According to latest figures, 34,000 people are living with diabetes in Counties Manukau and those are just the people we know about. That’s thousands of people who are coping daily with a complex disease that has a number of contributory factors, for example lack of access to healthy food or poor food choices, lifestyle issues, such as, lack of exercise and inability to afford good health care. In fact you can’t single out one cause – it’s a variety of factors that makes managing diabetes a challenge for patients, families and health professionals. What’s clear is we need a whole new way of thinking about how to manage the current diabetes epidemic – a whole new ‘paradigm’ shift, including providing services closer to patients’ homes. Who better then to lead the way than our primary care colleagues – the main source of care for our diabetic patients and their families. I’m joined by Dr Tim Hou, GP at Mangere Health Centre who describes the important role that GPs play in empowering patients – especially those with diabetes and their whaanau, to take a more active role in their health and well-being.
Just in case you missed it – we have just had Diabetes Awareness Week and World Diabetes Day (14 November). With diabetes in the news, now is as good a time as any, to review the role of primary care in helping to manage the current diabetes epidemic.
Our colleagues in primary care are doing a great job, however the size and complexity of the diabetes epidemic suggests that a ‘business as usual’ approach might no longer be enough.
The Primary Care team is still at the very heart of our healthcare system and this is not about to change anytime soon. Quite simply, there will always be a need for a trusted relationship with a health professional. While this may expand to embrace a team of professionals – your practice remains the patient’s primary healthcare home.
Importantly, this means that primary care functions as the co-ordinating centre for the diabetic patient in the community adding significant value over and above the provision of clinical care by the practice teams.
Given this special relationship, practice teams will have a keen focus on finding out more about the patient who has diabetes rather than just concentrating on the diabetes within the patient It’s about asking “what matters to you” as opposed to “what’s the matter with you”. With diabetes, optimal outcomes will only be achieved by the patient and the Primary Health Care team working in partnership on problem solving and the planning of care. This means a two-way transfer of knowledge in a trusting and equal relationship – something I think that primary care is in a unique position to deliver and build upon for patients with diabetes.
While we will need to know more about the ‘uniqueness’ of each of our patients we must also put systems in place like a register to manage a population of diabetics within our practices. This population focus will mean a change in the model of care for diabetic patients, away from the traditional GP focused 15 minute appointment, to a range of ‘wrap around’ care solutions.
At CM Health, we have been working on a planned, proactive model of care for the last few years under the At Risk Individuals (ARI) programme. This includes risk stratifying patients, using common assessment tools and introducing new tools like the Electronic Shared Care Plan. The plan is web based, contains all the patient’s clinical information, personal goals and is accessible to the patient, an enhanced care team including our allied health colleagues, pharmacy, diabetes nurse specialists and Senior Medical Officers. There is no doubt that the Shared Care Plan is a pivotal enabler for high quality planned proactive care.
The Care Plan also gives us the opportunity to share information with our ‘Self-Management’ colleagues and create opportunities for patients to take a more active interest in their well-being and in managing their health issues. The Self-Management Support process has the patient at its core interacting with our self-management support colleagues and primary health care teams facilitated by the electronic shared care plan which is regularly updated throughout the care plan cycle. It includes the opportunity for patients to access relevant care, for example, Health Coach support. The care will cross boundaries and the patient will remain at the centre with his or her primary health care team helping to co-ordinate their patient’s care. The feedback loop facilitated by a ‘sharable’ care plan which is unique to the patient could be the glue that supports team care and the principle of “One Family: One Plan: One Team”. This, as many will know, is something families have expected of us as health practitioners – something we have not always managed to deliver.
This connection with our Self-Management colleagues exposes us to our patients’ communities and non-medical networks. This can only enrich our understanding of our patients’ lives and improve engagement in their health and autonomy. With this we can achieve a shift from a multi-disciplinary focus which is our current ‘paradigm’ to a multi-sectorial focus, encompassing social services, education, justice, employment services, housing, churches and the multitude of NGO services available in our communities. An approach and model of care that should go some way to helping to reduce the inequities currently experienced across our diabetic population.
Undoubtedly working in this way will bring its challenges. But, the reality is the ‘business as usual’ model will not suffice. Some principles that will be useful to remember:
- Remain patient focused at all times
- Equity is important
- Primary Care is the home for diabetes care
- Co-operation with health and non-health providers is critical
- Encouraging a learning culture across the health system is important.
The two last principles will be assisted by forming face-to-face relationships with and between our CM Health localities and PHOs and made scalable with the aid of IT, such as electronic shared care plans.
To reinforce and facilitate the shift from the ‘business as usual’ model, we and our CM Health diabetes colleagues are currently working with 10 practices in our district to explore how we can leverage our different skill sets, create a more collegial working environment, improve patient care and assist primary care to increase practice capabilities. We’re on a journey and it’s about, as the saying goes “A journey of a thousand miles begins with the first step”. My thanks to Brandon Orr-Walker and the CM Health Diabetes team for their patience and efforts in fostering Integrated Care and especially those elements so critical to the care of our diabetes patients.
Dr Tim Hou