Creating a model of care within general practice that is grounded in patient education on chronic disease is no longer a concept but a culture with processes, partnerships, indicators and outcomes.
Chronic disease care planning and team care arrangements offers the general practitioner a framework to centralise care, monitoring, education and support for a patient in a more focused manner. The concept of ongoing routine reviews and education is central success of reducing burden of disease by increasing patient engagement, awareness of their disease/s, their overall status along with identifying means to improve or minimise further complications and comorbidities with support from the GP team.
The complexity of care and needs for a patient with diabetes is high, and thus diabetes offers one of the best disease models to build a centralised model of care around. Thus, diabetes education and management moves away from the former mindset of isolated education needs or a crisis intervention, to routine reviews and assessments allowing layered learning and skill building for the patient. Diabetes and other co-morbidities are addressed in a dynamic environment which offers on site specialised professionals who are part of the team working along side the GP and patient. These can include podiatrists, dietitians, mental health nurses and credentialed diabetes educators and the strong nursing teams.
Creating this centralised mode of care takes a focused team from administration, management, leadership, and clinicians with strong GP interest in improving patient wholistic health. Profiling a credentialed diabetes educator working full time in a multi- general practice setting will demonstrate the benefits of this model and key performance indicators to monitor a model of care and outcomes.