Introduction to Diabetes Change Principles

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Introduction to Diabetes Change Principles

• Dr Barry Fatovich, GP

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Overview

• Diabetes in Australia
• Gaps in Evidence and Practice
• Diabetes Aim
• Diabetes Change Principles / Ideas
• W12 Improvements

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Scope of Problem

• Approx 1 million people in Australia
• Higher in Aboriginal and Torres Strait Islander
  populations
• Half dont know they have it
• gt 7 of over 25 years of age
• 90 Type 2
• (Australian Institute for Health Welfare 2003)

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More Common in

• Chinese, Indian, Aboriginal, Torres Strait
  Islander and Pacific Island origin gt 35yo
• Hypertension, IHD, overweight
• FH diabetes or diabetes in pregnancy
• gt 55 years old

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Evidence Practice Gaps

• Evidence Practice Gaps Report, Aug 2003
  -National Institute of Clinical Studies
• Difference between what we know from evidence and
  what happens in current practice
• One area is diabetes

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Gaps

• Better blood sugar control improved outcomes
  and reduced complications
• UKPDS, Diabetes Control Complications Trial
  showed HbA1c was gold standard for measuring long
  term control
• American Diabetes Association recommends HbA1c
  every 6 months if stable and 3 monthly if not or
  treatment change

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Gaps

• NHMRC Guidelines
• 27 of those with diabetes meet minimum testing
  frequency range 15 -30
• Likely to have an impact on achieving target
  glucose control

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Gaps

• Similar evidence variable achievement of BP
  Goals, Cholesterol Levels lt 4
• Best practice between 20 -50
• Why are some practices achieving this?
• Many reasons for the Gaps

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Diabetes Aim

• 50 of patients with diabetes (Type 1 2)
  within participating practices have an HbA1c of
  7.0 or less

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Reasons for Gaps

• Unfamiliar patients and data concerning our
  patients
• No effective register / recall
• Suboptimal systems
• GPs often working without a team
• Protocols are difficult to use
• Lack of patient involvement, education

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Change Principles

• Building a Practice Team
• Establish a system for creating, validating and
  updating a register of people with diabetes
• Be systematic and proactive in managing care
• Involve patients in delivering and developing
  their care
• Adopt a multi-skilled, multi-agency approach to
  ensure effective co-ordination of the care

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Change Principle 1

• Building the practice team

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Change Principle 1 (Practice Team)

• Change ideas
• Set goals
• Engage the team
• Assign roles responsibilities
• Communicate
• Reflect review

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Change Principle 2

• Establish a system for creating, validating and
  updating the register

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Change Principle 2 (Register)

• Change Ideas
• Agree of definition of diabetes
• Develop register of people with diabetes
• Develop systems to maintain valid register

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Definition of Diabetes

• Random venous plasma glucose gt or 11.1mmol/L
• (OGT if between 5.5 11.0 mmol/L)
• Fasting plasma glucose gt or 7.0 mmol/L
• Plasma glucose gt or 11.1 mmol/L at 2 hours
  after OGTT
• Diabetes is not
• Gestational Diabetes Mellitus
• Previous GDM
• Impaired Fasting Glucose
• Impaired Glucose Tolerance

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Develop register

• Search patient population for
• Diagnosis of diabetes
• On insulin or diabetes medication
• GTT performed
• HbA1c recorded

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Maintain register

• Camp Hill Medical Centre, QLD
• Continually reminds doctors to use the correct
  diagnosis code when entering a diabetes diagnosis
  by firstly agreeing of what codes should be used
  and placing reminder laminated posters in
  doctors rooms.

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Change Principle 3

• Be systematic and proactive
• in managing care

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Change Principle 3 (Systematic, Proactive)

• Change ideas
• Establish clear practice arrangements
• Establish systems for delivering care to patients
  with diabetes
• Establish proactive call and recall arrangements
  for people with diabetes
• Use guidelines, protocols and computer templates
  to support care delivery

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Practice arrangements

• East Bentleigh Medical Group, VIC
• Found it important to have a strong GP driver
  who was engaged and motivated to lead and promote
  their diabetes clinics

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Delivering Care

• Establish practice protocols for the care of
  people with diabetes
• Ensure people with diabetes receive optimal care
  including use of drug therapies
• Identifying patients who may benefit from insulin
• Implement customised education program
• Undertake annual cycles of care to claim Service
  Incentive Payments (SIP)

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Call and Recall System

• Middle Ridge Medical Centre, QLD
• PN identified 280 patients to be recalled to
  complete annual cycle of care. They sent out 4
  letters per week to avoid overload. The patients
  were seen by the PN when they came in to complete
  major part of assessment before review with GP

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Guidelines for Care Delivery

• Kent Road Clinic, VIC
• As computerised templates proved too difficult,
  the PM created a checklist attached to patients
  paper records with the annual cycle of care items
  listed to be ticked off by the GP when complete.
  A green sticker identified the patients as having
  diabetes and recorded the date of the last SIP
  claimed

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Change Principle 4

• Involve Patients in developing
• and delivering their care

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Change Principle 4 (Involve Patients)

• Change Ideas
• Maximise self-management by people with diabetes
• Integrate the patients perspective constantly in
  the design of services
• Ensure written communication is appropriate and
  understood
• Pay special attention to the needs of people from
  hard to reach groups

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Patients perspective

• Woodville Family Practice, SA
• Invited patients on diabetes register to an
  information session on diet with a focus on
  cooking for people with diabetes. Information
  packs with recipes and cooking tips were given to
  attendees. In future, morning tea with diabetic
  friendly snacks will also be held

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Written Communication

• Written resources should be pitched at a reading
  age of seven to be understood by 90 of the
  population
• Available from Diabetes Australia

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Hard to Reach Groups

• Atherfield Medical Centre, NSW
• Organised diabetes clinic for Aboriginal and
  Torres Strait Islander patients in conjunction
  with Aboriginal Health Worker in an attempt to
  improve response rate of patients to attend the
  clinic for the management of their diabetes

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Change Principle 5

• Adopt a multi-skilled, multi-agency approach to
  ensure effective coordination of care

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Change Principle 5 (Multi agency)

• Change Ideas
• Support joint working between health
  professionals and managers in practice /
  Divisions and local state health services to
  enable integrated care for patients
• Analyse the patient journey and redesign where
  necessary

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Joint Working Relationships

• Alstonville Clinic, VIC
• Organised meeting between diabetes educator and
  clinic nurse to investigate the duplication of
  services. To avoid this duplication, they decided
  to improve communication and make the clinic
  nurse responsible for care planning with
  referrals to educator and dietician

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Patients Journey

• Mapping events between primary and secondary care
  from a patients perspective
• Look at ways to improve the patients journey
• Considering problems, constraints, services,
  evidence, skills etc

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Measures

• Patients with diabetes with a last recorded HbA1c
  of 7.0 within the previous 12 months
• Patients with diabetes with a last measured total
  cholesterol of lt4 mmol/within the previous 12
  months
• Patients with diabetes with a last recorded BP
  reading of lt130/80 mm Hg within the previous 12
  months
• Patients with diabetes that have had diabetes
  Service Incentive Payments claimed for them
  within the last 12 months

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Lockridge General Practice
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NPCC is the most positive initiative I have seen
in over 20 years in general practice ... We have
gained a network and resource for addressing and
hopefully solving some of the issues we face...We
really can make a difference !!! Dr Alan Leeb,
GP Illawarra Medical Centre