Integrated care pathway and organisational model for patients with diabetes

Good practice:

Adequate tools for coordination of primary and secondary healthcare services

BASQUE COUNTRY  / Population Intervention Plan for Diabetes (PIP DM):  44/4589 11/55

In the Basque Country, as in high-income countries, chronic diseases are the dominant epidemiological pattern. The incidence of type 2 diabetes mellitus has increased in our region in recent years. Indeed, it is predicted that prevalence of DM2 may reach up to 12% in the population over 30 year of age.

The direct costs of diabetic patients almost double not spending diabetic patient and between 6.3% and 7.4 % of health spending can be attributed to Diabetes.

It is estimated that the average number of annual visits of each diabetic patient to the general practitioner (GP) is nine, and that between one third and half of the visits to endocrinologist are related to diabetes.

Customer's need

Improving the prognosis of patients with DM and reducing its high morbidity is a priority around the world. It calls for an integrated action on risk factors. This requires the application of a correct therapeutic plan, which is properly organised with an adequate coordination between levels of care. This will lead a better control of diabetes. The training for self-care and empowerment is also essential for this population group.

The solution

This approach requires overcoming several challenges:

  • Move from disease centred care to patient centred care.
  • Ensure the continuum of care within the health system (primary care and specialised care).
  • Provide cost-effective delivery of care while trying to keep the patient at home.
  • Empower patients and carers to manage their own health condition.
  • Identify patients at risk by introducing monitoring and patient follow up at home. This will avoid decompensations and worsening symptoms.
  • Personalise care according the patient’s condition, health status and social and health care needs.

The aim of the programme is to provide an integrated and individualised approach to care for both the patient and caregiver. Provided by a multidisciplinary team, the programme ensures treatment and follow up for the patient. Using the best criteria, a higher quality of life and care is achieved. The follow up of the patients by the primary care professionals is essential in order to reduce the impact of the disease. This coordination of primary care and specialised care is important for:

  • Continuum of care within the health system.
  • Maintenance and functional recovery.
  • Improved quality of life.

The main focus of the programme is to improve health outcomes. 

Keys to success

  • Programme prioritised by Department of Health, and linked to the funding of the Health care provider.
  • Engagement and involvement of managers and clinicians in the definition of the organisational model and pathway.
  • High and common advanced ICT infrastructure for both levels of care, based on Electronic Health Care Record, e-prescription, Personal Health Care Record.
  • Structured training sessions to empower patients in the management of their own condition.

Good practice: Adequate tools for coordination of primary and secondary healthcare services

Good practice description

Staff use the same criteria for patient management, work in a coordinated manner and use shared medical records. Patients are stratified according to need. Allowing better care, personalised treatment, and targeted follow-up. This more coordinated approach improves relationships among health professionals. It also supports coordinated decision-making. Services need to ensure that therapeutic plans and monitoring indicators for chronic conditions are specific enough to apply directly to patients. These need to be coupled with opportunities to review plans, identify problems, and generate appropriate protocols for patients.

"We have reduced the gap between hospital and primary care"

Good practice example

The Basque Population Intervention Plan for diabetes is a service designed for patients with medium to high risk of health events with special focus on those that their glycaemic level are out of the threshold. Managers report that patients are more satisfied with the quality of care they receive.

The program

The programme involves healthcare professionals from different levels of care and settings. Depending on the status of the patient, the activities performed and agents involved can vary. The agents, and activities performed in each status of the patients, are described below: Primary care professionals (GP and primary care nurse) are principally responsible for a patient’s care, initial integral assessment (clinical, functional, psycho-social and social assessment), therapeutic / care plan definition and follow up, drug prescription, patient training and empowerment.

Improving the health outcomes, and to have the highest number of wellcontrolled diabetic patients, is achieved through a direct follow up to the patient by the primary care team (GP and nurse).

This includes:

  • Structured education about the disease: what is the hyper and hypoglycemia, recommendations for diet, exercise and foot care.
  • Measure of the glycosylated hemoglobin every six months.
  • Annual general exploration, including cardiovascular check and feet exploration.
  • Annual electrocardiogram.
  • Funduscopy examination every three years if there are no changes.

While the communication between healthcare professionals and patient is mainly via traditional channels (f2f, phone), health care professionals can communicate and share information through the Electronic Health Record and the electronic prescription. Additionally, healthcare professionals can exchange patient-related documentation or make consultations to avoid referrals by online consultations through Electronic Health Care Record. Once the patient shows worsening symptoms, the GP may refer the patient to a specialist or hospital if it is necessary. In turn, achieving the highest number of well-controlled diabetic patients. The population intervention plan for diabetic patients is a common programme. It is developed by a multidisciplinary team where clinicians and managers work in a collaborative way.

The outcome of this work is:

  • A new organisational model, which includes new roles and new functions.
  • A new common pathway.
  • Proactive patient identification using risk stratification tools.
  • Improved ICT infrastructure, which supports sharing information and patient monitoring.
  • A common set of shared objectives and indicators linked to health outcomes and process improvement.

Contact information

Javascript needed

Cristina Domingo Rico


  • Department of Health and Consumer Affairs of the Basque Government and Osakidetza. A strategy to tackle the challenge of chronicity in the Basque Country. 2010.

Program partners