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.
