Keywords: Mobile diabetes nurse; older adults; diabetes care; home healthcare; insulin management; interprofessional collaboration; continuous glucose monitoring; electronic medical records

Background:

The proportion of older adults living with diabetes is increasing worldwide. Many experience difficulties attending hospital-based follow-up due to reduced mobility and cognitive decline highlighting the need for collaborative care models that improve access to specialist diabetes support in the community.

Research questions:

Can a Mobile Diabetes Nurse model be integrated with primary care for safe insulin management and continuity of diabetes care for older adults living at home?

Method:

A Mobile Diabetes Nurse model was tested in a Swedish semi-rural municipality with 28,000 inhabitants. The model combined home visits, digital telehealth follow-up, and structured clinical support and education for home healthcare nurses within primary and municipal care. Twenty (20) older adults aged 75–95 years with type 1 or type 2 diabetes treated with insulin and continuous glucose monitoring (CGM) were enrolled via a hospital-based diabetes clinic and received ongoing primary care and home healthcare. Fifty (50) home healthcare nurses completed a two-hour education session focusing on insulin management and CGM use. Interviews with patients and healthcare professionals explored experiences of the model.

Results:

Home-based diabetes nursing improved access to care, increased patients’ sense of safety, and strengthened continuity across primary care, home healthcare, and specialist services. Identified challenges included limited digital infrastructure, fragmented medication and prescription records, and unclear responsibility for insulin dose adjustments between care levels. Educational initiatives increased home healthcare nurses’ confidence and competence. Shared electronic medical records and digital telehealth between specialist services and primary care facilitated coordination and continuity.

Conclusions:

The Mobile Diabetes Nurse model represents a promising approach to safer and more continuous diabetes care for older adults. Strengthened collaboration between specialist services, primary care, and home healthcare supports coordination of insulin-treated patients. Shared medical records and telehealth follow-up were key success factors.

Points for discussion:

How can primary care best coordinate insulin adjustments across specialist and home healthcare services?

What level of diabetes training is required for home healthcare nurses to ensure patient safety?