Nurses Take the Lead: New Care Model Aims to Fix Fragmented Diabetes Care for Indonesia’s Elderly

Type 2 diabetes in later life is rarely a single-disease problem. Older adults living with the condition frequently juggle multiple chronic illnesses, declining physical function, long lists of medications and self-management routines that depend heavily on family support. In Indonesia, where primary care services are delivered largely through community health centres, the pieces of care that should hold this complex picture together — structured education, regular follow-up, home visits, referral pathways, family engagement and communication between professions — can remain stubbornly fragmented. A new study published in BMC Nursing by researchers at Universitas Padjadjaran and Queensland University of Technology set out to address exactly that gap, designing and rigorously validating a nurse-led continuity of care model tailored to older Indonesians with type 2 diabetes.

The research team, led by Citra Windani Mambang Sari of the Doctoral Program in Medical Science and the Department of Community Health Nursing at Universitas Padjadjaran, used a sequential model-development design. Rather than testing a finished intervention, the study focused on the crucial early stages of building one: synthesising existing concepts, drafting the model and its supporting modules, submitting them to multidisciplinary expert scrutiny, refining the materials and finally checking whether the intended users could actually read and use them. This staged approach reflects a growing recognition in implementation science that interventions fail in the field far more often because of weak design and validation than because of poor ideas.

The intellectual architecture of the model draws on several complementary frameworks. The researchers integrated the Functional Consequences framework, which foregrounds how diabetes and its treatments interact with age-related changes in function; King’s Goal Attainment Theory, which frames care as a negotiated process in which nurse and patient jointly set and pursue goals; and Meiqari and colleagues’ continuity-of-care framework, which maps the informational, management and relational dimensions of seamless care. These theoretical anchors were combined with unpublished formative project findings, focus group discussions with community nurses, and systematic review evidence on continuity-of-care strategies for older adults with diabetes across Asia. The result is a model grounded simultaneously in theory, local practice experience and the best available regional evidence.

What emerged from this synthesis is a comprehensive care package in which the community nurse acts as the coordinating hub. Under the model, the nurse orchestrates physician-led structured diabetes education, shared goal setting with the patient, interprofessional home visits carried out by community nurses working alongside nutritionists and pharmacists, telephone follow-up with patients, multidisciplinary case conferences, family follow-up, and dedicated education sessions for patients and their families. Each element targets a known weak point in fragmented primary care: education that ends at the clinic door, home environments that health professionals never see, families left without guidance, and specialists and generalists who never compare notes.

Validation was handled with quantitative precision. Twelve purposively selected multidisciplinary experts — spanning community and primary care nursing, programme leadership, academia, medicine, pharmacy and geriatric diabetes care, each meeting predefined eligibility criteria — rated the model book and two accompanying modules on a four-point scale. The researchers quantified agreement using the item-level content validity index, calculated as the proportion of experts rating an item 3 or 4, and the scale-level content validity index average, with an acceptability threshold set in advance at 0.90 or above. The results were striking: because no expert rated any item below 3, every item-level index reached 1.00, and the scale-level average was 1.00 for all three instruments. Mean item scores stood at 3.86 for the model book, 3.82 for the older-adult and family module, and 3.90 for the health-worker module.

A perfect validity score is rare in instrument development, and its significance deserves careful reading. It indicates unanimous expert endorsement that the model’s content is relevant, clear and appropriate for its purpose — not that the model has been proven to work. The authors are explicit on this point, noting that the findings support progression to pilot and feasibility testing but do not establish implementation feasibility or clinical effectiveness. That distinction matters for readers weighing the study’s implications: content validation is a gate through which promising interventions must pass, but it is the first gate, not the last.

The team also tested whether the materials would be usable by the people expected to rely on them. Twenty-two intended users — twelve health workers and ten older adults with diabetes — completed structured readability and practicality appraisals, with items scored as a percentage of the maximum possible. The health-worker module scored 90.52 percent and the older-adult and family module scored 97.13 percent; both fell within the appraisal instrument’s defined category of very practical, which requires scores above 81.25 percent. For a module designed to be read and acted upon by older patients and their families, a practicality score approaching 97 percent is a notable signal that the materials communicate in language and formats that real users can navigate.

Expert scrutiny was not merely confirmatory; it shaped the model. Feedback from the panel informed refinements across a wide range of content areas, including the scope of primary care activities, the implementation flow of the model, the delineation of interprofessional roles, the involvement of family members, telehealth monitoring, emergency action guidance, nutrition, medication management, foot care and stress-management content. This iterative refinement loop — draft, rate, revise — is precisely what content validation is designed to achieve, converting the collective judgement of a multidisciplinary panel into concrete improvements before any patient encounters the intervention in routine care.

The study’s context gives it broader resonance. Indonesia’s population is ageing rapidly, and community health centres are the frontline for chronic disease management for millions of older people. Diabetes care in later life demands coordination across time and across professions, yet the components that deliver it — education, follow-up, home visiting, referral, family engagement and interprofessional communication — often operate in silos. A model that positions the community nurse as the connective tissue, supported by explicit modules for both health workers and families, offers a structurally plausible answer to a systems problem rather than a purely clinical one. The two-day training curriculum and twelve-week intervention pathway documented in the study’s supplementary materials suggest the team has already thought through how the model would be operationalised on the ground.

The researchers are careful to frame what comes next. The readability and practicality scores represent preliminary user appraisal among a sampled group of intended users and do not establish practicality in routine care. Future studies, the authors write, should assess caregiver usability, feasibility, fidelity, acceptability, workforce and resource requirements, and the model’s effects on self-management, glycaemic outcomes as measured by markers such as HbA1c, and functional well-being. Ethics approval for the work was granted by the Health Research Ethics Committee of Universitas Padjadjaran, and the publication was supported by Universitas Padjadjaran through the Indonesian Endowment Fund for Education under the EQUITY Program, with the funder playing no role in study design or reporting. If subsequent pilot and feasibility studies bear out the promise suggested by the unanimous expert endorsement and near-perfect practicality scores, Indonesia may gain a replicable template for nurse-led chronic care coordination — one built not on imported assumptions but on the realities of its own primary care system and the lived circumstances of its older patients and their families.

Subject of Research: Nurse-led continuity of care model development and content validation for older adults with type 2 diabetes in Indonesian primary care

Article Title: Development and content validation of a nurse-led continuity of care model for older adults with type 2 diabetes in Indonesian primary care

Article References: Sari, C. W. M., Haroen, H., Juniarti, N., Amalia, L., & Pardosi, J. F. (2026). Development and content validation of a nurse-led continuity of care model for older adults with type 2 diabetes in Indonesian primary care. BMC Nursing. https://doi.org/10.1186/s12912-026-05432-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05432-y

Keywords: continuity of care, community nursing, older adults, type 2 diabetes, primary care, model development, content validity, self-management, Indonesia, interprofessional care, family engagement, nurse-led care