1 / 12

Diabetes Outpatients

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

quentin-christensen
Download Presentation

Diabetes Outpatients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Diabetes Outpatients Presenter: Justine PattersonHospital: Fury

  2. Current Situation – Diabetes Outpatients Process

  3. Summary of Current Activity

  4. 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

  5. Key strategies / actions / innovations – already successfully implemented

  6. 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

  7. 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.

  8. 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”

  9. 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

  10. Chronic Care Management - Diabetes Outcomes so Far…2 HbA1c value Cholesterol level Drop in HBA1C @ 1y

  11. 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!”

  12. 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

More Related