The Diabetes Alliance aims to improve health outcomes and the experience of care for patients with Type 2 diabetes (T2DM) within their own general practice.
Population health data indicates that approximately 76,000 people in our region are registered with the National Diabetes Services Scheme (NDSS) as having been diagnosed with Type 2 diabetes. This represents 5.4% of the population and the incidence and prevalence of diabetes in the region is increasing.
Diabetes care in our region has been a disjointed experience. Due to the complex pathophysiology of diabetes, patients require a broad multi-disciplinary team to minimise the potential development of long term morbidity.
Diabetes Alliance Initiative
The Initiative is a tangible 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 Diabetes Alliance Initiative is a program that has been developed in partnership between Hunter New England Local Health District and the PHN and 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.
The end goal of the Alliance is for all people with diabetes in our region to have access to gold standard care that leads to improved clinical outcomes.
Diabetes Care Clinics
General practice-based clinics are the cornerstone of the Diabetes Alliance program.
The program combines the specialist skills of the LHD’s Diabetes Educators and Endocrinologists who travel to a patient’s own practice to work with patient’s own GP and Practice Nurse.
Prior to the clinic the patients and their carers work with their GP. 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
Consultations provide patients with insight into their condition and advises them 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:
- over 120 general practices across our region have participated in the program
- More than 400 GPs and 175 Practice Nurses have taken part in consultations
- More than 2000 patients have been seen in clinics
- Waiting lists for an appointment with an Endocrinologist at John Hunter Hospital have decreased significantly