Diabetes is a complex chronic condition managed by large Multi-Disciplinary Teams (MDTs) based in primary and secondary care. Despite advanced Information Communication Technology (ICT), communication between primary and secondary care team members can be ineffective and clients can be poorly informed about the process of care, their targets and outcomes.
During 2013 the East Coast Area Diabetes Shared Care Programme (ECAD), led by a CNS-Diabetes working in ECAD, developed a client-held Diabetes Passport for clients to bring to reviews in primary and secondary care. Results are entered at review enhancing communication between Health Care Professionals (HCPs) and informing and empowering clients so that self-care is promoted and supported.
The objective was to include all relevant stakeholders in the development of the Diabetes Passport so that the needs of all who would use it would be met. In doing so the following objectives could be achieved:
Clients informed of the process, targets and outcomes of care so that their knowledge and understanding are enhanced. Thus their self-care is promoted and supported. In addition, they can support enhanced communication between their HCPs in primary and secondary care.
Enhanced communication between HCPs in primary and secondary care.
Duplication of care reduced.
Increased satisfaction experienced by clients and HCPs.
Permission was gained from the developers of a pre-existing Diabetes Passport to use it as a template in developing a Passport for ECAD. The MDTs from the 3 hospitals in ECAD, General Practitioners (GPs) and Practice Nurses (PNs) on the ECAD steering committee and the medical lead of the audit department, St. Vincent’s University Hospital (SVUH), were included in the consultative process. Many changes were made to the Passport satisfying the suggestions recommended. On the advice of the medical lead of the audit department, SVUH, a focus group interview was held with ten clients living with diabetes and additional changes were made to the Passport.
Once all changes to the Passport were agreed, it was submitted to and
approved by the National Adult Literacy Agency (NALA) for Plain English.
The Passport has been circulated to local hospital diabetes centres, GP surgeries within the ECAD Programme and more recently to other GP surgeries in CHO 6 who have registered for the National Diabetes Cycle of Care.
In 2015 the Network of Diabetes Nurse Specialists in Primary Care adopted the Passport as a resource nationally.
The Diabetes Passport is an integral part of the Type 2 Diabetes Care Pathway developed by the ECAD Team in support of the National Diabetes Cycle of Care.
It is in circulation approximately 2 years. An audit is underway to ascertain the extent of Diabetes Passport usage amongst people with Type 2 Diabetes in CHO 6. The audit is establishing the number of people with a Diabetes Passport attending clinics within primary and secondary care settings and if entries are made to their Passports post diabetes review(s).