Das Diabetes-Ampelschema - Entwicklung eines Instruments für das hausärztliche Case Management bei Patienten mit Diabetes mellitus

Abstract

In order to sustain the continuity and quality of treatment in diabetic primary care patients, it is necessary to introduce structured and regularly performed monitoring system into the practice team. The monitoring aims at early and valid recognition of potential complications resulting from a chronic disease. Ideally the practice nurse is in charge of the case management. The central element of the case management is a colour coded instrument, the diabetes traffic light scheme, by which means the most important clinical parameters and patient adherence can be screened in regular intervals. Additionally, the instrument regulates in-practice communication by means of stratified action plans and enables ideal treatment continuity also in larger teams. The experiences resulting from the development of this diabetes-specific traffic light scheme can be beneficial for the future development of similar instruments in other chronic diseases.

Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study

“…In order to nevertheless enable complex health care and cope with rising costs, team-based approaches have been developed for treatment of the chronically ill. The cluster-randomised CARAT trial (Chronic CARe for diAbeTes) [3][4][5][6] showed that implementing the Chronic Care Model (CCM) in diabetes care via involvement of specially trained practice nurses [7,8] is feasible in small primary care practices (PCPs), improves the cardiovascular risk profile and is perceived by patients to be better structured care, at least on the short term. Little is known on the long-term effects of such an intervention.…”

“…The aim of this study was, therefore, to assess the feasibility and practicability of implementing the CCM in small PCPs in the long term. We assessed the proportion of patients still treated according to CCM 3 years after completion of the CARAT trial, as well as reasons for discontinuing the use of the CCM, and the development of previously [3][4][5][6]. The eligibility criteria for the CARAT trial were PCPs participating in routine primary care of unselected patients.…”

Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Systematic Review

“…The publication by Glasziou was the only one giving a broader overview on the topic [97]. Only a handful of publications reported a complete set of indicators that can be used for monitoring, but these were either not specific for primary care or not eligible for implementation in EMRs [98-101].…”

“…The underrepresentation of osteoarthritis and chronic heart failure is also reflected in the number of indicators detected in the primary literature, compared to a large number of records reporting on indicators for type 2 diabetes mellitus. Another topic repeatedly found in the results was the involvement of a clinical practice nurse in monitoring [101,107-109]. The clinical nurse can, for example, fill out a monitoring questionnaire in face-to-face sessions with the patient, on the phone, or even electronically.…”

“…However, literature beyond the indicator of blood pressure measurement remains scarce. Regarding diabetes mellitus, there is an extended monitoring tool that was designed as a disease management tool for practice nurses [101]. The tool’s design is based on a traffic light scheme to detect any deficit and need for action.…”