Hunter New England Local Health District (HNELHD)
Quality clinical care for diabetes is a huge challenge with 60,000
patients across the 131,000km2. This project improves diabetesrelated
outcomes with a model of integrated care and specialists
at a patient’s local general practitioner.
In our pilot project, 20 general practices were invited to a case
conference and individual consultations with experts and patient,
with a detailed assessment of patient lifestyle, psychosocial
aspects and medication changes. Over three days, general
practitioners and practice nurses received education by specialist
teams to offer care to patients with reduced specialist input.
Nearly 500 patients were seen over 14 months. At six month
follow-up these patients showed significant improvement in
diabetes control. Clinicians felt the experience was satisfying
and patients felt involved and supported, with improved
knowledge in diabetes management using the Patient
Activation Measure (PAMTM).
The project aims to expand to 40 new practices each year with
a regional diabetes registry to monitor diabetes outcomes and
support clinicians in the quality of the care.