| Project Objectives / Summary:
The projects key aim was to improve the continuity of care for patients with Type 2 Diabetes, in the Brisbane Inner South area, who were admitted to hospital for any reason or diagnosis.
Key deliverable:
Development of a flexible template of care for patients with Type 2 Diabetes who are admitted to the projects participating hospitals for any reason or diagnosis. This flexible and adaptable template of care formed the "acute diabetic episode" part of the "Management of Type 2 Diabetes in Adults: Queensland Standard Pathway 2000"
To achieve the above objective, the Diabetes Care Transition Project aimed to:
- Map the existing pathways of care with Type 2 Diabetes who have contact with hospital services;
- Define the processes involve in the care of clients with Type 2 Diabetes in the transition from the community to hospital and back to community.
The project involved a working party of GPs from the Brisbane Inner South Division, the PAH and MAH and a reference group of stakeholders which included working party members, hospital, Queensland Health and Diabetes Australia representatives.
Following a scoping exercise involving focus groups and questionnaires the following priority areas were identified:
- Appropriate and timely referral of inpatients to required services
- Assessment of patient knowledge and perception
- GP to hospital to GP communication
- GP collaboration with other community based care providers
- Improving patient access to services
- Within hospital working groups the criteria for a Type 2 Referral Assessment was developed.
The assessment takes into account the work capacity of existing services and best practice guidelines including the Queensland Health Allied Health Best Practice Guidelines and the Diabetes Mellitus in Adults Queensland Standard Care Pathway 2000.
The purpose of the assessment was to facilitate referral of high risk patients, with Type 2 Diabetes, who were admitted to hospital for any reason or diagnosis. If patients do not require referral they receive information from the ward diabetes resource folder, the duplicate copy of the assessment form and they are advised to return to their primary carer (GP or Indigenous Health Worker) for ongoing diabetes care.
Project Collaboration:
- Queensland Health (QH)
- The Mater Adult Hospital (MAH)
- The Princess Alexandra Hospital (PAH)
- Diabetes Australia Queensland (DAQ)
Project Outcomes:
The Type 2 Diabetes Referral Assessment was developed, approved and trialled at the MAH and PAH. Due to various issues, implementation of the Diabetes assessment did not directly impact on the referral of patients or patient outcomes.
Recommendations:
- Offer the GP education which was provided in this project to other GPs / Divisions of General Practice for increased reach and impact.
- The Type 2 Diabetes Referral Assessment be made available to other Queensland Hospitals for adaptation to local needs for local trial. That further trial of this process focus on implementation and that hospital based employees participate in implementation activities, with increased awareness and utilisation of communication tools, for example ward level communication books, hand over communication and hospital promotion material.
- Explore the possibility of incorporating a diabetes assessment into nursing assessments.
- Consideration be given to the development of a poster version of the referral criteria for adults with diabetes who are admitted to hospital (Allied Health Best Practice Guidelines for the Management of Type 2 Diabetes).
- The project reference group members participate/continue to participate in the QH diabetes special interest group forum.
- The Type 2 Diabetes Referral Assessment be made available to General Practices as a component of adult diabetes assessment prior to care planning.
- GPs continue to work toward implementation of effective diabetes and other chronic disease management strategies with the support of Division staff and networks established during this project.
- That Divisions collaborate on the provision of education to their members in order to increase the reach of health promotion activities.
- That General Practitioner education be followed by an audit process in order to assess efficacy and impact of education methods.
- The possibility of DAQ (Diabetes Australia, Qld) pursuing Patient Held Record development as per 1st reference group meeting recommendations.
- It is important that collaboration between the hospitals and BISDIV continues seamlessly, in order to harness this momentum for change.
Dissemination:
- Paper presentation at the 7th Annual National Health Outcomes Conference 'Health Outcomes 2001 The Odyssey Advances', Canberra, June 2001
- Presentation via the Queensland Health Diabetes Special Interest Group 2001
- Presentation at the Queensland Health Statewide Clinical Innovations Network October 2001
- Updates published in the newsletters of urban Brisbane Divisions of General Practice
- Paper presentation at the Inaugural AGPAL 'Quality in Practice' Conference, Gold Coast, March 2002
Outcomes of dissemination activity have included:
- Request for report dissemination
- Invitation to publish report on NIS website
- Approach by MBF to discuss developments in the area of diabetes- focussed on in-hospital assessment protocols
- Networking with Diabetes care providers
Lessons:
Organisational bureaucracy had a large impact on the success / failure of the process. Registered Nurses were unable to attend adequate in-service training; the hospital system seemed to focus on episodic illness, and change processes were impacted on from outside sources i.e. competition for health funding and lack of communication between health professions.
On the positive side, the project demonstrated that good collaboration between the Divisions and hospitals existed and this argues well for future work in this field.
Diabetes is a priority health area and the Division considers that this work, which is based on quality management from community, GP and hospital perspectives, will be sustainable and transferable.
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