Improving diabetes care in general practice through Joint Specialist Case Conference

HRT 1520 Innovations Workshops and Awards

19- 20 November 2015, Sydney

Organisation Name: Western Sydney Diabetes Initiative,

Western Sydney LHD

Presenters: Sian Bramwell, Mani Manoharan, Sumathy Ravi,

Prof Glen Maberly

Summary -

Key problem – Western Sydney has been identified as a diabetes “hot spot” The magnitude of the diabetes epidemic and demand on the LHD requires the bulk of type 2 diabetes management to be undertaken in general practice

Aim of Innovation – To build the clinical skills, confidence and capacity of GPs to better manage diabetes in primary care

What we did -The Blacktown Hospital Outpatient Diabetes medical team (Consultant, Community AT, RMO) and Credentialled Diabetes Educator visited general practices to deliver Joint Specialist Case Conferences (JSCC) to assist General Practitioner’s to better manage patients who present with diabetes

General Practices volunteered for the program and were identified by the Practice Support team at Western Sydney Primary Health Network (WSPHN). The practices selected patients with a range of complexities for review

Two to four JSCC sessions were delivered each week

A multi-disciplinary case conference format was used with the patient, GP, practice nurse and the Blacktown Hospital Outpatient Diabetes medical team present

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Key Problem

• The magnitude of the diabetes epidemic is placing a huge demand on the diabetes services at Western Sydney LHD

• Waiting time for diabetes Outpatient appointment was up to 4 months

• Evidence from several studies and have identified that diabetes care in the community may be inhibited by less that ideal levels of GP experience(1,2)

• This has often resulted in routine diabetes care being referred to endocrinologist within the hospital setting(3)

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Aim of this innovation

• For the bulk of routine Type 2 Diabetes Mellitus (T2DM) to be undertaken in general practice

• To build the clinical skills, confidence and capacity of general practice to manage type 2 diabetes

• To enhance the communication and integrate diabetes care between the hospital services and primary care

• To evaluate the benefit of case conferencing for the GPs, and the impact on patients health outcomes

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Current Situation – Western Sydney is a

Diabetes “Hot-Spot”People living Western Sydney have an increase chance of developing

diabetes compared to people living in the coastal suburbs (4)

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In a recent study examining the incidence of diabetes in patients

presenting through the Emergency Department at Blacktown hospital

68.5% of patient encounters had Diabetes or pre-diabetes (5)

Baseline Data / Current Situation

• 125 000 people with diabetes live in our Western Sydney patch (4)

• Patients need better diabetes management to prevent complications such as heart attack, stroke, kidney failure, blindness, amputations

• GP capacity needs to be enhanced to enable primary care and hospital services to better serve patients with diabetes

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Key changes Implemented

A new model of care has been developed in Western Sydney to assist GP to cope with the increased demand diabetes management is placing on primary care

• Joint Specialist Case Conference(JSCC) were conducted in general practice, with patient, GP, practice nurse and the Blacktown Hospital Outpatient Diabetes medical team present

• Between 5 – 10 patients were reviewed at each case conference, the patients varied from newly diagnosed to complex needs. Each individual case conference was 30 minutes

Key changes Implemented

• Between January 2014 and July 2015 over 500 patients participated in the case conferences with 80 GPs from 30 different General Practices

• A pilot evaluation was conducted on 40 patients, 3 – 6 months following the case conference which showed clinically significant reduction in HbA1c ( 0.87%), along with beneficial effect on systolic blood pressure, weight and lipid profile

• An evaluation form was provided for GPs to complete after every case conference

Outcomes so far

Evaluations of the first year:

• 3 – 6months after a case conference shows the team approach to diabetes results in a clinically significant reduction in HbA1c (0.87%)

• Reduction in Systolic Blood pressure (6.45mmHg)

• Reduction in weight (1.9Kg)

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Outcomes so far

• 97% of GPs reporting increased confidence in managing diabetes

• 85% of GPs felt they would decrease referral of less complicated cases to specialist services following case conference

• The waiting period for an appointment for the diabetes outpatient clinic has been significantly reduced to 2 weeks in most cases

• 97% of GPs reported the program improved the relationship between GPs and the specialist

This program is being expanded and will soon be introduced at Westmead

Lessons Learnt

• These findings illustrate the effect of JSCC in enhancing GPs ability to provide appropriate diabetes care in primary care

• JSCC improve communication between general practice and hospital diabetes services

• The evaluation has provided important insight about the acceptability, effectiveness and the impact of the program

• We have identified the important role the Practice Nurses play in T2DM management and the need to provide them with education and support

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References

(1) Cuddihy RM, Phyllis-Tsimakas A, Nazeri A. Type 2 Diabetes Care and Insulin Intensification is a More Multidisciplinary Approach Needed? Results from the MODIFY Survey. The Diabetes Educator.2011; 37:111-23

(2) Harris SB, Kapor J, Lank CN, Willan AR, Houston T. Clinical Inertia in patients with T2DM requiring insulin in family practice. Int J clin Pract.2008;62:860-8

(3) Lee CMY, Colaguiri R, Magliano DJ, Cameron AJ, Shaw J, Zimmer P, et al. The cost of diabetes in adults in Australia. DiabetesRes clin Pract 2013

(4) Astell-Burt T, Feng X, Kolt GS, McLean M, Maberly G. (2004).Understanding geographical inequities in diabetes: Multilevel evidence from 114,755 adults in Sydney,Australia. Diabetes Research and Clinical Practice, 106 (3), E68-E73

(5) Hor A, Hng TM, Ravi S, Feng X, Lin J, Astell-Burt T, Chipps D, Maclean M, Maberly G. HbA1c Screening in the Emergency Department: Opportunity for better Diabetes detection, prevention and care. Abstract 335, ADS & ADEA Annual Scientific Meeting, Adelaide 2015

Contact for this Innovation

• For more information Contact:

Siân Bramwell

Community Diabetes Nurse Consultant

Western Sydney Diabetes Initiative WSLHD

Tel: 02 8670 0016

Email: Sian.Bramwell@health.nsw.gov.au

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