFG-IGT)cansignificantlydecreasetherateofdiabetesonset,withparticularinterventions.These include intensive lifestylemodificationprogrammes, thathavebeenshowntobeveryeffective.Starting from the results of the study Screening Diabetes Palermo, we are developing a preventionprogramme aimed at high-risk individuals, especially with IFG and IGT. The programme providesdiagnosticpathways,therapeuticcareandaneffectiveorganizationalmodel,basedonthe1)trainingofthe operators; 2) the demedicalization, with the active involvement of support staff, particularly thesecretarial staffandnursing figures formedanddedicatedtodelegatepartof thewelfareactivities;3)the computerization; 4) a system of indicators that allowsmonitoring and periodic evaluation of theperformance.Leadingorganizationoftheprogramme/experiencePalermoGroupofItalianSocietyofGeneralPractitioner-SIMGPalermoContactpersonTindaroIraci([email protected])WebsiteReferences


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IGEAItaly

Shortdescriptionoftheprogramme/experienceIGEA is a national comprehensive strategy to support the implementation of a chronic diseasemanagementinterventioninItaly.In2006,withintheNationalPreventionPlan,theNationalInstituteofHealth (ISS), and the Italian Centre for Disease Prevention and Control of the Ministry of Health,developedIGEAasaNationaldiabetesdiseasemanagementprogramme.Themainactivitieswere:• development of evidence-based decision support tools through the definition of “The national

guidance on the management of type 2 diabetes mellitus” that provides minimum clinical andorganisational requirements for an integratedmanagement of type 2 diabetesmellitus, including asystem of indicators. Recommendations were formulated, by a multidisciplinary work group,accordingtoGRADEmethod;

• promotion of multidisciplinary health-care teams, as an effective means of achieving the goal ofimproving health-care outcomes; organization of national cascade-training programme aimed tosupport Italian Regions in promoting multi-professional team working, and communication in acommunity of practice perspective, involving health professionals, personswith diabetes andotherrelevantstakeholders.

• definitionofthecorecharacteristicsof informationsystemsthataresustainableandwell integratedin the given area and that encourage communication not only among physicians but also betweenphysicians and patients, so as to achieve long-term coordinated care. Development of a system ofindicators.

Yearofimplementation,levelofimplementation,fundingTheprogrammewasimplementedstartingin2007.ItisonInstitutionalandlocallevel.TheInstitutionallevelactivitieswerefundedbytheMinistryofHealth,thelocallevelactivitieswerefundedbyRegions.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Thereisadefinedevaluationframework,assessingimplementation,processandoutcome.AseriesofindicatorshavebeendefinedtobeusedalloverItaly:implementation,process,intermediateoutcome,long-termoutcome.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?IGEAimprovesthequalityofcare,placingthepersonatthecentreofthecareorganisation,throughthedevelopment of an organizational model that: guarantees effective interventions for all persons withdiabetes; implements evidence-based interventions; ensures that both the quality of care andimprovementsinoutcomecanbemeasured;promotesthepartnershipbetweenprimaryandsecondarycare inmultidisciplinaryhealth-careteams;promotesthepatientempowerment;ensuresthatthecare


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model can be gradually implemented in the entire Country taking into account regional healthorganizationaswellaslocalneedsandcapabilities.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?The2005-2007NationalPreventionPlanspecificallygaveRegionsthetasktoplanandorganize“diseasemanagement”programmes fordiabetes toprevent thecomplicationsof thedisease.Then the specificobjectiveof IGEAwas thedevelopmentof tools to support the regionalhealthAuthorities toward theimplementation of disease management for people with diabetes. The Regional Health Authoritiesplayedtheroleofbridgingbetweenthecentralgovernmentalagencies,regionalgovernmentsandLocalHealth Agencies. Cooperation from academic bodies, scientific societies, representative of patientassociationswasassured.Positivelessons:Top-downandbottom-upapproacheswerebothused.IGEAwasdevelopedwiththecooperationofthepatientsandallthehealthprofessionalsinvolvedinthecareofpeoplewithdiabetes.IthasaNationaldesignthatensureslocalimplementation.Negativelessons:resistancetowardschangefromsystemsandprofessionalswhoarenotaccustomedtomultidisciplinaryteamapproach.Theimplementationofintegratedcaresystemsneedsbothstrongpoliticalengagementandmiddle/longtermfunding.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?IGEA isan integralpartof theNationalDiabetesPlan thatdefines the strategicapproachandoutlinescommonobjectives and recommendations for the Italian regions, toward high quality care for peoplewithdiabetes.Aseriesoftoolshavebeenproduced,aspartofIGEA,tosupporttheregionalhealthAuthoritiestowardthe implementationof diseasemanagement for peoplewith diabetes: guidelines formanaging type 2diabetes in adults; information systemdesign for themanagement of type 2 diabetes; structure andclinicalindicators;trainingprogrammeforhealth-careprofessionals;carepathwaysfordiabetes.Leadingorganizationoftheprogramme/experienceNationalInstituteofHealth-RomeContactpersonMarinaMaggini([email protected])Websitewww.epicentro.iss.it/igea


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ReferencesMaggini M, Raschetti R, Pricci F et al. Gestione Integrata del diabete mellito di tipo 2 nell’adulto –Documentodiindirizzo.Roma,IlPensieroScientificoEditore.2008(www.epicentro.iss.it/igea).

Maggini M, Raschetti R, Giusti A et al. Requisiti informativi per un sistema di Gestione Integrata deldiabetemellitoditipo2nell’adulto–Documentodiindirizzo.Roma,IlPensieroScientificoEditore.2008.(www.epicentro.iss.it/igea).

MagginiM.IGEA-Achronicdiseasemanagementprojectforpeoplewithdiabetes.AnnIstSuperSanità2009;45:349-352.

MagginiM, Raschetti R, Giusti A et al. La gestione Integrata del diabetemellito di tipo 2 nell’adulto.Manuale di formazione per gli operatori sanitari. Roma: Il Pensiero Scientifico; 2009.(www.epicentro.iss.it/igea).

NotoG,RaschettiR,MagginiM.GestioneIntegrataepercorsiassistenziali.Roma,IlPensieroScientificoEditore.2011(www.epicentro.iss.it/igea)

Maggini M, Raschetti R, Giusti A et al. Gestione Integrata del diabete mellito di tipo 2 nell’adulto –Documento di indirizzo. Aggiornamento 2012. Roma, Il Pensiero Scientifico Editore. 2012(www.epicentro.iss.it/igea).


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DiabetesnursingspecialityNorway

Shortdescriptionoftheprogramme/experienceTheprogrammegivesstudentsexpertiseindiabetesnursing,withspecialfocusoninformation,supportandguidancetopatientsandtheirfamiliesinhowto:-promotepreventionofcomplications-livingwithdiabetes(coping)-increaseself-management-increasequalityoflifeThis programme aims to develop the student's research competence and facilitate increasedresponsibilityinmanagementofpatientswithdiabetes.Theprogrammewillenablestudentstocombineclinicalexperienceandexpertisewith thebestavailableknowledge fromresearch toprovide follow-upandtreatmentofhighprofessionalquality.

Yearofimplementation,levelofimplementation,fundingAvailable only at Bergen University College. The programme is funded by the Norwegian Government(apart fromasmall tuitionfeepersemester).All studiesat thecollegeareentitledto loansandgrantsfromtheNorwegianStudentLoanFund.Admission requires that the students have completed a 3-year nursing programme fromcollege/universityand1yearofpracticeaftercompletingthebachelor'sdegree.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Thecollegeworkscontinuouslytoimprovethequalityandrelevanceofitscourses.Qualityimprovementis driven by formal requirements from the government. The college's quality assurance system wasexternallyevaluatedin2010andapprovedbytheNorwegianAgencyforQualityAssuranceinEducation.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Morethan200000(~4%ofthepopulation)peopleinNorwayhavediabetes.Halfofthemdonotknowtheyhavediabetes.It iscrucialthathealthcareprofessionalshavethenecessarycompetenceandthatthehealthserviceshavethecapacitytoserveacontinuousandsystematicfollow-upinthesepatients.Monitoring and treatment of diabetes requires high expertise in both medical as psychosocial andeducationaltopics.Information,supportandguidancearecentraltasksforadiabetesnurse.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Theprogrammeisflexibletonewevidenceandchangesitscurriculumaccordingly.


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Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Diabetes nurses can take someof the burden from theGPs shoulders in themanagement of personswithdiabetes.Thesepatientrequiresregularfollow-upandguidanceinlifestylechangesthatmaytakemoretimethanthegeneraldurationofaGPconsultation.Leadingorganizationoftheprogramme/experienceBergenUniversityCollegeContactpersonopptak@hib.noWebsitehttps://utdanning.no/utdanning/hib.no/klinisk_sykepleie_-_diabetessykepleieReferences


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TheNationalGuidelinesforprevention,diagnosisandtreatmentofdiabetes

Norway

Shortdescriptionoftheprogramme/experienceThekeycomponentsoftheprogrammearerecommendationsconcerning:

• diagnosisoftype1andtype2diabetes• regimensforfollow-up• deliverysystemdesignandpatientself-managementtraining• necessarylifestylechanges• treatmentofoverweight/obesity,hyperglycemia,ketoacidosis,coma• treatmentandeducationofpatientsrequiringinsulin• treatmentofhypertension,dyslipidemia• preventionandtreatmentofmacro-andmicrovascularcomplications• treatmentofchildrenandadolescentswithdiabetes• preventionandtreatmentoffootulcers• diabetesanddentalhealth• diabetesandpregnancy• laboratoryanalysisindiabetes

Yearofimplementation,levelofimplementation,fundingPublishedin2009.ThisisthenationalclinicalguidelinefordiabetesinNorway.Allproceduresinprimary-andspecialisthealthcarehavetoadheretotheserecommendations.Anew,electroniceditionwaspublishedinSeptember2016thatwillreplacetheguidelinefrom2009.Theoldguidelinewaswellimplementedandacknowledged.DevelopmentofnationalguidelinesisfundedbytheMinistryofHealth/theNorwegianDirectorateofHealth.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)ThereisanongoingprocessofdevelopingnationalqualityindicatorsfordiabetesinprimaryhealthcareinNorway.Todayweonlyhaveoneindicatorappliedinspecialistcare(majorlimbamputationrate)thatmeasurestheimplementationofgoodclinicalpracticeindiabetes.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?The national clinical guidelines arewell implemented and agreed on. The newly revised guideline hasinvolved70multidisciplinaryhealthcareprofessionalsfromprimary-andsecondarycare.WehaveusedtheGRADEmethodologyandtheguidelineispublishedelectronicallyinaway,thatmakesitpossibletointegratetherecommendationsinclinicaldescisionsystems/electronicmedicalrecords.


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Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?We are lacking a system that evaluates the quality of diabetes care in primary care in Norway. Thenationaldiabetesregisterhaveonlya15%coverage.Afactorforsuccesswasthedevelopmentofapatientversionoftheguidelineswhichfocuseson,amongothers, educational information about self-management, the importance of regular follow-up andinformationaboutdiabeteswritteninlaylanguage.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?The revised versionof the guidelineshasbroughtmore attention to early diagnosis of diabetes, closefollow-up of high-risk individuals and intensive lifestyle intervention in people with high risk and inpersonswithdiabetesandoverweight/obesity.Theres isalsoan increased focuson routines for referrals fromgeneralpractitioners to specialistsandtheimportanceofregularityinnephrological,neurologicalandophtamologicalassessments.Leadingorganizationoftheprogramme/experienceTheNorwegianDirectorateofHealthContactpersonMonicaSørensen([email protected])Websitehttps://helsedirektoratet.no/retningslinjer/diabetesReferences


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NCD-strategy:Prevention,diagnosis,treatmentandrehabilitationofnon-communicable

diseases-cardiovasculardisease,diabetes,COPDandcancer

Norway

Shortdescriptionoftheprogramme/experienceTheNCD-strategyacknowledgethatcardiovasculardisease,diabetes,COPDandcancerhavesomethingin common; theymaybepreventedby lifestyle interventions including a healthy diet, regular physicalactivity,smokingcessationandlimitedalcoholconsumptionandavoidanceofoverweightandobesity.Thestrategyalsoacknowledgethatthechangescannotbedoneinthehealthcaresectoralone,butwillhave toengage trans sectorialand thepolicymakers in sectorsof transport,workplace, cityplanning,andeducation,amongothers,willhavetocooperateinordertoachievethegoalssetforthintheplan.Regarding the diabetes specific part of the strategy, national goals for prevention, diagnosis andtreatmentofdiabetesismentioned.Subsequenttoitspublishment,theNorwegianDirectorateofHealthhasbeengiventheassignmenttocreateadetailedplanforfollow-upofthegoalsstatedinthestrategy.Yearofimplementation,levelofimplementation,fundingTheNCD-strategywaspublishedin2013.Theplanisnotyetimplemented.Theimplementationofthestrategyisnotfunded.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Today,thereexistnoevaluationframeworkorindicatorsthatenablesmonitoringofthegoalssetforthinthestrategy.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?This strategy is a step in the right direction of seeing prevention of chronic diseases as a whole.However,Norwayhasa longway togobefore the theoretical goalsare specifiedand implemented inpractice,andwhenweareabletomonitortheimpactoftheplan.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Thedecisiontoassemblethenationalgoalsforcancer,chronicobstructivelungdisease,cardiovasculardisease and diabetes in the same strategy might help stakeholders and health care managers to


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implement the goals locally and regionally in that they only have one document instead of four, andbecausetheinitiativesoverlap.Thechallengesare lackof funding, lackofpublicityandacknowledgeamonghealthcareprofessionalsandlocalstakeholders,andlackofspecifiedactionsthatwillhelpusreachthegoals.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Followingthestrategy,Norwayisre-structuringtheprimaryhealthcaresectortowardtheChronicCareModel,and interdisciplinaryteamsareencouragedtotakeforminprimarycaretohandlethesurge inlifestylerelateddiseases.Leadingorganizationoftheprogramme/experienceNationalMinistryofHealthServices(owner)TheNorwegianDirectorateofHealth(executingauthority)ContactpersonMonicaSørensen([email protected])Websitehttp://www.regjeringen.no/pages/38449517/ncd_strategy_060913.pdfReferences


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PatientEducationandHealthMasteryNorway

Shortdescriptionoftheprogramme/experienceThetargetgroupsfortheNorwegianNationalAdvisoryUnitonLearningandMasteryinHealthprogrammearepeoplewithchronicdiseasesordisabilitiesandtheirfamiliesandfriends.Theprogrammeisgroupbasedandfacilitateself-relianceforpeoplewhohavelong-termhealthchallenges,aswellastheirnextofkin.Theaimsoftheprogrammeistostrengthenpatient’smasteringandtoincreasetheirqualityoflife.Theprogrammeisavailableinseverallanguages(i.e.englishandurdu)andhaveadurationofatleastsevenhours.Yearofimplementation,levelofimplementation,fundingTheprogrammehasexistedsince1997.InNorway,personswithchronicdiseaseshaveastatutoryrighttoeducationabouttheirdisease.Untilnowtheprogrammehasonlybeenavailable inspecialisthealthcareathospitals,butitisincreasinglybeingofferedinmunicipalitiesacrossthecountry.Allpatientswithtype1andtype2diabetesisofferedtoparticipateinthecourse.Participantspayonlyadeductibleofapprox.€37andreceivecompensationsfornecessarytransporttothecourselocation.TherestofthecostiscoveredbytheNationalhealthbudget.Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The courses are usually led by a diabetes nurse, a dietitian and a physiotherapist. The NorwegianDiabetesAssociationisusuallyrepresentedatthecourseaswell.Thereexistastandardizedmodelinhowtoimplementandevaluatethecourse.Theevaluationisdonebythe participants themselves. There exist no national or external office for evaluation of the quality oreffectsoftheprogramme.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Theprogrammeaimstogivepeoplewithdiabetestoolstoimprovecopingineverydaylifeandtakeintoaccount patient’s individual values and preferences. The curriculum focuses on making neccessarychangesinknowledge,skillsandattitudesintheparticipantsandisdevelopedthroughaongoingprocesswherespecialistsanduserorganizationsworktogether.All courses are offered in groups to promote within-group effects of motivation and sharing ofexperience,challengesandfacilitatorsofsuccessfullself-management.


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Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?

• TheprogrammeisavailableforeveryonewithdiabetesandtheirfamiliesandmostlyfundedbytheNorwegianGovernment.

• Healthprofessionalsareleadingthecourse• Thecourseisinteractiveandallowfortheparticipantstodiscussindividualexperiences• Themost important aspects of managing diabetes are covered such as healthy diet, physical

activity, smoking cessation, coping with stress, and glucose control. Also, prevention ofcomplications,oral,-andfootcarearetaught.

Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Theprogrammeenablespersonswithdiabetestotakeinformeddescisionsinmeetingswithhealthcareprofessionalsandincreasetheirabilitytomanagetheirlifewithdiabetes.Therecommendationsgivenatthecoursemay,iftheyarefollowed,preventmacro-andmicrovascularcomplicationsindiabetes.Leadingorganizationoftheprogramme/experienceTheNorwegianDiabetesAssociationOsloUniversityHospital,[email protected]://mestring.no/in-english/http://diabetes.no/leksikon/s/startkurs/References


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DiabetesPreventionandCareDevelopmentProgramme2010-2020

Slovenia

Shortdescriptionoftheprogramme/experienceAtadoptionoftheProgrammebySlovenianGovernmentinApril2010,itwasbasedontheResolutionontheNationalPlanofHealthCare2008–2013"SatisfiedUsersandProvidersofMedicalServices",thatsetamong itsdevelopmentprioritiesandessentialobjectivesgreaterhealthy lifeexpectancyanda furtherincrease in the quality of life for all population groups, reduction of health inequalities and earlydetectionofchronicdiseasessuchasdiabetes.TheResolution,withinitshealthcareobjectives,envisagedacomprehensiveapproachtothetreatmentofpatientsbasedonefficientprovisionofservices,includingappropriate restructuring of activities through reassigning particular scopes of work to different worklevels and health-service personnel. The role of nurses and midwives in assuming new independentfunctions concerning treatment of chronic patients was expected to be enhanced. In addition, theResolutionstressedtheimportanceofcooperationofthecivilsociety.

Basedonconsiderationsconcerningthedimensionoftheproblemcausedbydiabetes,theincreaseinthenumber of patients with diabetes and the burden that this implies for the healthcare system and inaccordance with the objectives of the Resolution, Diabetes Prevention and Care DevelopmentProgramme2010-2020hasbeenprepared.

TheProgrammeconstitutesthestrategicbasisfortakingactioninthefieldofprevention,earlydetectionandtreatmentofdiabetesandforensuringmonitoring,researchandtraininginthisarea.Moreover,theProgrammehas tobeunderstoodasacompletion tootherpublichealth-relatedstrategiesused in themanagementofriskfactorsandchronicdiseases,andasastartingpointforprocessestakingplaceinthehealthsectorwithregardtoorganisationandfinancingofhealthinsuranceandtoinformationtechnologysupport for the health sector. The Programme as a whole is based on cooperation between partnerswithinandoutsidethehealthsector.

TheDiabetesPreventionandCareDevelopmentProgramme2010 -2020addresses theobjectives thatSloveniawishestofulfilinthefieldofdiabetes.Theseare:

• preventionoftype2diabetesingeneralpopulation,• preventingand/ordelayingtheonsetofdiabetesamongpeopleathighriskfortype2diabetes,• enhancingearlydetection,and• reducingthecomplicationsandmortalitycausedbydiabetes.

Thecentreofinterestisafullyempoweredpatientabletoactivelyparticipateintheprocessofmedicaltreatmentandcareandtotakefullresponsibilityforhis/herhealthwithaviewtolivingafullandqualitylifedevoidoftheproblemscausedbydiabetes.Suchpreventionandcareofpatientswithdiabetesmustbe based on professional guidelines, standards and clinical pathways through taking account ofcontinuousprofessionaldevelopmentinthearea.Inaddition,theProgrammeenvisagesputtinginplace


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amonitoringsystemthatwillprovideverifyingtheeffectivenessofthediabetespreventionandcareandenhancethequalityofdiabetescare.

Implementation of the Programme will enable the citizens of Slovenia to enjoy better and moreproportionateaccessibilitytodiabetescare,bettercoordinationoftheprocessesofdiabetespreventionancare,morecomprehensivemedicalcareandmorerationaluseofresources.

SuccessfulimplementationoftheDiabetesPreventionandCareDevelopmentProgramme2010-2020isexecutedvia two-yearactionplans tobe issuedby theMinistryofHealthandapprovedby theHealthCouncil, if necessary; these plans are to define processes and the concrete activities of key partners.These action plans are expected to facilitate better cooperation between partners and links betweentheir activities, monitoring of results regarding diabetes care and to correspondingly upgrade futureactivityinthisarea.

TheProgrammeandthecurrentActionPlanareinlinewiththeResolutionontheNationalPlanofHealthCare2016–2025.

Yearofimplementation,levelofimplementation,fundingYearofimplementation:starting2010,ending2020,whennext10years’NationalDiabetesPlanwillbeputinplaceFunding: up to 2016, no specifically dedicated funding related only to diabetes was used. However,diabetes is included in several core national-wide projects at system level, such as restructuring themodel of care in primary care (registered nurses as care coordinators) and in up-grading of healthpromotion centres (such as with new educational programmes for people with disturbed glucosemetabolism,andwithtype2diabetes,andorientationintolocalenvironment).Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)EveryActionPlanisfollowedcloselyduringmeetings(5-8peryear)ofSteeringGroup,withspecialfocusonbarriersandopportunities.Onceyearly,afulldaystrategicmeetingisorganisedtoboosttheactionsanddiscussandincorporatenewideas.AReportontheactivitiesinActionPlanisproducedannually,thatincludes short description of the activities achieved, describes actions, that were not successful anddefines, what are the next steps in such cases. Report also includes results of other, non-plannedactivitiesandunexpectedsuccesses.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?ThisProgrammeissustainableinachievingtheresultsasplannedinActionPlans,achievessynergiesandiscomplementarytootherprocesses/projectsinhealthcare,thusresultinginsystem-widechanges.Itisseenasasuccessbyitspartners/institutions,suchasMinistryofHealthandNationalPatients’DiabetesAssociation.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive:ownershipoftheProgrammebyallpartners/institutioniscrucialforitsimplementation,andisbuiltbestduringthepreparatoryphase.Inclusivenessofdifferentpartnersandtheirbroadperspectives


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isanopportunityandstrength,andnotapotentialthread.Sustainabilityofthecommitmenttotheideasandaimsof theProgramme results from the sharedvaluesandbeliefs frommembersof theSteeringGroup.Overtheyears,interactionsamongpartners/institutionschange,too.Negative:solutiontosomeofthecrucialobstaclesareoutoftheinfluenceoftheSteeringGroupandthepartners/institution, thatare involved in theProgramme implementation.This factmaybeasourceofexhaustionoftheSteeringGroup,ifnotaddressedintherightway.Therearedifferencesintheinterestamong the partners/institutions, and the level of energy that is put in the planned actions is veryvariable. During such a long Programme (10 years), representatives of the partners/institutions in theSteeringGroupmaychangetheir interest,ormaybereplacedbynewones.Thisisanopportunity,butalsoathreadifnottakenintoaccount.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Themostimportantfactoristhetrust,thatisbeingbuiltamongrepresentativesofthepartners,thatarerepresentedintheSteeringGroup,andamongthepartners/institutionsinsomecases.Thisisthebasisfor the actions/projects,where people fromdifferent partners/institutionswork together and achievethe results, that have a higher value. Some projects could not even happen without a trustfulcollaboration.Thenextimportantfactorisflexibilityinleadershipandplanning–onceayearafulldaymeetingisorganisedtograspnewopportunitiesandideasandconnectpeople/partners/institutionstowork together. Complementarity to other processes/projects in Slovenia is a very important value todrivethechange,too.Leadingorganizationoftheprogramme/experienceMinistryofHealth,SloveniaContactpersonVesnaKerstinPetrič([email protected])JelkaZaletel([email protected])Websitehttp://sladkorna.ezdrav.si/References


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TrainingofRegisteredNursesforcarecoordinatorsinhealthpromotionandcareforselectedchronicdiseasesinprimarycare–

courseondiabetes

Slovenia

Shortdescriptionoftheprogramme/experienceThe coursewas developed in 2011,when existentmodel of care in familymedicinewas upgraded byintroducing Registered Nurses as care coordinators in health promotion and care for selected chronicdiseases, one of them being type 2 diabetes. Since there were no experiences at the beginning, thecourse included several opportunities for the participants to give feedback on the usefulness andeffectivenessof the training, theknowledgeandskills that theywere stillmissing,andgenerallyaboutbarriers,obstacles,aswellassuccessesintheirday-to-dayexperience.Theflexibilityoftheagendawaskeptalsoduringthenextyears,sinceitwasperceivedasagoodcharacteristicoftheparticipants,sothattheythemselvescansteertheagendatoacertainextent.Description of the agenda: duration is 26 hours of face to face training, and approximately 4 hoursindividualworkattheownpractice.

Day1:introductionwithexamtostrengthenthefocus,presentationofbasicfactsondiabetespreventionand care (with strong focus on impaired fasting glucose/impaired glucose tolerance, including its careplan), presentationof roles andprotocols of familymedicine indiabetespreventionand care, and theroleofRegisteredNurseascarecoordinator,workshoponperceivedopportunitiesandbarriersfortheirwork,thatincludesgivinganswersandtargetedinformation,lecturesonspecifictopicsindepth(basicsofdiet,hypoglycaemia).

Day2:lecturesonspecifictopicsindepth(multifactorialtreatment,goalssetting,pharmacotherapy,safeuseofthedrugs,diabeticketoacidosisandDAHS,diabeticfoot-basics,stepwiseeducation,otherchroniccomplications),descriptionofelementsofyearlypatient’sreport that includes individualisedtreatmentgoalsandtherolesofmembersofhealthcareteam,atleastonexamplefromapeer-RegisteredNursealready working in the team, workshops (meal planning, innovative approaches to meal planning,screeningfordiabeticfoot).

Day3ofthetrainingis2-4weeksafterday2,andduringthisperiod,awrittenassignmentisgiventotheparticipants, asking to reportbackon their real experience (at least onepersonwith impaired glucosemetabolism,atleastonepersonwithtype2diabetes,theirunderstandingandperceivedeffectivenessofexistentpreventionprogrammesathealthpromotioncentres,theirknowledgeaboutthecoordinationofcare with secondary level diabetes specialist team, and about sharing the experiences with otherRegisteredNursesatprimarycare).

Day3:feedbackfromtheirwrittenassignmentsaswellasexperiencesduringtheirownworkisthebasis


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ofthetraining,mergedwithtraininginskillsofcommunicationwithpatients,andthebasicsaboutgroupwork. Workshops (selfmonitoring of blood glucose, standards of organisation of care, screening fordiabetic foot,useofbloodglucosemeters,basicknowledgeabout insulinpens,mealplanning), lecture(diabetes and driving), and refreshment of the knowledge and understanding about the roles ofRegisteredNurses,theiractionstobetakenaccordingtotheresults,interpretationofyearlyreport,andplanningofthevisit.Theagendaallowsincludingadditionallectureonthetopic(s),thatwasperceivedasneededbytheparticipantsaccordingtotheirexperienceintheirrealwork.

Day 4: Workshop (screening for diabetic foot, patient empowerment/use of didactics appropriate foradults),role-play(patientwithnewlydiagnosedtype2diabetesatfirstvisitatRegisteredNurse),lecturesand debate on the rules of national payer (Health Insurance Institute Slovenia) and presentation ofNationalDiabetesPatients’Associationandofactivitiesofa localbranch.Questionnaireonparticipantssatisfactionwiththetraining.Finalexamforparticipants.

Lecturers: diabetologist with skills in coaching, Registered Nurses-diabetes educators, family medicinespecialists, diabetologists, Registered Nurse from family medicine, pharmacist, responsiblerepresentativesfromnationalpayer,andpatients’representatives.

FromNovember2011 tillDecember2016, 16 groupsofparticipants completed the training, giving thetotalnumberof455participants.

Since2016, at leastonceyearly two-day refreshment courseswill beavailable, andwill also feedbackintothechangesoftheagendaofthetraining.

Yearofimplementation,levelofimplementation,fundingYearofimplementation2011.Funding:publicresourcesIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)Feedbackfromtheparticipantsissoughttwiceduringthecourseviaworkshops.Attheendofthecourse,evaluation form isdistributed,asking tograde thecoursenumericallyandgive feedbackasdescription(suchaswhatshouldbekept,whatshouldbechanged,commentsondidacticalmethodsused).Duringrefreshmentcourse,theRNsareaskedagain,whattypeofknowledge/skillstheyaremissingafteratleastofoneyearofclinicalwork.Thisinfoisthenusedtoadapttheagendaofthetraining.Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Registered Nurses are trained as care coordinators as a part of national-wide system level change inorganisation of healthcare at primary care. The training course evolved during 5 years based on thefeedback of the participants during, as well as after the training. It includes a variety of didacticalapproaches, builds not only knowledgebutmostly skills and focuses alsoon values andbeliefs of theparticipants.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive:enthusiasmoflecturersiscontagiousandcanbespreadtoparticipants.Participantsneedalotofpersonalencouragementtodevelopandimplementtheskillsforthenewroleinthehealthcareteam.


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Afterinitialresistancein2011,aftergoodexperiencespatientsseethisroleoftheRNasveryimportantandreporthighdegreeofsatisfaction.Avarietyof lecturersfromdifferentprofessionsandinstitutionsas well as presentation of National and Local Diabetes Association give the participants the broadperspectiveofdiabetespreventionandcare.Negative:othermembersofhealthcareteam(doctorsandnurses)arenotattendingthecourse.Awareness of the role of the Registered Nurses in the healthcare teams varies among differenthealthcare teams. Coordination of care, when shared care is needed (for example with specialistdiabetes care), is not assuredoptimally. Certain skills (suchas screening fordiabetic foot) seem tobehardtobegraspedduringthetraining,andobviouslysubstantialadditionalchangeshavetobemade.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Leadingorganizationoftheprogramme/experienceUniversityMedical Centre Ljubljana -Department for endocrinology, diabetes andmetabolic diseases,Association of nurses in endocrinology (diabetes educators) at Nurses and Midwives Association ofSlovenia,andDepartmentforfamilymedicineatMedicalfaculty,LjubljanaContactpersonJelkaZaletel([email protected])MatejaTomazinSporar([email protected])MatejaBulc([email protected])WebsiteReferences


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Nationalprogrammefordiabeticretinopathyscreening

SloveniaShortdescriptionoftheprogramme/experienceNational programme for diabetic retinopathy screening is national payer (Health Insurance InstituteSlovenia)fundedscreeningprogrammethatoffersregularnational-widesystematicdiabeticretinopathyscreening for patients with diabetes and is organized regionally. The first step of the procedure isperformedbyRegisteredNurse:clinicaldataarecollected(suchastypeofdiabetes,diabetesduration,level ofHbA1c, arterial hypertension) and best-corrected visual acuity is determined. Then, RegisteredNurse performs digital retinal photography (2 fields for each eye, with midriasis) and sends (using ITtechnology) the photo and the data collected to the ophthalmologist. Ophthalmologist defines theabsence or grades the diabetic retinopathy according to the standardised coding and schedules thepatient for next annual screening examination or ophthalmological eye examination and treatment ifneeded.

Screening takes place at 8 regional screening centres in Slovenia situated in regional ophthalmologyclinics with direct access and referral to treatment. The ophthalmology clinic provides any necessarytreatmentandfollow-ups.Thereferraldoctor(familymedicinespecialistsordiabetologist)aswellasthepatientgetsreport,statingdiagnosis,andschedulesnextfollowupforscreeningortreatment.

Standards/qualitycriteria

Standard1: - toreducenewblindnessandvisual impairmentduetodiabeticretinopathy/evaluatethenumberofblindandvisuallyimpairedpatients

Standard2:-toensureallpatients,includingthosewithnewlydiagnoseddiabetesarescreenedontime/Timebetweenthediagnosisofdiabetesandscreening.

Standard 3: - to maximize the number of referred patients that performed the screening procedure/Percentageofscreenedpatientsofallreferred.

Standard4:Toensurephotographsareofadequatequality/Percentageofpatientswhereadigitalimagehasbeenobtainedbutthegradingisnotobtainable

Standard5:Toensuregradingisaccurate/Percentageofnormalimageswithnodiabeticretinopathyanddiabeticretinopathythatarere-gradedindependentlyaspartofqualityassurance.

Standard6:-Toensurereferraldoctorandpatientareinformedoftheresults/Timebetweenscreeningprocedureandissuingofletterstothereferraldoctorandpatient.

Standard7:Toensuretimelytreatment/Timebetweenreferralandtreatment

Standard8:Toensuretimelyrescreening/Timebetweenrescreening

Standard9:Toprepareannualreportontheprogramme/Analysisofcriteria


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Yearofimplementation,levelofimplementation,funding2016Isthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)PleaseseeaboveWhyshouldthisprogramme/experiencebeconsideredagoodpractice?Theprogrammeprovidesregularhighlyaccessiblediabeticscreeningtoallpersonswithdiabetes.Withdirect referral to ophthalmologic examination and treatment if needed timely treatment is achieved.Withtimelytreatmentbettertreatmentprognosisandbettervisualacuitycouldbeexpected.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Positive:existenceofnationaldiabetesguidelines, that includealsodiabetic retinopathyscreeningandtreatment. High level of commitment and joint effort of ophthalmologists (and to certain extentdiabetologists) to complete the exhaustive procedure that is in Slovenian system needed to for newresourcesintothisprogramme.Negative: Low level of awareness of this programme among healthcare professionals and patients.Drivers for referral for patients with diabetes to regional centres (and not to their usualophthalmologists) arenotwell addressed. Low levelofprimary carehealthcare teams involvement. ITsystems foruniformdatacollectionarenot fully inplaceyet.Newanduniformmodeloforganisationdisruptsalsothoselocalpractices,thatwereachievinggoodresultsandwereclosetotheplacewherethepatientslive/orthepatientswereusedto.Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?Withsystematicnationalscreeningprogrammefordiabeticretinopathywecanlowertheincidenceandprevalenceforvisualimpairmentandblindnessamongpatientswithdiabetesatnationallevel,whichisourprimarygoal.Withthisprogrammethequalityofcareforpatientswithdiabetesisimprovedintermsof better accessibility for eye examination and with that we can achieve higher rate of populationscreened,andtimelyreferralforappropriatetreatmentofdiabeticretinopathy.Leadingorganizationoftheprogramme/experienceDepartmentofOphthalmology,UniversityMedicalCentreLjubljana,SloveniaContactpersonMojcaGlobocnikPetrovic([email protected])WebsiteReferences


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COMPETENTPATIENTINDIABETESSpain

Shortdescriptionofthememe/experienceThe following items are included in the education programme: health promotion interventions(choice of food, physical activity), diabetes knowledge, prevention of diabetes complications,managementofstressandcopingwitheverydaylivingactivities.The target groups are: all the persons with diabetes, persons with diabetes with comorbidities,personswithanewdiagnosisofdiabetes,andrelativesandcaregivers.The following criteria are defined in the education programme: goals, rationale, target group(inclusionandexclusion criteria), setting (e.g. primary care), schedulingof theeducation sessions,number of participants, environmental requirements (e.g. an appropriate and accessible facility),qualificationofthetrainers/educators (e.g.certifiedtraineesregardingcontentandmethodology),corecomponentsoftheeducator/trainer'srole(e.g.clinicalpractice,healthpromotion,counsellingandbehaviouralchangetechniques),monitoringoftheeffectivenessandqualityoftheprogrammeandsourceoffunding.Yearofimplementation,levelofimplementation,fundingIsthereadefinedevaluationframework?Listtheindicators(structure,process,outcome)The following outcome criteria are measured: diabetes knowledge (ideally measured using standard,validated, questionnaires) and quality of life; empowerment/self-efficacy (ideally measured usingstandard,validated,questionnaires).Whyshouldthisprogramme/experiencebeconsideredagoodpractice?Trainingpatientsinspecificabilitiesandaptitudesinordertomanagetheirdiseaseleadstogreaterself-care,betteruseofhealthresourcesandservicesandbettertreatmentadherence.Whicharethereasonsforsuccess(positivelessonslearned)andfailure(negativelessonslearned)ifany?Patientsevaluationofthiscoursehasbeenverypositive(anaverageof9ona0-10scale).Trainingleadstoworkingtogethertoimprovethequalityoflife.Supportandcooperationnetworksarecreatedbythepatients,andrelationswiththehealthprofessionalsimprove.


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Howdoes this programme/experience help in driving the change toward prevention and improvementthequalityofcareforpeoplewithdiabetes?The patient learns how to control better his or her glycemia, improve his or her lifestyle (nutrition,exercise), is able to handle better the symptoms and complications. The patient takes charge of histreatmentandknowshowtosolveproblemsthatmayarise.Leadingorganizationoftheprogramme/experienceGalicianHealthService(SERGAS)[email protected]


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Table1-PotentialGoodpracticesbyTypeandCountry

ACTIVITY COUNTRY TITLE PAG.

PREVENTION Austria Generalscreening 16 Croatia ProgrammeofHealthCareforPersonswithDiabetes-Prevention 29

Germany AOKCheckUpPlus 43

Germany SMS.Besmart.Joinin.Befit 45

Greece IPIONI-NationalPilotProjectonPreventionandHealthPromotionforOlderPeople 55

Italy ScreeningDiabetesPalermo 77

Slovenia Nationalprogrammefordiabeticretinopathyscreening 96

EDUCATION Austria TherapieAktiv–Educationprogrammeforpersonswithdiabetes 6

Austria AktivtreffDiabetes-Effectivenessofapeersupportprogramme 8

Austria TrainingforDiabeticsType2Carinthia 10

Croatia ProgrammeofHealthCareforPersonswithDiabetes-Education 23

Germany MEDIAS2programme 47

Italy C.U.R.I.A.M.O.-Innovativemultidisciplinaryinterventionforchangingthelifestylesofpersonswithtype2diabetesmellitusand/orobesity

60

Italy GroupCareModel:TheTurinexperience 69

Norway PatientEducationandHealthMastery 88

Spain Competentpatientindiabetes 98


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TRAINING Austria Continuousdiabetescounseling 18

Austria DiabetesEducationforDietitians 20

Austria UniversitycourseonDiabetesCare 22

Croatia ProgrammeofHealthCareforPersonswithDiabetes-Training 31

Germany TrainingsoftheGermanDiabetesSociety 51

Italy MasterCourseonEndocrinologyandDiabetesfornursingpersonnel 67

Norway Diabetesnursingspeciality 82

Slovenia TrainingofRegisteredNursesforcarecoordinatorsinhealthpromotionandcareforselectedchronicdiseasesinprimarycare–courseondiabetes

93

HEALTHPROMOTION

Austria NationalActionPlanMotionNAP.b 12

Austria AustrianNationalNutritionActionPlan(NAP.e) 14

Croatia ProgrammeofHealthCareforPersonswithDiabetes–HealthPromotion 25

Italy C.U.R.I.A.M.O.-HealthyLifestyleInstitute’sModel 58

MANAGEMENT Croatia ProgrammeofHealthCareforPersonswithDiabetes-Management 27

Finland RegionalNetworkofdiabetologistsanddiabetesnurses 33

France Asalée-Generalhealthresponseteam 35

France Sophia 38

Germany TheSaxonianHealthCareModel(DiabetesManagementProgramme 40


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MANAGEMENT Italy DiabeticRetinopathyCentre 63

Italy SINERGIA-Chroniccaremodelforthemanagementofdiabetes 73

Italy Patient-centeredapproachforthepreventionandtreatmentofpatientswithdiabetesmellitus 75

Italy IGEA 79

NATIONALPLAN/STRATEGY

Norway TheNationalGuidelinesforprevention,diagnosisandtreatmentofdiabetes(2009/2016) 84

Norway NCD-strategy:Prevention,diagnosis,treatmentandrehabilitationofnon-communicablediseases-cardiovasculardisease,diabetes,COPDandcancer

86

Slovenia DiabetesPreventionandCareDevelopmentProgramme2010-2020 90


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