Effectiveness of the Transformation model, a model of care that integrates diabetes services across primary, secondary and community care: A retrospective study

Abstract

Aims The primary aim was to evaluate the effectiveness of a model integrating diabetes services across primary, secondary and community care (Transformation model). The secondary aim was to understand whether changes resulted from the model. Methods The model was implemented In Leicester, Leicestershire and Rutland (UK) across three clinical commissioning groups, the acute trust and accompanying stakeholders. One clinical commissioning group (Leicester City) implemented the entire model and was the primary evaluation population. A quasi‐experimental interrupted time series design was employed. The primary outcome was number of Type 2 diabetes‐related bed‐days per 1000 patients. Results In the primary population, the mean number of Type 2 diabetes‐related bed‐days per 1000 patients was increasing before model implementation by 0.33/month (95% confidence interval: −0.07, 0.72), whereas it was decreasing after implementation by a mean value of −0.14/month (−0.33, 0.06); a statistically significant difference (p = 0.04). Secondary analyses showed: nationally, there was no significant change between the pre‐ and post‐periods so it is unlikely that large secular change drove the improvement; the other two Leicestershire clinical commissioning groups saw improvement or stability; underlying processes worked as hypothesised overall; diabetes biomedical markers deteriorated in the primary care population suggesting a change in case‐mix due to moving some patients out of secondary care. Conclusions Given that the initial aim was to shift services from secondary to primary care without causing harm, an improvement is better than expected. This observational evaluation cannot show conclusively that improvements were due to the Transformation model, but secondary analyses support this.

Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic

“…The World Health Organisation defines integrated care as “the management and delivery of health services such that people receive a continuum of health promotion, health protection and disease prevention services, as well as diagnosis, treatment, long-term care, rehabilitation, and palliative care services through the different levels and sites of care within the health system and according to their needs” 4 . Integrated care focuses on care coordination around the patient, either through vertical integration between acute and community or social care services, or horizontal integration across services at a similar level 5 , 6 .…”

“…While some evaluations of integrated care show promising results in terms of patient outcomes (preventable hospitalisations, bed-days, clinical outcomes) 5 , 7 , 8 , findings have been inconsistent 9 – 12 . Proposed reasons for the inconsistencies are that integrated care models are complex and difficult to implement in real world settings.…”

“…Type 2 diabetes, with its increasing prevalence 16 , 17 and significant burden on the individual and the wider health system 1 , 18 , 19 is often used as an exemplar condition when developing, testing, and evaluating new models of integrated care. Models of integrated diabetes management often involve realignment of services in different settings according to risk or need, for example, management of people with uncomplicated diabetes in primary care, with management of complicated diabetes between primary and secondary or solely in secondary care 4 , 20 , Strategies to support implementation of integrated diabetes care models typically include workforce changes and new ways of working 21 , including the creation of new clinical staff/teams (e.g., co-location of specialities 20 , 22 , 23 , introduction of new staff/roles, often specialist nurses 24 , 25 ), revision of professional roles 26 , ongoing training (e.g., upskilling of general practitioners/practice nurses 5 , 23 , 27 , 28 ), or learning collaboratives (e.g., joint meetings to support greater multidisciplinary team working 24 , 29 ).…”