Poster Presentation Australian Diabetes Society and the Australian Diabetes Educators Association Annual Scientific Meeting 2014

An integrated primary/specialist community model of diabetes care: the role of the Credentialed Diabetes Educator (#270)

Tien-Wen Jane Tsai 1 , Linda Zanette 1 , Claire Jackson 2 , Anthony Russell 1 2
  1. Diabete & Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
  2. School of Medicine, University of Queensland, Brisbane, Queensland, Australia

Background:  The increasing prevalence of Type 2 diabetes mellitus (T2DM) is leading to increased demand on specialist diabetes clinics. In response to this, a novel model of care for management of complex T2DM was developed. We describe this model and in particular, the crucial role of the Credentialed Diabetes Educator (CDE).

Aim: To develop an effective and efficient model of diabetes care that facilitated a coordinated journey for the patient through the health care system.

Methods: The care of patients referred by their GP from a defined post code region to the PA hospital diabetes outpatients was transferred to a community based GP practice. A weekly diabetes clinic was conducted by a multidisciplinary team including two GPs (Clinical Fellows) who had been up-skilled in T2DM management, a CDE and Endocrinologist.  The CDE initiated contact with the patient and collected the social and medical history; including complications screening and arranging appropriate pathology requests.  Relevant allied health referrals were arranged. On clinic day, the Clinical Fellow developed a management plan that was confirmed with the attending Endocrinologist.  The patient was again reviewed by the CDE for education especially regarding effective self- management strategies, medication changes; including injectable medications; or for ongoing insulin stabilization.

Outcomes: Clinical outcomes improved. More patients were discharged back to their usual GP and waiting times have reduced at the hospital. Patient feedback emphasized the importance of the CDE in the model’s success.

Conclusion: This innovative model of care, utilizing a multi-disciplinary team of up-skilled GPs with a CDE and supporting Endocrinologist to deliver care in the community has been successful. The CDE plays a crucial role in case management. The model is now being assessed in a randomized control trial.