State diabetes program Hidalgo pilot phase 2, WDF16-1376

Objectives

To improve the quality of outpatient diabetes care based on established clinical outcomes:

• Glycaemic control: A1c below 7.0 percent; pre-prandial capillary blood glucose: 90-130 mg/dl; postprandial capillary glucose below 160 mg/dl.
• Blood pressure control: systolic/diastolic blood pressure lower than 135/80 mm Hg.
• Lipoprotein profile: LDL cholesterol below 100 mg/dl; triglycerides below 150 mg/dl.
• A 5% reduction of body weight within one year.
• Screening for microalbuminuria, follow up and antihypertensives in positive cases.
• Daily foot examination by patients, by physicians at every visit.
• Establish and maintain a social network in Tepeji del Rio.

Approach

• Prepare intervention with local health authorities and mobilise targeted primary level units and communities.
• Train HCPs from targeted primary level units based on well-established and certified six-month online/interactive comprehensive diploma course on diabetes and prevention supervised by REMEDI; the diploma course content will be differentiated towards nurses and physicians. Graduates will be provided with guidelines and educational material to be applied at their respective primary level units.
• Roll out of comprehensive diabetes care and prevention activities at targeted primary level units, incl. through provision of baseline medical and nutrition consultations to registered diabetes patients and through continuous and regular follow up visits; Key component of care is patient education, incl. peer-to-peer; Referral system incl. screening and care for complications with local secondary/tertiary level hospitals to be strengthened.
• Implementation of awareness activities out of targeted primary level units through mobilisation of CHWs and distribution of teaching material, and through various local media/social media channels.
• Monitoring and evaluation of intervention through introduction of a new patient record system and through data collection on various WDF aligned clinical indicators (incl. HbA1C measurements) and through continuous liaison with authorities.

Expected results

• 30 nurses and 30 physicians from 15 primary level units (two of each category from each unit) to have completed comprehensive diploma course on diabetes; 15 primary level units will then have been provided improved capacity, incl. necessary material, equipment and screening supplies etc
• 60 CHWs mobilised.
• At least 3,000 diabetes patients to have been provided comprehensive diabetes care and up to 500 new cases diagnosed.
• Up to 50,000 people reached through the various awareness and media activities.

Results upon completion

• 159 nurses and 161 physicians have completed comprehensive diploma course on diabetes; 15 primary level units have been provided improved capacity, incl. necessary material, equipment and screening supplies etc. apart from training of staff and improved registries
• Almost 3,000 patients have been provided comprehensive diabetes care at the 15 clinics based on enrolment registries (cohort monitoring)
• Almost 55,000 people screened for diabetes of which more than 4,000 were diagnosed and offered care over the three-year project trajectory