CODE : Comprehensive Diabetes and Eye Care
Diabetes is recognized as a public health issue in India and is estimated to affect over 40 million people. Complications due to diabetes in the eye, kidneys and feet are major burdens on economic well being of patients. It has been shown that good quality and consistent all round care for diabetics can reduce incidence of complications. In a developing country like India medical care is unevenly distributed geographically and there is a clear urban/rural divide.,. There is also a vast range of quality and especially in chronic conditions lack of standards is an issue.
The provision of health care for people in need is stretched due to the increase in non communicable diseases. This needs both medical and financial responses. The Nayana Model proved the ability of harnessing available resources to innovative economic and care delivery models resulted in a multiplier effect with increased compliance, patient satisfaction and increase in the number of standardized centers providing diabetes related eye care.
However such models have a limited focus and the overall quality of life is beyond the scope of specialty services provided. Many studies have shown that comprehensive care especially in case of diabetes helps in improving quality of life.
The current project detailed below will try to provide and prove a model of holistic care that will address the above dilemmas. It will further attempt to provide an organic extension of the successful economic model of the WDF05-110 Nayana Mobile Eye Care unit and implement lessons from the field work of over 3 years. The core of the current proposal will remain economic sustainability and easy replication. It will also try to achieve the goals of creating permanent human and physical infrastructure in the target areas.
Another innovation being proposed will be the patient centric economic model (PACE) which we feel in a country like India can ensure long term compliance and address quality of life issues on an ongoing basis.
Sri Keshava Trust
Vittala International Institute of Ophthalmology
Prabh Eye Clinic and Research Center
Project Title : CODE : Comprehensive Diabetes and Eye Care
Project Duration : June 2009 – May 2014
Project Work Area : Karnataka
Karnataka State -Districts of a,b,c,d
Total Population Targeted: NN million , Project Radius out of Base: 190 km maximum
Figure 1 Karnataka
Main Deliverables of the Project
1. World Class Diabetes related eye complications diagnosis and treatment
within 50 kms of the patients’ residence
2. Training and up grading of diagnostic and treatment delivery skills of local
3. Training and standardization of treatment for diabetes with emphasis on Hb1Ac
based monitoring at physician / diabetologists level based onIDF guidelines.
4. Maintenance of a Diabetes Wellness Care Record that can be used across the
5. Provision of subsidized lab services for monitoring of multiple metabolic parameters
with mobile based sample collection.
6. Provision of equipment/technicians for foot and heart care.
7. Creation of an economic model that benefits all stake holders and ensures
8. Training in diabetes and public health implications in a three tier manner to
students of medical and nursing colleges with the aim of sensitizing and human.
9. Primary prevention by including patient families and schools in which their children
learn as platforms for creation of awareness.
10. Long term tracking of Wellness Quotient of patients in project areas.
Part A Equipment
Mobile units with provision for eye care and other diabetes care will be built to suit the needs of the project.
Vanswill be equipped with the following equipment for diagnosis and treatment of diabetes related eye conditions
YAG laser, Diode laser, Fundus Camera with Angiogram, Visual Fields machine, B scan, Tonometry, Visual Acuity Charts, Power generation and air conditioning equipment, computer and communication equipment.
Packing and transportation mechanism will be custom made as on the Nayana I mobile unit.
Van will also take the sample collection and filed lab equipment in triplicate. Basic equipment like hand held Hb1Ac and basic parameters, a Doppler and monofilament for neuropathy screening and a ECG machine along with computers and communication equipment. Power generation and air-conditioning will also be provided.
The counseling team will be equipped with Audio visual equipment and material in vernacular languages.
A central lab will be created to standardize all tests that are recommended as GCP guidelines in diabetes and shall offer its services in a subsidized manner
The project is aimed to be implemented in X towns of Y districts. These towns are selected based on population, current infrastructure, connectivity and geographical spread to ensure the primary goal of a single day travel and treatment for every patient..
We plan to create networks of care providers and care seekers in every town and in what we classify as feeder population centers. A hub and spoke model with the spokes never more than 1.5 hour bus or rail journey will be targeted. The two vans will provide services to these towns at least once a month, covering 25 working days.
The Hub and Spoke
The hub and spoke model will be used for basic diabetes screening and for referral care. The hub is envisaged as a hospital with inpatient beds and a physician/staff capable of (similar to a Taluk/district Hospital) the spokes are planned to be PHC/CHC level medical centers capable of offering basic infrastructure to the mobile teams.
In this way each van day can service three basic diabetes centers and one ophthalmic center.
Mobile Unit Staff
The vans will be staffed with with specially trained personnel. The single set of ophthalmic equipment will be used at the hub level in conjunction with a qualified ophthalmologist, aided by two staff who will travel on the van
The multiple sets of basic and continued testing equipment for basic diabetes care will travel with staff each ( 3 sets, 6 personnel).
There will be two sets of drivers.
The central lab will work on all days of the month and provide support to the project areas in conjunction with the sample collection efforts of the vans. This will be a quality bench marked laboratory with regular QC checks.
The patient has the ability to now seek both specialized and primary care at different days or on the same day as he so wishes. The breaking up of responsibilities will also involve patients with no complications to make use of the facilities independently.
Training of ophthalmologists, physicians, diabetologists and patient care service providers will be in situ and will follow the calendars of the vans.
Training of medical and nursing students will be done in conjunction with their schools and colleges of study.
The Primary prevention team will work on its own calendar in association with local voluntary organizations and patient groups.
We will create networks at three levels and also catalyze the interactions between the networks to ensure that the patient ultimately benefits.
The network will consist of
3. Other Specialists from fields like Cardiology, Surgery, Nutrition etc
The networking of ophthalmologists will be done in a non discriminatory manner with entry being open to all those who desire to participate. The ophthalmologist will also have to commit to the project timeline.
Training of ophthalmologists will consist of screening, diagnosis, diagnostic tools and interpretation of test results. The training will then continue into providing skills or enhancing of existing skills in treatment of diabetes related complications of the eye.
Training will initially be provided by a consultant/senior fellow from VIIO and subsequently the doctor is supported only with equipment and technical help. A second line consultation facility will be made available through an internet based consultation mechanism with the base hospital in Bangalore. A self assessment combined with pre and post training evaluation will allow us to tailor training to individual needs.
Diabetologists/physicians will form important linkages in the CODE model. An effort will be made to introduce both forward and back ward linkages based on non competing assurances with all the other nodes of the networks like ophthalmologists, other specialists and patient groups. The local ophthalmologists will be the key drivers in recruitment and liaison with the local doctors in other specialties and primary care givers. A need for standards and for comprehensive patient records will be stressed along with the exposition of the PACE model of charges. In case of government entities the charges will be decidedin conjunction with the implementing agency like NRHM or MOHFW.
Ensuring patient well being and continued care will result in higher revenues for the primary care givers.
Training in first level diagnosis and monitoring of diabetes related complications in the foot, eye, kidneys and heart will be given if necessary; the doctors will be encouraged to make use of the central laboratory services provided by the project. Training will be provided in counseling and involvement of the clinic non medical staff will be stressed.
In case the doctors have their own laboratories or have access to some of the equipment they will be encouraged to make use of standard tests like HbA1c and to implement practice guidelines.
Patient care workers, nursing staff, receptionists and allied staff will be the front line personnel in all clinics, they will be targeted for enhanced counseling, record keeping and patient care services.
A model of “At Home” premium services for patients unable to come to the clinic and with the ability to afford the same will be provided and will be based out of the primary care giver clinics.
At the center of all networks will be the patient. Patients will also be encouraged to form Diabetes Clubs to ensure peer support and in the later stages of the project we will encourage the patients to use mechanisms like group exercise, group buying and peer home visits to make sure that compliance and ownership of wellness is ensured. An important need exists to educate and support the patient by involving family and other support mechanisms in the care cycle. This will also help us to screen and possibly counsel at risk secondary relatives of existing patients.
The patient will also form the spearhead for primary prevention programmes in schools where they have a say or their children study. Sustained below the line publicity is also possible with low cost inputs via patient groups. Our prior experience in involving non allopathic care centers/patient contact points will also be used in this project.
Economics – The PACE model
One of the main reasons shown in many studies for the failure of prevention of complications in patients; in spite of counseling and provision of care is the ignoring of total costs involved to the patient and perhaps to his immediate family.
We propose to implement a radical way of pricing the services based on compliance and on certain parameters like glycemic control as measured by HbA1c levels. The charges will be structured to incentivize better compliance and control.
In case families are affected together then a family based pricing mechanism will be offered. The local practioner will be encouraged to offer similar schemes for diabetic patients, some of the lab charges and facility usage charges paid by the patients will be shared with the local doctor to ensure that any discounts offered to patients are mitigated to a certain extent at least.
In case the patient and his family is earning less than USD 30/month then all services to the patient that can be provided through the project will be made available for free.
Local practitioners will be encouraged to provide “At Home” services at premium rates for monitoring of basic parameters and for sample collection. Technology like mobile phones will be used for conveying of results.
Apart from the above patient groups will be encouraged to make bulk purchases of essential medication to ensure that they are offered discounts. We will try to bring patient groups and manufacturers to the table for mutually beneficial transactions.
The project will be staffed with the following personnel
Project Director 1
Project Coordinator 1
Record keeping and
secretarial staff 2
Measurement of Outcomes:
a. Number of Trained Doctors
b. Number of Trained Ophthalmologists
c. Treated Patients
d. Newly detected diabetics
e. Lab usage
f. Financial data
g. Programme statistics
h. Permanent infrastructure creation like diabetes clubs, micro clinics etc
a. Glycemic control improvement
b. KAP in patients and families
c. KAP in Care providers
d. KAP in second line staff
A monitoring will oversee the project and projected outcomes and issues on a quarterly basis. A continuous feedback mechanism for trouble shooting and fixing of day to day issues will be set up.