Diabetes Project

Introduction

An initial survey of diabetes in Northland and in the Kaipara in particular, acknowledges that diabetes is a disease which is on the increase. It is a disease that is life-long and engages a client in multiple encounters with various service providers across all sections of the healthcare delivery system. It is a disease for which there is no current known cure.

Diabetes affects between 2 and 5% of all New Zealanders and in Northland is responsible for about 5.9 % of all deaths in Maori. It is a disease for which there is a great deal of personal cost, estimated at approximately $300-$400 per year.

Diabetes accounts for approximately 5% of the total health care budget. It is known that a great deal of that budget is used to treat the complications of diabetes. The actual cost of diabetes is complex because there are virtually always hidden costs associated with treating the complications of diabetes. There is considerable room to look at reduction of spending when we move into more preventative work.

Several issues, which will take prominence, deal with information systems between service providers looking at the issue of monitoring, screening and assessment on an ongoing basis.

As was mentioned previously, service provision for diabetes often takes the form of episodic, crisis-management. One of the key issues is to move from acute care management to the monitoring of diabetics along a ‘wellness-continuum.’

Project Aim

The aim of this project was to look at the specific issues for diabetics living in the Kaipara region from a service delivery perspective.

The aims of Integrated Care Pathways are to:

• Facilitate introduction of guidelines and systemic and continuing audit into clinical practice.
• Improve multidisciplinary communication and care planning.
• Reach or exceed existing quality standards.
• Decrease unwanted practice variation.
• Improve provider-client communication and client satisfaction.
• Identify research and development questions.
  (Campbell, Hotchkiss, Bradshaw, Porteous, (1998).)

Project Development Process

Key concepts of case management, disease management, care coordination and service integration are an integral part of the design of care pathways for diabetes.

1. Case Management - assignment of key worker to manage care/guidelines detailingcare.
2. Care Coordination Systems - detail referral practice, information exchange between providers and quality management systems.
3. Service Integration -implementation of case management and admission, referral/follow up and discharge protocols which integrate the activities of the Kaipara primary providers and secondary providers in Whangarei.
4. Disease Management -Best Practice Guidelines implemented as directed to key disease areas.

A proposal that service provision by care providers be reviewed within specific terms of reference, included:

• Establishing the existing level of service provision.
• Reviewing current service practice.
• Redesigning service strategies based on Best Practice Guidelines.
• The design and implementation of information systems to:
  a) enhance inter-agency service provider collaboration in the care of clients with diabetes.
  b) establish systems of audit to assess effectiveness of diabetes care in the community.

This project will establish and track referral, admission, discharge and follow-up relationships between diabetes service providers in the primary, secondary and tertiary sectors of delivery.

Best Practice Guidelines for care delivery will be adopted by diabetes service providers. Protocols will be developed to monitor and track efficiencies in service provider/client relationships. 

Quality Improvement mechanisms will be built into these systems.

1. Integrated Care Pathways for all clients with diabetes has been developed and implemented.
2. Best Practice Guidelines are developed in collaboration with Kaipara diabetes service providers and the three other Integrated Care Projects currently being implemented in Auckland and Otago.
3. Information systems are installed that link all service providers to a centralised data base/register of clients with diabetes in the Kaipara to: assist inter-agency coordination of management of clients with diabetes
   • evaluate effectiveness of integrated care pathways and case management of clients with diabetes, both Iwi and other, by means of an annual audit.
   • identify continuing or emerging barriers to access of services.
   • to assess the cost of each aspect of diabetes management, both simple and complex, so as to be able to define the cost of the current service and predict future needs.
   • access literature and research concerning current trends in diabetes management, nationally and internationally, so that the quality of the service can be enhanced.
   • effectively link in to the National Diabetes Database enabling Kaipara Care Incorporated to compare the effectiveness and costing of diabetes services with other areas of New Zealand for future planning.
4. The establishment of a multidisciplinary team to take over the responsibility for the implementation and monitoring of the project.
   (See Asthma project re Memorandum of Understanding. The same principles apply here.)
   A process to regularly assess consumer and provider satisfaction with both diabetes services and health promotion activities, is established.
5. The Professional Development needs of service providers are addressed by means of regular in-service and staff training. By a process of consultation the needs of diabetes service providers are identified and appropriate specialty services accessed to deliver the upskilling. Service providers are supported by management to attend these in-service and staff training opportunities.

Regular diabetes staff training will improve staff morale and enhance collaboration and coordination of diabetes services.
This will also ensure consistency and accuracy of the information given to clients with diabetes.

• The Integrated Care Pathways for Referral Model for Diabetes Care has been developed.
  In consultation with service providers, the individual roles of each service provider in diabetes care delivery have been defined.
  Standardised tools for referral have been designed. These tools will assist in providing both consistency and quality of information concerning clients accessing the different diabetes service providers and include:
  1. Referral to diabetes service providers.
  2. Summary of diabetes care by CHE services to Dargaville Medical Centre.
  3. Acknowledgment of admission to hospital from ward to Diabetes Nurse Educator.

By identifying pathways of referral between providers, clients with diabetes can expect an improvement in the quality of the care they receive by all service providers.

Effective referral pathways will also highlight areas that need extra resources in order to provide an excellent standard of care, as well as avoid costly duplicity of services.

• The Board of Te Runanga O Ngati Whatua is in agreement with the proposed pathways model and, in partnership, is now examining the development of Iwi services for diabetes within the Kaipara region.
• The need for Professional Development and training in Diabetes Management has been identified by all service providers involved in diabetes management. To this end, the Inservice Department at Whangarei Hospital and the Northland Health Diabetes Lifestyle Centre, have undertaken to develop and deliver a programme that will address the education needs of nurses working in the Kaipara. This training programme will be based upon the comprehensive Waitemata Health Diabetes Resource Nurses Course.
• The Diabetes Physician working with the Northland Health Diabetes Services, has expressed her commitment to provide continuing General Practitioner upskilling in Diabetes Management.