Population health data indicates that approximately 76,000 people in the HNECC Primary Health Network region are registered with the National Diabetes Services Scheme (NDSS), having been diagnosed with Type 2 diabetes (https://map.ndss.com.au/#!/). This represents 5.4% of the regional population of approximately 1.4 million. The incidence and prevalence of diabetes in the region is increasing.
Diabetes care in the HNECC Primary Health Network region is a disjointed experience for many. Due to the complex pathophysiology of diabetes, patients require a broad multi-disciplinary team to minimise the development of long term morbidity.
Diabetes Alliance Initiative
The Initiative is a real life example of how integrating care can lead to a seamless, person centred approach that can be delivered in a flexible manner to benefit patients, clinicians and healthcare systems. The goal of the Alliance is to support all people with diabetes in our region to have access to gold standard care that leads to improved clinical outcomes.
The Diabetes Alliance Initiative is a program that has been developed in partnership between Hunter New England Local Health District and the Hunter New England Central Coast Primary Health Network. Including other external stakeholders, this collaboration has allowed the cross-organisational sharing of skills, knowledge and resources to develop a person centred model of care that is efficient, cost effective and sustainable.
The initiative supports the valuable role played by GPs and practice nurses as the basis for improving clinical outcomes, by ensuring primary care clinicians have access to the tools they need to provide the best evidenced care.
Diabetes Care Clinics
General practice-based clinics are the cornerstone of the Diabetes Alliance program. The program sends a specialist team, comprising a Diabetes Educator and Endocrinologist, to see patients with diabetes in their General Practice with their own GP and Practice Nurse. Patients and their carers are invited to participate by their GP practitioner who prepares the patient for the appointment. This involves the following:
- informing the patient about the program and what to expect at the appointment
- providing information to the patient and collecting their written consent to participate
- collecting clinical measures and asking the patient to complete a 3 day blood glucose and food diary
(Diabetes Alliance Clinic Team)
Patient consultations provide insights into their condition and advice on the most effective ways to manage their diabetes. Patients are provided an individual management plan by their GP, negating the need for a specialist consultation. Patients are reviewed by the Clinic team at a six monthly follow up.
In addition to improved clinical outcomes, the clinics also provide an understanding of issues and barriers experienced by healthcare providers and patients. They have informed a review and co-design of the referral criteria that ensures patients receive appropriate care in the right place at the right time. Primary care clinicians also benefit from enhanced skills and education that allows them to more effectively manage patients with T2DM.
Since the commencement of the Diabetes Alliance Initiative in 2015:
- 107 general practices across our region have participated in the program
- 393 GPs, 7 Endocrinologists, 8 Diabetes Educators and more than 150 Practice Nurses have taken part in consultations
- More than 1,850 patients have been seen in clinics
- Waiting lists for an appointment with an Endocrinologist at John Hunter Hospital have decreased significantly
Click on the image below to view a brief video describing the benefits of the Diabetes Alliance program to clinicians and patients.
Attached in 'Related Resources' are a series of Quality Improvement Ideas including information and practice resources for the better management of diabetes.