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Diabetes Outpatients. Presenter: Justine Patterson Hospital: Fury. Current Situation – Diabetes Outpatients Process. Summary of Current Activity. Current Situation - problems. Management / Staff perspective: Referrals – appropriateness, content, grading, manual
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Diabetes Outpatients Presenter: Justine PattersonHospital: Fury
Current Situation - problems Management / Staff perspective: • Referrals – appropriateness, content, grading, manual • Process works for non-urgent referrals, circumvented for urgent referrals • DNA rate Patient perspective: • Multiple appointments with different services • Appointments during work time
Key strategies / actions / innovations – already successfully implemented
Chronic Care Management – Diabetes • Aim of Project • To reduce preventable morbidity and mortality in people with diabetes through improved clinical management & by providing timely & integrated care. • Improvement Sought • Patient clinical indicators • Target high risk patients • KPIs • Clinical - HbA1C, BMI, BP, Lipids, smoking • Diabetes Module commenced 2001, wider roll out 2003
Chronic Care Management – Diabetes…2 • Resources • DHB $2.1 million total for CCM this year • Total $400 + gst per patient / year • Staff • Hospital – 2+ Chronic Care Nurses. Help from 4 specialists • PHOs – 0.5-2.0 Clinical Programme Managers in each • DHB - 0.7 Clinical Director, 1.0 Project Manager, 0.5 IT Support, 1.0 Analyst.
Chronic Care Management - Diabetes Key Changes Implemented • High need patients • 4 free GP visits per annum • 6 hours nursing time per annum • Structured notes • Embedded within practice computer software • Empowered primary care • Secondary outreach/ training • Electronic decision support • Regular reporting on progress • Empowered Patients • Care Planning - patient held “wellness plans”
Chronic Care Management - Diabetes Outcomes so Far • Growth in enrolments • 7,227 patients to 31 March 07 • Targets high needs patients • 67% CCM diabetes enrolees Maori or Pacific • High levels of engagement • 80% patients seen in the last 6 months • Improvements in clinical indicators • HbA1C and cholesterol
Chronic Care Management - Diabetes Outcomes so Far…2 HbA1c value Cholesterol level Drop in HBA1C @ 1y
Chronic Care Management – DiabetesLessons Learnt • What we recommend to others • Multidimensional approach – not just one initiative (CCM, FAMA, POAC, etc.) • Team approach – within practices and between primary and secondary • IT support so processes and outcomes are easily measured and tracked over time • Don’t expect saved bed days for diabetes within the short term • Use of Community Health Workers for patient engagement • Continued promotion important “If you can’t measure it – you can’t manage it!”
Chronic Care Management – DiabetesLessons Learnt …2 • What we will do differently • Greater emphasis on supporting patients self management • Earlier and greater focus on training (clinical – nurses; IT) • More help to practices to improve their systems • Greater use of reports for quality improvement (implementation of Clinical Governance at provider level) • Ensure better access to diagnostics (echo/spirometry) • ? Trial financial incentives for outcomes • Capacity of sector - rate limiting step