HARP : DIABETES CARDIOVASCULAR RISK MANAGEMENT PROJECT

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HARP DIABETES CARDIOVASCULAR RISK MANAGEMENT
PROJECT
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DIABETES CARDIOVASCULAR RISK MANAGEMENT PROJECT

• Project Submission Successful Dec, 2003
• Project Commencement Feb, 2004
• Project Completion June, 2007
• Project Funding 1.4 million

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Project Partners

• Dandenong District Division of GP
• Lead Agency Fund Holder
• Southern Health, Acute Primary Care
• South East Primary Care Partnership
• Auspice

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Project Goal

• Provide an integrated disease management and
  preventative program that is
• consumer focussed
• targets individuals with Type 2 diabetes high
  cardiovascular risk/ established disease
• that will reduce diabetes related in-patient
  episodes and Emergency Department presentations
  at Dandenong Hospital.

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Project Recruitment Referral Streams

• Staged approach
• Coronary Care Unit June 04 Pilot start 27/4/04
  32 patients from 25 GPs 4 had their max 2
  visits phone contact if issues
• General Practitioners Referrals from Oct 04
• Emergency Department July 05

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Project Evaluation

• Indicators include
• Clinical status
• Number of admissions to inpatient wards
• Length of stay for related admissions to
  inpatient wards
• Number of related presentations to the Emergency
  Department
• Consumer satisfaction
• Quality of life
• Stakeholder/ service provider satisfaction

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GPs
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DCAS

•     Provides assessment, health action plan,
  service coordination role 
•      Consumers identified as having high
  cardiovascular risk factors, or a recent
  cardiovascular incident in CCU or having complex
  issues will be referred on to the Diabetes
  Cardiovascular Advisory clinic at Dandenong
  Hospital (Southern Health), for further
  assessment and treatment plan(DCAC) as necessary.
•   Tracks and monitors consumers as they
  move through the Service System.

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DCAC

•   Insulin stabilisation program with CNC
  (Diabetes) and Endocrinologist.
• Specialist written and/or phone support for GPs.
  HARP team Endocrinologist will communicate
  directly with consumers Endocrinologist and/or
  other Specialists, as appropriate.
•    Max two follow-up Outpatient appointments with
  DCAC per episode.
•  GPs will be notified in writing if one of their
  patient attends this service.

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Clinic assisting targets

• 1-2 visits to advise / trouble shoot in high risk
  patients
• NOT an ongoing Mx service refer to Pte Endo or
  MMC clinic prn dont refer if already in this
  system
• Recommendations for GP to implement review
• Encourage data when requested

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Target Group

• Type 2 diabetes
• Over 35 yo
• Prior Cardiac event OR
• High risk on Tool calculation

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Risk Assessment
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Relative Risk
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Relative risk demonstration INACCURATE FOR
MODIFICATION
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Absolute Risk
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Risk Assessment all factors
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Risk tool

• Paper or computer for primary prevention
• Absolute 5 yr CV event risk of
• 35-65 yo gt 10-15
• 65-75 yo gt 15
• gt 75 yo gt 20
• No risk tool perfect exclude duration of
  diabetes/ control/ family history

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Essential Referral requirements

• HbA1c, Chol TG HDL LDL
• Pt in target group
• Medical summary
• Medications
• Statewide referral form

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• HARP Diabetes Cardiovascular Risk Management
  Project
•  Date
• Dear Dr
•  
• Re
  
•  
• DOB.
•  
• Your patient has consented to be involved in the
  Hospital Admission Risk Program and was reviewed
  in the Diabetes Cardiovascular Advisory Clinic
  (DCAC) today. The aim of this program is to
  improve cardiovascular risk in patients with Type
  2 Diabetes.
• To assist you in annual cycle of care
  requirements, we have made the following
  assessment and recommendations
•  
• Lifestyle/Healthy Eating recommendations
•  
• D. N. Educator Review Date
• Dietitian Review Date
• Smoker/ Non-smoker
• BMI (Target lt25 or long-term
  weight
• loss of 5 of starting
  weight)
• Waist

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Please Embrace HARP Project

• Division welcomes feedback
• Fantastic hand picked team
• Very approachable by phone
• If you dont