Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes.
BACKGROUND
Most people with type 2 diabetes (T2D) have glycaemic levels outside of target. Insulin is effective in improving glycaemia and most people with T2D eventually need this. Despite this, transition to insulin therapy is often delayed in primary care.


OBJECTIVE
To develop a model of care (Stepping Up) for insulin initiation in routine diabetes care in Australian general practice. To evaluate the model for feasibility of integration within routine general practice care.


METHODS
Drawing on qualitative work and normalisation process theory, we developed a model of care that included clarification of roles, in-practice systems and simple clinical tools. The model was introduced in an educational and practice system change intervention for general practitioners (GPs) and practice nurses (PNs). Five practices (seven GPs and five PNs) and 18 patients formed the feasibility study. Evaluation at 3 and 12 months explored experiences of GPs, PNs and patients.


RESULTS
Fourteen patients commenced insulin, with average HbA1c falling from 8.4% (68.3 mmol/mol) to 7.5% (58.5 mmol/mol) at 3 months. Qualitative evaluation highlighted how the model of care supported integration of the technical work of insulin initiation within ongoing generalist GP care. Ensuring peer support for patients and issues of clinical accountability and flexibility, managing time and resources were highlighted as important.


CONCLUSIONS
The Stepping Up model allowed technical care to be embedded within generalist whole-person care, supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin. Testing of the model's effectiveness is now underway.
Department of General Practice, University of Melbourne, j.furler@unimelb.edu.au.
John S
JS
Furler
Department of General Practice, University of Melbourne.
Irene D
ID
Blackberry
Chronic Illness Alliance.
Christine
C
Walker
Department of General Practice, University of Melbourne.
Jo-Anne
JA
Manski-Nankervis
Department of General Practice, University of Melbourne.
Jenny
J
Anderson
Department of Medicine, St Vincent's Hospital and.
David
D
O'Neal
Department of General Practice, University of Melbourne.
Doris
D
Young
Department of Medicine, St Vincent's Hospital and School of Medicine, University of Melbourne, Melbourne, Australia.
James
J
Best
D000368:Aged; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D001315:Australia; D003266:Continuity of Patient Care; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000451:nursing / Q000523:psychology; D005240:Feasibility Studies; D005260:Female; D058006:General Practice / Q000379:methods* / Q000458:organization & administration; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D057184:Practice Patterns, Nurses' / Q000458:organization & administration*; D059017:Primary Care Nursing / Q000379:methods*; D036301:Qualitative Research; D011787:Quality of Health Care; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin
Diabetes mellitus type 2; general practice; patient care team; primary nursing; quality of health care.