The medical home
Quality and safety in diabetes care start with coordinated, ongoing and comprehensive primary healthcare. Primary care is the central component of care across the spectrum of patients with diabetes: those dealing with a new diagnosis, managing (often multiple) medications, with complications of diabetes and multimorbidity, through to patients at the end of life.
A general practice chosen by a patient to provide ongoing, comprehensive, patientcentred care is known as a ‘medical home’. The medical home is responsible for the patient’s healthcare across their entire health journey, and this approach results in better health outcomes for patients and their families.6 Australian general practice encapsulates the medical home model.7
This model has measurable benefits, including improved continuity of patient care,8 and improved quality and cost effectiveness of care for patients with a chronic disease.9 Medical homes reduce disparities in access to quality care among traditionally difficult to reach groups,10,11 which leads to improved overall population health 12 and lower overall healthcare spending.13–15 The RACGP’s Vision for general practice and a sustainable healthcare system is based on the patient-centred medical home model and is informed by RACGP’s definition of quality general practice.
A model for chronic disease management
For patients with type 2 diabetes across the spectrum, structured care programs that are easy to implement, well supported and meet the needs of the individual are required. These programs bring together healthcare teams, evidence-based guidelines, useful support tools and good systems to support patients throughout their journey.
Refer to Chapter 5. Structured care and patient education for more information.
The Chronic Care Model (CCM), developed by the MacColl Institute identifies the fundamental elements of a healthcare system that supports high-quality chronic disease care:
- health system (organisation and mechanisms)
- delivery system design
- decision support
- clinical information systems
- self-management support
- the community.
The CCM has been shown to be an effective framework for improving the quality of diabetes care.16
GPs can help create a health system that facilitates easy and appropriate access to care for people with diabetes by reducing barriers associated with accessing, and maintaining healthcare across primary care and other health tiers.
General practices can access the Australian Government system level incentives to support diabetes care. This support is provided through Medicare Benefits Schedule (MBS) payments to GPs, nurses, allied health professionals and general practices. These include the Chronic Disease Management (CDM) items (formerly known as Enhanced Primary Care), which provide support for developing management plans and organising team care.
Patients have experienced improvements in process and clinical outcomes with these management plans and team care arrangements.17
ABORIGINAL AND TORRES STRAIT ISLANDER POINT
It is recommended that all practices identify patients of Aboriginal or Torres Strait Islander descent.
Registering patients also allows access to the Closing the Gap Pharmaceutical Benefits Scheme (PBS) co-payment, earlier interventions (as determined by PBS criteria) and access to specific MBS item numbers.
Refer to Appendix A in the PDF version. Accessing government support for diabetes care in general practice.
Delivery system design
Diabetes care requires a proactive preventive approach to keeping patients as healthy as possible rather than episodic or reactive intervention when complications arise. An effective system to achieve this will engage patients with a range of healthcare providers using good communication and information technology.17
Collaborative multidisciplinary teams are best suited to provide diabetes care, facilitate patient self management, identify those patients who require individualised support and coordinated case management.18,19 Using multidisciplinary care and engaging the wider team have been shown to improve outcomes for people with diabetes.20
A team approach provides flexible and comprehensive care to meet individual patient needs. Roles within a general practice team are not mutually exclusive, and clear guidance is required to identify the team member primarily responsible for key activities. Teamwork success may be supported by workflow coordination and management of structured care programs (care planning).
Accessible guidelines for diabetes management and associated issues (eg management and prevention guidelines for all types of diabetes; refer to Austroads and National Transport Commission, Therapeutic Guidelines Limited [TGL] antibiotic guidelines) are required for GPs to make decisions about diabetes care that is consistent with evidence and meets regulations.
Having electronic records also facilitates decision to support this goal by ensuring prescription error checking against medication allergy, and drug–drug and drug– disease interactions, creating diabetes clinical measures and databases, facilitating risk assessment such as cardiovascular disease (CVD) risk scoring and thus providing a basis for data collection linked to quality improvement processes.
Clinical information and recall and reminder systems
Structured diabetes care programs are based upon good information management systems (eg registers, recalls and reminders) combined with risk factor, complication assessment management and comorbidity strategies. Management plans are most effective when they involve a team care arrangement and are reviewed regularly.17 Structured recall systems ensure a patient receives formal reviews at regular intervals. Several studies have shown that computerised recall systems, monitoring and reminding patients and practice team members about appointments, investigations and referrals, improve diabetes care.21–24 Computerised systems can also provide automated reminders, generate mailing lists of those overdue for preventive activities and help minimise repeat data entries.
Combining a reminder system with a practice register ensures that the reminder system is systematic and targeted. This can prevent patients with diabetes missing out on basic care such as screening for retinopathy and foot care. Depending on the complexity of individual patient needs, structured recall may occur on a three-month to 12-month basis.
For example, during a consultation, the GP and patient make key management decisions or team care changes dependent on care plan progress. A recall is added in a time frame suited to the patient’s needs. This cycle then repeats. Another example is where a structured recall may ensure that all necessary investigations are completed before the next practice visit by the patient.
The aim of self-management support is to facilitate skills-based learning and patient empowerment. Diabetes self-management, education and support programs improve understanding of, and belief in, the importance of those factors that influence diabetes (eg goals, complications, living with a chronic illness), and thus might be able to be modified by patients’ behaviours and actions (eg self-monitoring of blood glucose [SMBG], dietary choices and physical activity). Other factors, such as medication(s), foot care, individual complication risk assessment and understanding of laboratory results, may need engagement with a health professional team.
Community resources and policies can be harnessed to improve the quality of the practice service including:
- National Diabetes Services Scheme (NDSS)
- Diabetes Australia resources
- Primary Health Network (PHN) collaborations
- local endocrinology specialist services – private and tertiary-level care
- allied health support teams including CDEs, Accredited Practising Dietitians (APDs) and Accredited Exercise Physiologists (AEPs)
- partnerships with universities or hospitals in providing diabetes care
- medication advice at pharmacies
- diabetes support groups, diabetes support applications and online support groups
- community health centres.
Translated diabetes resources are available from the NDSS diabetes portal, which includes resources from Diabetes Australia, Diabetes Australia state and territory agents, and non-government organisations.
ABORIGINAL AND TORRES STRAIT ISLANDER POINT
Some PHNs run chronic care coordination programs for Aboriginal and Torres Strait Islander patients that can help access practical help in attending a range of specialist and allied health appointments.