Diabetes Alliance: Adult Diabetes Integrated Care Delivered in General Practice

The Diabetes Alliance integrated care intervention includes three core activities: 1. Specialist-led case conferences in general practices with adult patients with diabetes:- Each general practice enrolled in the Diabetes Alliance initially receives 3 days of diabetes case conferences. Case conferences of 40 minutes duration are held for 10 new patients per day (i.e. 30 patients seen after 3 days), within the general practice setting. A single Diabetes Alliance review appointment of 20 minutes duration is booked approximately 6 months after the initial case conference. For all case conferences, patients are seen by a visiting tertiary specialist (Endocrinologist/Diabetologist) and Diabetes Educator, together with their own General Practitioner (GP) and Practice Nurse. Consultations include discussions of diabetes classification, complications and comorbidities, and treatment planning. Smoking, nutrition, alcohol, physical activity, psychosocial issues, diabetes-related distress, and depression are discussed. Each patient is asked to complete a 3-day food and physical activity diary, and blood glucose profile (all pre- and post-meal levels) in lead up to the case conference, so advice can be tailored to the individual. Recommendations are then implemented by patients and their usual GP without the need for ongoing specialist follow up. GPs are encouraged to deliver the Annual Cycle of Care across all practice patients with type 2 diabetes. Minimum requirements for the diabetes cycle of care are based on general practice guidelines produced by The Royal Australian College of General Practitioners (RACGP) and Diabetes Australia. Adherence is measured by recording the number of case conferences per practice and time to follow-up. 2. Whole general practice diabetes data analysis and feedback:- Aggregate feedback reports are used for practice-level monitoring and evaluation of clinical and process outcomes. Feedback is provided by the visiting endocrinologist and NPS MedicineWise facilitator, and the general practice staff develop a plan for their own quality improvement. Practices receive performance reports every 6 months. Aggregate performance reports include data for adults with type 2 diabetes at the general practice site, compared to all general practices in the Hunter New England Region, and nationally. The reports provide a summary of the practice profile, prevalence of modifiable lifestyle factors, proportion of patients reaching the treatment goals, and treatments being used. 3. Educational programs for primary care clinicians:- Endocrinologists provide 3 x 3 hour face-to-face Masterclasses for GPs, registrars, and allied health staff. Examples of topics included screening, diagnosis, and classification of diabetes, pathophysiology of types of diabetes, and medications. Diabetes Educators also provided a full day of education for practice nurses on similar topics. Diabetes Alliance Masterclasses are not exclusive to those primary care clinicians who participate in the case conferencing and/or general practice feedback activities; they are intended to have a broader reach. Attendance records are collected, which can be used to determine participation in all three Diabetes Alliance activities. The Diabetes Alliance is a real-world model of care, being implemented on a rolling basis. The pre-intervention period begins 13 months prior to the start of the Diabetes Alliance case conferencing at each general practice, through to 1 month prior (i.e. 12 months). The post-intervention period begins 6 months after the last case conferencing at each site, and lasts 12 months to capture tests that are required annually.