Dehko Proceeds

Transcription

1 Dehko Proceeds

2 2 Development Programme for the Prevention and Care of Diabetes DEHKO Primary Prevention of Type 2 Diabetes Developing Diabetes Care and its Quality Supporting Self-Care of Persons with Diabetes Dehko Proceeds Published by Finnish Diabetes Association Edited by Leena Etu-Seppälä Programme for the Care Organization Education Prevention of Type 2 Diabetes ( ) Quality Criteria and Rehabilitation Population Strategy Quality Monitoring High-Risk Strategy Systems Peer Support Groups Strategy of Early Diagnosis and Management Basic Education and Further Cooperation between Training of Health Care Staff Finnish Diabetes Association s Implementation of the Local Branches and Health Care Prevention Programme: Modern Medication FIN-D2D Project Influencing Municipal Decision-making Layout by Aino Myllyluoma Printed by Hermes Printing ISBN

3 3 Table of Contents Foreword...4 Starting-points for Activity in Plan to Implement National Dehko Projects in Dehko s Recommendations for Action in APPENDICES Summary of Dehko Interim Assessment s Conclusions and Recommendations FIN-D2D Project in Brief...36 Dehko s Publications...37 Contact Information...38

4 4 FOREWORD TThe Development Programme for the Prevention and Care of Diabetes (DEHKO ) has proceeded well according to plans. Dehko is a 10 year long, extensive national programme, which will be implemented in three main ways: preventing type 2 diabetes, developing diabetes care and its quality and supporting selfcare of a person with diabetes. The main goal of the whole programme, the prevention of type 2 diabetes and its complications, appears to have begun its implementation particularly well. Finland has been a pioneer in diabetes prevention studies, which has given a scientific basis and boost for Dehko s type 2 diabetes prevention programme. Finland continues to lead the rest of the world, and particularly the prevention programme and its implementation project, FIN-D2D, are quoted and referred to in international meetings and publications. The prevention programme is the first programme in the world which has been created and concretely implemented on national level. Moreover, the good cooperation and partnership between the Finnish Diabetes Association and the Finnish Heart Association has often been observed attentively internationally. Rooting the prevention programme into primary health care and occupational health care practices is essential, and the key players are succeeding in doing this. Primary health care is the core of the Finnish service system, because it reaches Finns from all walks of life. This makes it possible to influence people s health behaviour and prevent diabetes. On the other hand, occupational health care reaches the majority of the working population. One of the major achievements of Dehko implementation so far is also the creation and utilization of a large cooperation network. Cooperation is essential in preventing type 2 diabetes, because due to its complications, type 2 diabetes can be seen more and more as an artery disease. This makes the prevention of the disease even more important from the point of view of public health, and the same measures which can be used to prevent other public health problems, can be used also here. The Ministry of Social Affairs and Health regards the cooperation between major public health organizations as important, also when considering the national health programmes and strategies which are taking place now. The Development Programme for the Prevention and Care of Diabetes, Dehko, is in line with the set national health objectives and it provides an excellent tool for achieving those objectives.

5 5 It has been a pleasure to see that already in this stage several external parties have assessed Dehko. According to their assessments, Dehko is an ambitious, but a realistic public health programme, which proceeds towards logically set goals. On the basis of the feedback received by the Ministry of Social Affairs and Health, it can be said that Dehko is an action programme which is respected and actively used on national level. It is particularly important to note that national and municipal health care decision-makers have become aware of the seriousness of type 2 diabetes and its complications, as well as of the huge costs of untreated diabetes. The goals which were originally set for the programme are still valid today. Some of Dehko s 25 Recommendations for Action have been achieved already, and the rest of them are making good progress. Together with prevention, the key challenges for the next couple of years are improving the glycemic control of people with type 1 diabetes, building a care quality monitoring system and increasing health care provider s diabetes know-how on all levels of health care. These challenges are similar to those faced by the whole national health care services system. Now is the right time to include the monitoring and reporting of diabetes and its care in a national monitoring system. We look forward to the results of the current pilot project on using the existing registers to monitor diabetes complications. It is important to take into use the quality criteria which was created in connection with Dehko, and use them in the future as a basis to monitor the quality of diabetes care. The current national recommendations for further training offer a good framework for health care staff training, and I hope that they will be used to improve diabetes know-how. I congratulate Finnish Diabetes Association on the valuable work they have done so far. Finnish Diabetes Association has taken active initiative to encourage both governmental and non-governmental parties to take part in the project. I hope that in the hands of its very capable leaders, the programme will continue to be as successful as it has been so far. Helsinki, 16 th November 2004 Liisa Hyssälä Minister of Health and Social Services

6 6 Starting-points for Activity in Background The Development Programme for the Prevention and Care of Diabetes, Dehko, was accepted as Finland s national diabetes programme for the years in a big consensus meeting in In the programme clear goals were set for development work, and to achieve those goals, accurate and precise action recommendations were written down, as well as the names of the key players who would be responsible for carrying out the planned measures. Moreover, Dehko includes assessment plan which covers the entire lifespan of programme. Finnish Diabetes Association, which initiated, coordinated and financed Dehko from the very start, is also responsible for the coordination and nation-wide projects of Dehko s implementation. The implementation of national projects began right after the consensus meeting. The key players of Dehko s implementation are primary health care, specialized medical care, hospital districts and their diabetes working groups, and occupational health care. In addition, the Ministry of Social Affairs and Health, municipalities and local health care authorities, National Research and Development Centre for Welfare and Health, National Public Health Institute, Social Insurance Institution in Finland and Association of Finnish Local and Regional Authorities each have their roles in implementing Dehko s key measures. Cooperation with Finnish Heart Association, Association of Finnish Pharmacies, Finnish Centre for Health Promotion, UKK Institute for Health Promotion Research, health care s professional bodies, other public health organizations, polytechnics and physical education organizations is vital to achieve Dehko s goals. Since 1999 Finnish Slot Machine Association has been the main sponsor of Dehko, together with companies which produce diabetes medicine and care supplies and equipment. The newest commercial sponsors for Dehko are pension insurance company Varma and food stuff company Vaasan&Vaasan. Dehko Implementation at Halfway Stage Now after five years, at halfway stage of implementing the programme, we can see that Apart from one re-defined issue, all goals are still valid and possible to achieve. All 25 Recommendations for Action are under way: some of them have been achieved already, others are in stage 2, and the rest of them are under development. Implementation of Dehko s measures has created high quality cooperation particularly in six areas: 1 Cooperation between Finnish Diabetes Association and Finnish Heart Association has evolved into strategic partnership to attain common goals. 2 By 2004 multiprofessional cooperation in health care has created quality criteria for five diabetes care fields and a group counselling model for treating people with type 2 diabetes. 3 Joint Dehko s FIN-D2D project ( ) between five hospital districts, National Public Health Institute, primary health care, occupational health care and Finnish Diabetes Association makes world diabetes history by rooting type 2 diabetes prevention into health care system. 4 Shared financial contribution of the Ministry of Social Affairs and Health, Finnish Slot Machine Association, Finnish Centre for Health Promotion, hospital districts, National Public Health Institute and Finnish Diabetes Association to the implementation of FIN-D D Project sets a unique example for the rest of the world to follow.

7 7 5 Cooperation project between National Research and Development Centre for Welfare and Health, Social Insurance Institution in Finland and Finnish Diabetes Association in creates the foundation for developing a permanent monitoring system for the incidence and complications of diabetes and for the mortality of people with diabetes 6 Systematic cooperation between Finnish Diabetes Association s local branches and health care has led to the discovery of new tools which can be used to support the selfcare of people with diabetes Practical implementation of Dehko has been reported and monitoreded in four annual symposia held for the key players of Dehko, at the first national Dehko Days in 2003, in several health care training events, in international meetings and congresses as well as in Dehko s and Finnish Diabetes Association s publications By 2004 five external assessments have been made of Dehko: Dehko as a Public Health Programme (director Tauno Telaranta of Kotka s Social and Health Department, 2000); Introducing Dehko at Health Care Centres (UKK institute for Health Promotion Research, 2001); Dehko as One of the Major Projects Funded by the Finnish Slot Machine Association (Finnish Slot Machine Association, 2002); Finnish Diabetes Association as a Health Promoter (Finnish Centre for Health Promotion, 2002); and Dehko Interim Assessment (Pertti P. Ahonen and his expert team, 2003) Dehko basic information materials, development projects, research studies and reports form a publication series of over 40 printed materials Strong commitment of the main sponsor Finnish Slot Machine Association and commercial company partners has made it possible for the Finnish Diabetes Association to coordinate the programme in long-term. What Next? We have good resources and favourable circumstances to implement Dehko in the next couple of years. Diabetes and the prevention of type 2 diabetes are actively discussed in the media, and health care staff has a positive attitude to Dehko. A recent profile study of Finnish Diabetes Association shows that Dehko and the prevention of type 2 diabetes have become as important to the 50-year-old Finnish Diabetes Association as its flagships, the Diabetes magazine and the Diabetes Centre. This publication Dehko Proceeds summarizes Dehko s original goals, the coordinator Finnish Diabetes Association s action plan for to implement national projects, and the updated key measures. Appendices include the conclusions and recommendations of Dehko s Interim Assessment and Dehko s FIN-D2D Project in a nutshell, Dehko s publication list and the contact information of Dehko and FIN-D2D Project. Understanding the project as a whole as well as seeing the current situation helps all the key players to do their job in the upcoming years. At the moment, preventing diabetes and its complications is one of the biggest challenges faced by the entire world. With the help of our diabetes programme Dehko and its FIN-D2D Project, we continue to proceed amongst the pioneers in this field. Leena Etu-Seppälä Secretary General of Dehko Finnish Diabetes Association

8 8 DEHKO OBJETIVES FOR YEAR 2010 There will be a quality system of diabetes care in each care unit, a natural part of which is regular and comprehensive diabetes training within primary health care. Measures aimed at the prevention of type 2 diabetes will be a permanent function of primary health care. There will be a computerized diabetes registry in each care unit and in each hospital district, as well as a national diabetes registry. The care organization for people with diabetes will be based on smooth-running care chains, shared responsibility for care be tween primary health care and specialized medical care, and flexible consultation practices. Each person with type 1 diabetes will have access to individual high quality self-care. All people with type 2 diabetes will receive sufficient education in self-care, and their cardiovascular risk factors will be treated along with their hyperglycemia. People with diabetes will have the skill for self-care and have a high level of satisfaction with their care. The cooperation between the health-care system and the diabetes branches in supporting self-care will become established as a permanent form of activity. The objectives concerning health outcomes targeted for 2010 are as follows: The glycemic control of people with diabetes will have improved so that at least 50 per cent of people with type 1 and type 2 diabetes have optimal glycemic control, and no more than 30 per cent have unsatisfactory and 20 per cent poor glycemic control. The insidence of cardiovascular disease among people with diabetes drops by at least on-third. The complications related to diabetes will decrease according to the objectives of the European St. Vincent Programme: leg amputations at least by one-half diabetic retinopathy at least by one-third diabetic nephropathy by one-third

9 9 Plan to Implement National Dehko Projects in In general During , eight expert teams and a coordinating group led by professor Marja- Riitta Taskinen compiled The Development Programme for the Prevention and Care of Diabetes, Dehko. This programme, which was approved as Finland s national diabetes programme for , includes eight concrete care and care organization goals, and five goals for health outcome. To achieve these goals, Dehko includes 25 recommendations for action, ten of which are the key measures. According to an external interim assessment conducted in 2003, the gradual forward movement of the programme has been logical, and already in its early stages the programme has affected and developed everyday health care practices. According to the assessors, there is no need to change Dehko s course, but the new demands which have emerged as time has passed, require Dehko to fine-tune, re-focus and re-assess its action during the implementation of the next stage of the programme. Checking Goals As the implementation of Dehko is halfway through, we can conclude that the set goals are still valid today. The only point worth checking is the proposal of a three level diabetes register as a separate register, which may not be well-founded in the present circumstances. Building a diabetes care quality monitoring system is in under way. It uses an electronic health care record system which is now under development, the existing registers and regular care quality surveys to collect data. From the end result s point of view, there are no discrepancies between the original register project and the current quality monitoring system projects. Updating Recommendations for Action Progress has already been made in all recommendations for action which were set in 2000: some have already been achieved and they have proceeded to the next stage; others are in the middle of the implementation process; and the rest are beginning their implementation. The reform of reimbursed medicine is now being prepared. People with type 2 diabetes can not get reimbursements for certain new diabetes medicine. The third key action should be re-assessed so that a reimbursement system should be created, which supports the comprehensive care of people with diabetes, regardless of their diabetes type and financial situation. Moreover, the recommended action on the dental care of a person with diabetes has been re-assessed to meet the current demands. The situation of implementing measures has been updated, and further measures for will be presented in this publication on pages

10 10 KEY AREAS OF ACTIVITY IN Prevention of type 2 diabetes and its complications; early diagnosis and care Improving glycemic control of people with type 1 diabetes and preventing complications; early diagnosis and care Supporting self-care know-how and abilities of people with diabetes Building a diabetes care quality monitoring system Enhancing diabetes know-how of health care providers Prevention of type 2 diabetes and its complications; early diagnosis and care The main goals of Dehko are to prevent type 2 diabetes and diabetes complications. The keys to achieving these goals are the prevention programme s recommendations for action and the wide local, regional and national cooperation. The central issue in the prevention of type 2 diabetes is rooting the prevention programme into a permanent function in everyday primary and occupational health care practices by means of Dehko s FIN-D2D Project ( ), and assessing the feasibility, significance and cost-effectiveness of the programme. It is important from both national and international viewpoints to secure the implementation of the programme, and this requires unwavering commitment from project partners, sponsors and key players. Side by side with the implementation of FIN-D2D Project, the model will be made available to the entire primary and occupational health care systems: project plan, material and Websites are accessible to everyone. How the project proceeds will be reported regularly in different training events, publications and in the media. The national Dehko Days in 2006 will be the most visible Finnish event and the 19th World Congress of the International Diabetes Federation (IDF) at the end of 2006 the most visible international event to make an interim assessment on the results of the project. The essential point in preventing diabetes complications is the prevention of obesity, metabolic syndrome and cardiovascular diseases, which will be carried out through wide national cooperation. Health 2015 programme, World Health Organization s physical activity and nutrition strategies, Finnish Government s Resolution on the Development of Health-enhancing Physical Activity, Action Programme for Implementing National Nutrition Recommendations, Dehko s Type 2 Diabetes Prevention Programme , Finnish Heart Association s new Heart Programme of the Finns, Fit for Life programme and the activities of the Finnish Centre for Health Promotion will form the basis of Population Strategy to develop suitable infrastructure for health enhancement.

11 11 In connection with the screening of risk groups, the early diagnosis of type 2 diabetes will become more common in health care. Dehko s Model and Quality Criteria of Effective Lifestyle Management, Quality Criteria of Good Care of Person with Diabetes, Quality Criteria of Patient Education, Quality Criteria of Podiatry and The Group Counselling Model for Educating People with Type 2 Diabetes provide the tools for treating people with type 2 diabetes. The current Care Guidelines enable health care providers to make the care practices more systematic. On the basis of a survey on comprehensive rehabilitation of people with diabetes, conducted by the Finnish Diabetes Association in 2004, a functioning system for the rehabilitation of people with type 2 diabetes will be built. This will be done in cooperation with all parties who are responsible for organising the rehabilitation. Improving glycemic control of people with type 1 diabetes and preventing complications; early diagnosis and care When developing care for people with type 1 diabetes, it is important to aim such tools and support at health care and people with diabetes, which enable to improve the glycemic control. Special focus will be on children, adolescents and young adults at the age group. The 2001 care guideline of people with type 1 diabetes, which was compiled by the Medical Advisory Board of the Finnish Diabetes Association in 2001, will be updated. In addition to the already existing quality criteria on children s diabetes care, a new care model will be introduced. Moving adolescents from children s care units to adult s care units will be investigated, and the well-functioning models will be published in Dehko s publications, which makes it accessible to the whole health care system. The most important areas in preventing and treating diabetes complications are the prevention of retinopathy, nephropathy, neuropathy and cardiovascular diseases. The preventive emasures will be conducted in wide cooperation with Finnish Federation of the Visually Impaired, Finnish Association for Organ Transplant and Kidney Patients, Finnish Association of People with Mobility Disabilities, Finnish Heart Association and Stroke and Dysphasia Federation in Finland. By cooperating with mental health experts and organizations, new approaches will be created to support the mental strength of people with diabetes. On the basis of Finnish Diabetes Association s rehabilitation survey, Diabetes Centre s courses will be developed and a well-functioning system for rehabilitating people with type 1 diabetes will be built. This is going to be done in cooperation with national bodies and organizations which are responsible for health care and rehabilitation. Enhancing diabetes know-how of health care providers Dehko s ninth key action involves the recommendations to increase diabetes know-how in all basic education and further training of the professional groups in health care. On the basis of surveys done in and the present training situation, diabetes education and training of health care providers will be improved and enhanced in the fields of diabetes know-how: 1) by developing training cooperation with the professional health care organizations, 2) by supporting and reinforcing models which have been created in Dehko cooperation with polytechnics, 3) by developing Diabetes Centre s role and training services to meet the needs of health care, and 4) by using Finnish Diabetes Association s diabetes know-how project to develop Internet tools for supporting professional further training. Finnish Diabetes Association negotiates with the central professional health care organizations on training cooperation in a diabetes area. With the help of diabetes working groups in hospital districts, the situation, plans and needs of a regional diabetes training can be evaluated. The Medical Advisory Board of the Finnish Diabetes Association will estab-

12 12 lish an education working group to plan diabetes training for doctors. Since 2001, Helsinki Polytechnic Stadia s multiprofessional Dehko project has educated students on how to instruct people with type 2 diabetes, and this will become a permanent function. The model is developed in cooperation with Stadia s teachers, students and the Finnish Diabetes Association s local branches in the Helsinki region. The efforts of a Dehko group formed by five polytechnics, Association of Finnish Diabetes Nurses and Finnish Diabetes Association s representatives, resulted in 2004 in the creation of guidelines for the basic and special qualifications required of a diabetes nurse. In addition, the group prepared a syllabus for professional special education of 30 study points (20 credits). At the moment, the group is planning diabetes training of 2 6 credits for social and health care sector. The new syllabus, which has been implemented since the beginning of 2005 in the Oulu region, Pirkanmaa, Satakunta, Savonia and Stadia Polytechnics, will be observed closely, and the experiences will be published as a Dehko Report in May Building a diabetes care quality monitoring system The critical stages of building the monitoring system will take place in 2005, when the foundation for permanent monitoring practices of diabetes and its complications incidence and the mortality of people with diabetes will be created. It is done in cooperation between National Research and Development Centre for Welfare and Health, the Social Insurance Institution in Finland and Finnish Diabetes Association. On the basis of care quality pilot surveys carried out in 2004, permanent quality indicators will be defined and the negotiations on who carries out the plan will be held. In 2005 the first Diabetes Barometer will be created. The foundation of the monitoring system will be anchored for permanent use in Benchmarking system will be built in cooperation with National Research and Development Centre for Welfare and Health, and Dehko s Web pages are developed to introduce examples of best practices. Supporting self-care know-how and abilities of people with diabetes The self-care know-how and abilities of people with diabetes is supported by tools which are created for this purpose: cooperation between Finnish Diabetes Association s local branches and health care, OMA and Self-Support group activities, care update days for people with type 1 and 2 diabetes, and national family, adolescent, retired people and physical activities organized by the Finnish Diabetes Association. OMA group activity is developed to support people with type 1 diabetes in a group setting. The group is led by a health care professional and a person with diabetes together. The training of new OMA group instructors continues, OMA group activity will be possibly expanded to cover the whole Finland and an instructor network will be created. Self-Support groups are originally a peer support model created by the Finnish Heart Association to promote good health. In One Small Decision a Day Project the model was developed in cooperation between Finnish Heart Association and Finnish Diabetes Association. today it is a part of both association s permanent activities. Peer support groups exist in several areas of health enhancement, and they are used especially in the weight management and physical activity fields of type 2 diabetes prevention and care. Finnish Diabetes Association s local branches are encouraged to start their own Self-Support groups and to promote their existence and activities to health care. The widely popular care update days are training events for people with type 1 and type 2 diabetes, where diabetes care experts talk about the current topics in the field. Finnish Diabetes Association s local branches are supported and encouraged to organize similar events in more and more regions.

13 13 USING INTERIM ASSESSMENT S MESSAGES In Dehko interim assessment (appendix 1) special focus was put on certain points, which have been addressed in the activity which has been already carried out or which is still under way, in the implementation plan , and in the further recommendations of the measures. The foundation for proceeding in has been strenghened: 1)Fastening Dehko and type 2 diabetes prevention programme more strongly on Health 2015 programme: Dehko and Dehko s 2D project are visible in health care s national agenda, and both the Finnish Slot Machine Association and the Ministry of Social Affairs and Health are committed to the programme and to the project s financing. The central authorities are well represented in Dehko s direction and monitoring group and in the FIN-D2D Project s monitoring group. 2)Influencing municipalities: Dehko s municipal strategy working group has compiled a Municipal Strategy in 2004, which states that Finnish Diabetes Association and its local branches began a long-term strategy of influencing the prevention of diabetes and the development of care, as well as securing the prerequisites of self-care. 3)Expanding working groups: Particularly Type 2 Diabetes Prevention Programme and its population strategy and FIN-D2D Project are based on a wide cooperation between various players. The circle of partners has already grown bigger, and it will continue to expand during the next couple of years. 4)Integrating researchers into Dehko implementation: The contribution of researchers increases continuously in the assessment of the programme s implementation, progress and results. The researchers of National Research and Development Centre for Welfare and Health, the Social Insurance Institution in Finland and National Public Health Institute have in cooperation with the practical implementation players of Dehko a central role in building the care quality monitoring system. In FIN-D2D Project National Public Health Institute is assessing the feasibility, effectiveness and cost-effectiveness of type 2 diabetes prevention programme during Also in Dehko assessment the researchers play an important role. 5)Developing benchmarking system and launching best practices in prevention and care: Diabetes care benchmarking system will be developed in in connection with Dehko quality monitoring system. The launching of good diabetes prevention and care practices into the use of all health care units is continued by Dehko Reports, by Dehko Website and by Dehko Days in February )International reporting, interaction and influencing: Both Dehko Programme and Programme for the Prevention of Type 2 Diabetes, as well as Dehko interim assessment report s conclusions and recommendations, have been translated into English. These publications have been distributed free of charge to International Diabetes Federation and its member associations, world s diabetes players and World Health Organization s diabetes cooperation centres. This is continued also in Dehko, type 2 diabetes prevention programme and FIN-D2D Project have been and will be presented in international diabetes meetings.

14 14 DEHKO ASSESSMENT The main elements of assessing Dehko s current situation are Dehko Interim Assessment (Dehko Report 2003:5), Glycemic Control of People with Diabetes in Finland in study (Dehko Report 2004:1), Care Satisfaction of People with Diabetes in Finland study (Dehko Report 2003:4) and surveys relating to the monitoring of care quality. Dehko s second interim assessment will be conducted in late 2006, and it will look at the implementation of the key issues which were brought up in the first interim assessment. As for Dehko s FIN-D2D Project, Finnish Diabetes Association will have an external study made on the implementation of the project. The assessment of the project s effectiveness is conducted by National Public Health Institute. COOPERATION IN DEHKO S IMPLEMENTATION Finnish Diabetes Association has been reponsible for initiating, preparing, financing and coordinating the implementation of Dehko since Dehko was accepted as Finland s national diabetes programme for in the consensus meeting in Already during Dehko s preparation stage, Finnish Diabetes Association created a cooperation network. An estimated hundred diabetes researchers, practical care professionals, people with diabetes and other partners were involved in building Dehko. Once the implementation of Dehko began, authorities, government institutes, organizations and various experts were invited to take part in the programme. The cooperation network has grown bigger year after year, particularly during the preparation of type 2 diabetes prevention programme and the implementation of population strategy. The key cooperation partners of Dehko are the Ministry of Social Affairs and Health, the Ministry of Education, National Public Health Institute, National Research and Development Centre for Welfare and Health, Social Insurance Institution in Finland, and from nongovernmental organizations Association of Finnish Local and Regional Authorities, Finnish Heart Association as the strategic partner, Finnish Association for Organ Transplant and Kidney Patients, Finnish Federation of the Visually Impaired, Stroke and Dysphasia Federation in Finland, Association of Finnish Pharmacies, Association of Finnish Diabetes Nurses, Finnish Association of Podiatrists and several other professional health care organizations. The Ministry of Social Affairs and Health and the main sponsor, Finnish Slot Machine Association, as well as the pharmaceutical companies which act as Dehko s main sponsors, sponsors and supporters, are regularly informed of Dehko s progress. The strong commitment of financial supporters is an essential prerequisite for implementing Dehko.

15 15 DEHKO S RECOMMENDATIONS FOR ACTION IN Key Measures 1. Recommendation for Action in 2000: Prevention of type 2 diabetes is declared as one of Finland s health policy objectives in the WHO s Health for All in the 21st Century Programme. A national overall plan is outlined for the prevention programme, the necessary funding is allocated for it. A broad public awareness campingn is organized to initiate prevention. Type 2 diabetes prevention has been generally accepted as a national objective, and a sufficient funding has been granted to the prevention projects. Prograame for theprevention of Type 2 Diabetes (funded by Finnish Slot Machine Association and Dehko s commercial supporters) was compiled in 2003, and its implementation project, the FIN-D2D Project (funded by the Ministry of Social Affairs and Health, hospital districts, Finnish Slot Machine Association, National Public Health Institute and Finnish Diabetes Association) which is conducted in the primary and occupational health care of five hospital districts, began in the same year (appendix 2). Public awareness campaigns on type 2 diabetes prevention were organized by the Finnish Diabetes Association in 2001 and 2004, the start level study on the public s diabetes awareness level was conducted in 2003, and the communication strategy for was developed also in By taking into account the Health 2015 programme s main principles, the population strategy of type 2 diabetes prevention programme will be implemented in cooperation with the Finnish Heart Association and other national players. Dehko s FIN-D2D project will be finalized according to project plans, and as to the population strategy, project areas will also function as pilot areas. Project s results will be used in whole Finland to make the preventive functions of type 2 diabetes and other public health problems a permanent part of primary and occupational health care practices. National Public Health Institute is going to estimate the effectiveness, cost-effectiveness and feasibility of the prevention programme, and an external expert group will assess the practical implementation of the project. Ministry of Social Affairs and Health, National Public Health Institute, municipalities, hospital districts, primary health care, occupational health care, Finnish Diabetes Association, Finnish Heart Association, Association of Finnish Pharmacies, Fit for Life programme and Finnish Centre for Health Promotion. 2. Recommendation for Action in 2000: The non-pharmacological therapy of type 2 diabetes is improved, and annual monitoring of cardiovascular risk factors and treatment of cardiovascular diseases are organized in all care units of the primary health-care system.

16 16 The model and quality criteria for effective lifestyle management were published in 2003 as a part of the Programme for the Prevention of Type 2 Diabetes. The annual monitoring of cardiovascular diseases is one of the central indicators of Quality Criteria for Good Care of a Person with Diabetes (2002). Influencing primary and oocupational health care so that they will adopt the model and quality criteria of effective lifestyle management as permanent functions. Further training of health care providers will be intensified in lifestyle management. The weight management groups instructor training, developed by the Finnish Diabetes Association and Finnish Heart Association, is continued, and its impact on the groups implementation is going to be assessed. Peer group activity will be activated particularly in the fields of weight management and physical activity. Primary health care, occupational health care, Finnish Heart Association, Finnish Diabetes Association and physical activity and sport organizations. 3. Recommendation for Action in 2000: The criteria for granting preferential reimbursement of drugs altered to favor the lowering cardiovascular risk factors. Lipid lowering agents should be granted preferential reimbursement status for all diabetic patients who need them. People with diabetes should be able to start using antilipemic and antihypertensive drugs with preferential reimbursement on less strict indications than those required for non-diabetic people. By means of minister audiences, comments, pronouncements and petitions, Finnish Diabetes Association has influenced the preparations of medicine reimbursements reform. This together with the introduction of the so-called refunded medicine from 1 April 2003 onwards, the changes in the rules of medical reimbursements from 1 January 2004 on, the launching of new diabetes medicine and the questions on their reimbursement status, have been the main issues under discussion. A medicine working group was established within Dehko to prepare Finnish Diabetes Association s comments on the matter. The Care Guideline on Hypertension (2002) defined accurately the issues of medicating blood pressure of a person with diabetes. However, the medical reimbursement level remains higher than in the Care Guideline. The Care Guideline on Blood Lipid Perturbation was published on in 2004 and gives further support to the efforts which aim at making the reimbursements of blood lipid metabolism medicine available for people with diabetes. Finnish Diabetes Association s Medical Advisory Board actively advocated the translation of the European Care Guideline on Coronary Heart Disease regarding the care of people with diabetes into Finnish. The prepations of the medical reimbursement reform are followed closely, and efforts will be made to create a reimbursement system which supports the comprehensive care of people with diabetes, regardless of their diabetes type and financial situation, and which also supports the prevention of type 2 diabetes and its complications. The medication of lipid metabolism perturbation are proposed to be reimbursed. The Social Insurance Institution in Finland s guidelines on the reimbursement of

17 17 hypertension medication will be proposed for re-assessment, so that they would be more in the line of current Care Guideline. Ministry of Social Affairs and Health, The Social Insurance Institution in Finland, Finnish Development Centre of Medical Care ROHTO, Finnish Diabetes Association and its Medical Advisory Board and Finnish Heart Association. 4. Recommendation for Action in 2000: Uniform quality criteria for diabetes care are introduced in Finland, which all units that provide diabetes care ( specialized medical care/ primary health care) must meet as adapted to local circumstances. In Dehko s multiprofessional expert teams prepared quality criteria, which were published in Dehko s report series, into health care s use: Good Care Quality Meter and Quality Criteria of Person with Diabetes, Care Quality Criteria and Quality Meter of Child with Diabetes, Quality Criteria of Educating Person with Diabetes, Quality Criteria of Podiatry of Person with Diabetes and Lifestyle Management Quality Criteria of Person with Type 2 Diabetes. The first resource and quality surveys based on the quality criteria of both adults and childrens diabetes care were carried out in The systematic quality training aimed at diabetes teams began in autumn The first course, which was organized at the Diabetes Centre, consisted of three parts, and it also included interim assignments. Functionality of quality indicators as care quality meters are tested by regular measurements and the standards will be defined. They will be developed into a working foundation for a diabetes care quality monitoring system. The upcoming Care Guideline for Rethinopathy in Person with Diabetes and Care Guideline on Pregnancy Diabetes enable the systematic quality improvement of these diseases. Proposals for Care Guidelines in other diabetes care areas will be made as well. Care quality is developed also by means of multifaceted professional further training. A quality meter, created by the National Research and Development Centre for Welfare and Health, will be used in customer satisfaction surveys of people with diabetes, as well as in studying the attitude of people with diabetes to the care they have received. To assess the quality of life of people with diabetes, a separate quality meter will be developed according to an international model. Primary health care, specialized medical care, National Research and Development Centre for Welfare and Health, Finnish Medical Society Duodecim and Finland s Diabetes Education Study Group DESG. 5. Recommendation for Action in 2000: In order to monitor, assess and improve quality, a three-level diabetes registry is established in Finland, consisting of operational unit registries, regional registries and a national registry. In order to put a national diabetes registry into effect, a survey of the current situation is carried out and a pilot project is initiated.

18 18 study of the possibilities of establishing a national diabetes register was carried out in 2002 and it was published as a Dehko Report. On the basis of the study, a new diabetes register is not going to be established as such, but a diabetes care quality monitoring system will be set up in Finland. In this monitoring system data will be collected from three levels: 1.basic data from electronic health care records in care units 2.regional comparative care quality data from surveys conducted in care units 3.data on the incidence, complications and mortality of people with diabetes from national registers Finnish Diabetes Association has hired a quality manager for to build the care monitoring system in cooperation with experts and authorities. Finnish Diabetes Association has participated in the development of a national electronic health care record for diabetes s part. The quality and resources of both adults and childrens diabetes care were investigated in pilot studies in autumn National Research and Development Centre for Welfare and Health, Social Insurance Institution in Finland and Finnish Diabetes Association conducted a joint study in on using the existing registers to collect national diabetes data. Continuing to influence the development of an electronic health care record so that it will better support the high quality care of a person with diabetes. Studies and negotiations on the practical arrangements of regular quality monitoring will be carried out, and on the basis of the conducted measurements the testing of the revised quality indicators continues. A permanent monitoring system on the incidence and complications of diabetes and mortality of people with diabetes is developed. The first Diabetes Barometer will be produced. Finnish Diabetes Association, Ministry of Social Affairs and Health, National Research and Development Centre for Welfare and Health, Social Insurance Institution in Finland and National Public Health Institute. 6. Recommendation for Action in 2000: In order to make self-care possible, all people with diabetes are guaranteed individual and continuous education. The distribution of selfcare equipment is appropriately organized following the recommendations of the Medical Advisory Board of the Finnish Diabetes Association and those of the Ministry of Social Affairs and Health. In 2003 Quality Criteria for the Education of Person with Diabetes were created for health care. During 2004 Finnish Diabetes Association compiled the study and proposals on the comprehensive rehabilitation of a person with diabetes into further measures. Cooperation between Finnish Diabetes Association s local branches and health care has been systematically developed to support self-care of people with diabetes. The cooperation has been assessed and as a result a cooperation model has been built. A concrete example of the cooperation is the joint development of Dehko s OMA group activity

19 19 model and material relating to it, as well as establishing over 30 OMA groups as support groups for people with type 1 diabetes during The objective of the groups is to improve the glycemic control of people with diabetes. A new form of activity is the diabetes care update events, organized by the Finnish Diabetes Association s regional committees, where care information is updated in lectures held separately for people with type 1 and type 2 diabetes. As a result of Dehko cooperation, a group education model for people with type 2 diabetes has been created and tested for health care s use. The distribution of care supplies and equipment has been conducted in Finland s municipalities mainly according to the recommendations of Finnish Diabetes Association s Medical Advisory Board, Ministry of Social Affairs and Health and Association of Finnish Local and Regional Authorities. The use and implementation of the quality criteria in care units will be monitored. In the professional further training of diabetes care special focus will be put on the education and comprehensive rehabilitation of people with diabetes. A national plan for organizing rehabilitation for people with diabetes will be compiled. Negotiations will begin on how the overall plan is carried out. The development of cooperation between Finnish Diabetes Association s local branches and health care continues, and the cooperation model as well as OMA group activity will be promoted to those areas where it is not yet used. OMA group activity model is used also in the development of a group education model for people with type 1 diabetes. The care supplies and equipment guideline, compiled by the Finnish Diabetes Association s Medical Advisory Board in 1998, has been updated in 2005, and in the future the guidelines will be included in Diabetes Care Guidelines. Finnish Diabetes Association and its Medical Advisory Board, Finnish Diabetes Association s local branches, primary health care, specialized medical care, Ministry of Social Affairs and Health, Association of Finnish Local and Regional Authorities, Finland s Diabetes Education Study Group DESG and Association of Finnish Diabetes Nurses. 7. Recommendation for Action in 2000: Every health-care centre should have an appointed physician responsible for diabetes care and a diabetes nurse who coordinate diabetes care, training and quality control in their health-care centre. Each unit of specialized medical care should have an appointed diabetes team headed by a specialized physician in charged of diabetes care ( the responsible physician). The service at least a podiatrist, nutritionist, psychologist and physical therapist or physical education instructor should be at the disposal of the diabetes teams both in the primary health care and the specialized medical care system. A person with diabetes is an equal member of the diabetes team in his/her care unit. According to a study conducted in on the glycemic control of people with diabetes in Finland, over 90 per cent of both people with type 1 and type 2 diabetes had a diabetes nurse and physician with diabetes responsibility in their care unit. Care quality and resource

20 20 surveys in care units of children with diabetes and primary health care s and specialized medical care s care units of adults with diabetes were carried out in As to children, almost every care unit had a diabetes nurse and physician with diabetes responsibility. As for adults, the results on care arrangements will be announced by late According to the available information, only some primary health care units can benefit from the services of a nutritionist, podiatrist, psychologist and physiotherapist to take care of people with diabetes. In connection with regular quality measurements, the resource situation of diabetes care will be monitored. Care units are encouraged to develop care organizations also on the basis of client feedback. Finnish Diabetes Association offers information, training and tools for health care providers so that they can develop their activities. Examples on the successful arrangements of care of people with diabetes, as well as examples on functioning care chains between primary health care and specialized medical care, will be published in Dehko s Website. Primary health care, specialized medical care, National Research and Development Centre for Welfare and Health, Finnish Diabetes Association and its local branches and professional health care organizations. 8. Recommendation for Action in 2000: Every hospital district should have an appointed diabetes working group, whose task is to improve and coordinate diabetes care. In addition to the different care units (including occupational health care and private sector), people with diabetes should be represented in the working group. A diabetes working group is acting in all hospital districts except in that of the Ahvenanmaa. The composition and representation of people with diabetes in the working groups was studied in autumn Because only part of the groups have a person with diabetes as one of their member, a letter referring to Dehko s Recommendation for Action was sent to the working groups chairpersons in early Based on the survey which was directed at the diabetes working groups chairpersons, the activities, status and problems of the working groups has been investigated in Cooperation with hospital districts diabetes working groups will be increased: a meeting between Finnish Diabetes Association and the chairpersons of the diabetes working groups is going to be held annually. In addition, a working group representative from each hospital district can participate yearly free of charge in the Dehko player symposium and in Dehko Days. Special emphasis will be placed on developing cooperation with people with diabetes responsibility in Ahvenanmaa Islands and in other Swedish-speking areas in Finland. An effort is made to find a person with diabetes as a representative, nominated by the regional committees of Finnish Diabetes Association, into every hospital district s diabetes working group. Hospital districts and their diabetes working groups and Finnish Diabetes Association and its regional committees.