The Diabetes Journey was a partnership of 21 representatives from acute, sub-acute and community services, across 14 different health and community services organisations in the EMR. The objective was to support the collaboration of partner agencies to develop an integrated and coordinated health system that enabled a seamless client journey and consistent quality in the provision of chronic illness care.
The Improving the Diabetes Journey project (The Diabetes Journey) was a strategy to improve care for clients with type 2 diabetes in the Eastern Metropolitan Region that was supported by the Inner East and Outer East Primary Care Partnerships and member agencies.
Some gaps in the existing services system at the project’s inception were found to exist. These included a lack of consistent leadership and governance in diabetes care across the Eastern Metropolitan Region (EMR), a need for greater involvement of acute, sub-acute, GP and community services to implement a consistent and co-ordinated approach, and the need for access to common online diabetes information and care pathway decision-making tools.
The Inner East and Outer East PCPs focused on developing objectives and a mix of strategies to address these gaps in service coordination and delivery based on the Wagner Model of Chronic Care. The strategies are aligned with three of the six elements of the Wagner model – self-management support, delivery systems design and clinical information systems.
The Diabetes Journey led to the establishment of a leadership and governance group with members from key agencies which enabled stronger cross-agency partnerships. A key outcome of this project was the development of an agreed framework for service delivery for people with type 2 diabetes across the EMR. The framework outlines the services that all consumers in the EMR with type 2 diabetes should have the opportunity to access, at different life or disease stages. Agreement across the EMR was made on following:
- a priority pathway tool,
- a type 2 diabetes care pathway,
- consistent consumer information.
- Inner East PCP’s contribution to the work in diabetes care was strongly focused on system change.
The Inner East PCPs and their partners also participated in the EMR Diabetes Initiatives Steering Group (DISG) which was established following the development and implementation of the Integrated Diabetes Education and Assessment Service (IDEAS) in partnership with Eastern Health Endocrinology Department and Whitehorse Community Health Service ( now Carrington Health). The EMR DISG aimed to provide oversight to further service development and replication of IDEAS and support other diabetes initiatives that improved service coordination and consistency of service delivery for people with diabetes. This included the “Improving the Diabetes Journey” Project roll-out.
Key Success Factor
The key success factor for this project was having a recognised regional group including acute diabetes service providers, Medicare Locals, community service providers and EMR PCPs. This group worked together to provide an integrated and coordinated platform to identify and progress regional diabetes services improvements and innovations. An additional success factor was the opportunity to integrate and sustain the findings of The Diabetes Journey into the HealthPathways Melbourne website – a website used by GPs to identify clinical pathways and services that they can refer to. Integration of resources and effort across the region enabled progress of a regional service redesign project that will ensure education programs for people with type 2 diabetes are evidence based and appropriate for the specific needs of the different EMR communities.
The focus of the Inner East PCP work is on partnership development and service system integration and coordination. The service improvement and innovation was achieved by focusing on a regional approach and governance for type 2 diabetes across EMR. Specific areas that have been improved include;
- Governance and Leadership: A regional governance structure is in place that involves all key stakeholders and provides a platform for diabetes services to be better managed and coordinates their efforts.
- Partnerships: Better coordination of partnerships between community-based primary health care, acute services and Medicare Locals, creating greater opportunity to integrate prevention and early intervention services into regional responses to type 2 diabetes care.
- Resources: Integration of The Diabetes Journey learnings and tools into the HealthPathways initiative creates opportunity for a stronger interface in diabetes care to be established between acute services, GPs and a range of community base diabetes services.
An independent evaluation of the project was conducted in 2012- 2013. Qualitative and quantitative data was collected to describe the impact and outcomes of implementation of the Improving the Diabetes Journey project tools and to provide recommendations for future action.
Key findings of the evaluation include;
- The Diabetes Journey tools and processes have increased confidence in the consistency of practice in diabetes care across the region.
- All organisations had made changes to systems and processes to embed The Diabetes Journey components into care delivery.
- There is strong organisational support and ongoing commitment to continue using The Diabetes Journey tools standardize practice across the region.
The results indicated that across the catchment there were improved governance and leadership arrangements and partnerships between community-based primary health care, acute services and Medicare Locals. The results also revealed that integration of The Diabetes Journey findings and tools into Health Pathways (led by Inner East and Eastern Medicare Locals) is likely to create opportunities for a stronger interface in diabetes care between acute services, GP’s and a range of community based diabetes services. Overall the evaluation found that Improving the Diabetes Journey had improved the delivery and consistency of care and promoted best practice clinical care.
How did the Primary Care Partnerships Contribute to the Success of the Project?
“I think the success of the ITDJ was also the way in which the PCP provided leadership of the Project coordinating and delivering activities with all stakeholders. If the workshops hadn’t been organised and resourced through the PCP, I doubt the end results would have been achieved. The process helped engage and support partners to implement changes using a PDSA (Plan, Do, Study, Act) approach.” Janine Scott General Manager Primary Health Care, Carrington Health