IS THE HOLISTIC MANAGEMENT MODEL (‘EVERYONE UNDER ONE ROOF’) REALLY A GAME CHANGER?

I would like to firstly dedicate this blog to two members of our team who have experienced losses of family members. We, at the CDE, are a family as much as a team, and these losses have shaken us all to the core. I want them to know that we are praying for their comfort and strength during these trying times.

This question posed in the blog title recently entered my thoughts when I found myself in a discussion with one of our dieticians and diabetes nurse educators regarding the best management plan for a client at the CDE. I personally am grateful for our multi-disciplinary team consisting of diabetes nurse educators, dieticians, podiatrists, a nurse for dynamic testing, a pharmacy and doctors. This team centred approach ensures our clients receive education and all ancillary services under one roof. As a result, clients do not ‘fall into the cracks’ and miss a consult with a vital team member. In addition, we are constantly bouncing ideas off each other and changing management depending on our feedback. Healthcare practitioners can all attest to the fact that good education is key to managing any medical condition, but it takes on an even more vital role in the complexity of diabetes care. I wonder then: “is the benefit of this multidisciplinary team together in one centre at the CDE a fluke, or is there evidence out there supporting this model?” If this model is objectively a proven winner, surely this should be gold standard for care of any person with diabetes.

The cost of managing diabetes and diabetes related complications has been shown to be up to 9 billion pounds a year in the UK.¹ South African figures are similarly dire with a report in 2018 estimating public sector costs of around R 2.7 billion, and by 2030 this is expected to be R 35.1 billion.² This financial toll aside, the impact on poorly managed clients is not quantifiable. The person is affected physically, psychologically, socially, and spiritually in some cases.³ The goal therefore is to achieve glycaemic goals like HbA1c and ‘time-in-range’ safely and timeously, but this is not always possible with a sole clinician managing a client in his/her rooms. There simply is not enough time to take a history, examine, work out a treatment plan and educate fully.

A report from the Siriraj Continuity of Care Clinic showed that the proportion of their clients that achieved a target HbA1c of less than 7% was 7.8% higher than achieved in a ‘usual care’ group. Similar to the CDE approach, this clinic focuses on education, lifestyle changes, and psychological well-being in addition to medical management.⁴ Holistic management centres like this have education at the core of their success. The skills developed involve the person with diabetes, and often the family members, which improves success of glycaemic and other risk factor management further.⁵ A confident client who takes responsibility for his/her role in diabetes self-management is even more efficient than the physician-led up-titration of medication, including insulin.⁶

A well-counselled client can work through issues like the fear of hypoglycaemia to effectively manage their glucose levels. They are further able to react quickly to changes in glucose levels or seek assistance before ending up in hospital and requiring admission. The CDE provides a dedicated 24-hour Hotline number for OUR clients, and I can anecdotally confirm that we have prevented many thousands of admissions due to timeous counselling and proactive intervention telephonically.

The simple fact is that the CDE model works, and the data out there supports this. The sad fact is that the role of essential team members like diabetes nurse educators is undervalued to the point that funders will not fund their consultations. These adversities have led to a paucity of well-trained ancillary members to support the development of more centres like ours or support doctors alone out there. I hope that funders, the health departments and other role players realise that this model DOES INDEED work. The expense in developing and investing in such centres will have immense current and future benefits for our clients with diabetes, and for national health and productivity. This is a certainty!

References^‍

1. Hex N et al. (2012). Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med; 29(7):855-862
2. Erzse et al. (2019). The direct medical cost of type 2 diabetes mellitus in South Africa: a cost of illness study. Glob Health Action; 12(1): 1636611
3. Centers for Disease Control and Prevention (2021). Diabetes Prevention Recognition Program - Standards and Operating Procedures. Available at:
   https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf
4. Chalermsri C et al. (2014). The effectiveness of holistic diabetic management between Siriraj Continuity of care clinic and medical out-patient department. J Med Assoc Thai; 97:197-205
5. Likitmaskul S et al. (2016). Outcomes of holistic care for patients with type 1 diabetes by multidisciplinary teams in Thailand. Diabetes Res Clin Pract; 120:S123-S.
6. Russell-Jones D et al. (2019). Take Control: A randomized trial evaluating the efficacy and safety of self- versus physician-managed titration of insulin glargine 300 U/mL in patients with uncontrolled type 2 diabetes. Diabetes Obes Metab. 21(7):1615-1624.