End to End (E2E) Implementation of the Model of Integrated Care for Type 2 diabetes

The aim of this research, funded by the Sláintecare Integration Fund, was to evaluate the implementation of a new multidisciplinary diabetes integrated care team involved in delivering the national model of intergrated type 2 diabetes care in Ireland. Prof. Sean Dinneen , the Sláintecare -funded project and Dr Sheena McHugh led the evaluation of implementation.  Researchers, Dr Fiona Riordan and Ms Lauren O’Mahony from the School of Public Health, UCC, worked together with co-investigators from the Department of General Practice (UCC), NUIG, and the HSE.

Why are we doing this research?

Diabetes places a significant burden of care on the individual, health care professionals and the wider health system. Sláintecare, the national health strategy, aims to change the way health services are delivered in Ireland to make sure that care is delivered in the right place, at the right time, by the right person. To help change the way diabetes care is delivered in Ireland, a Model of Care for Type 2 diabetes was developed to shift care away from the traditional hospital-based model with its focus on the management of complications, to community-based care with a focus on prevention of complications. With the support of the Sláintecare Integration Fund, two community health networks were resourced with a Diabetes Integrated Care Team for 12 months (September 2020 until August 2021). Each diabetes integrated care team has a diabetes clinical nurse specialist, a podiatrist and a dietitian. This team supports the implementation of the Model of Care in a community health network (geographical area with a population of ~55,000) and liaise closely with the hospital specialist team and GPs to deliver integrated care.

The aim of our research was to evaluate the implementation of this multidisciplinary diabetes integrated care team, and to identify facilitators of and barriers to implementation. 

What was involved?

Together with researchers in NUIG and the UCC Department of General Practice we:

  1. Carried out a survey among local GP practicies to describe how diabetes care is currently delivered in general practices and within integrated care teams in each network.
  2. Analysed service activity data collected by the diabetes intergrated care team.
  3. Interviewed GPs, Practice Nurses and members of the diabetes integrated care team, (Clinical Nurse Specialists) (Diabetes Integrated Care) Dietitians and Podiatrists to understand their experience of the local team based approach to diabetes management.
  4. Surveyed and interviewed people with type 2 diabetes to understand their experiences of the community diabetes integrated care service.

E2E Project outputs


  • Riordan F, O'Mahony L, Sheehan C , Murphy K, O'Donnell M, Hurley L, Dineen S, McHugh S.M,  Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic [version 1; peer review: 3 approved, 1 approved with reservations]. HRB Open Res 2023, 6:1 (https://doi.org/10.12688/hrbopenres.13635.1)


  • AICI22 1st All-Ireland Conference on Integrated Care, UCD Dublin. (Oral presentation) 'An Evaluation of Introduction of Diabetes Community Specialist Teams in Two Community Health Care Networks'.  Presenter: Lorna Hurley (on behalf of Riordan F, O’Donnell M, Sheehan C, McHugh S, Murphy K, Liew A, Humphreys M, Kennedy D, O’Mahony C, Gleeson M, O’Brien S, O’Reilly O, Dinneen SF) 10 March 2022



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