Jayne James, SESLHD - T2 The Road to Self-Management

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Jayne James, Diabetes Pathway Manager, & Tom Chapman, Redesign Manager, SESLHD delivered this presentation at the Clinical Redesign & Process Mapping conference. This conference provides case studies of succesful redesign projects to assist delegates in identifying the root causes of issues impacting patient journeys and then develop and implement sustainable change processes to improve the way health care is delivered.

Find out more at www.healthcareconferences.com.au/clinicalredesign13

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Jayne James, SESLHD - T2 The Road to Self-Management

  1. 1. T2 The Road to Self Management Tom Chapman – SESLHD Chronic Care Redesign Manager Jayne James – SESLHD Integrated Diabetes Pathway Manager
  2. 2. South Eastern Sydney Local Health District SESLHD Region • 9 Local Government Areas • Sydney's Central Business District to the Royal National Park Sydney • 2011 census – Population 830,000 – Northern Sector 45% – Southern Sector 55%
  3. 3. South Eastern Sydney Local Health District SESLHD • 7 Hospitals • 2 Medicare Locals – Eastern Sydney – South Eastern Sydney
  4. 4. Trends in obesity and inadequate physical activity Since 1997, the proportion of overweight or obese residents has increased by about a third. This is a prime driver for the escalating rate of hospitalisations for diabetes among our residents. In turn, the increasing prevalence of diabetes is driving increases in people requiring dialysis for chronic kidney disease.
  5. 5. Percentage of population Diabetes or high blood glucose, persons ≥16 years, South Eastern Sydney LHD 9 8 7 6 5 4 3 2 1 0 SESLHD Diabetes population is increasing ~ 0.3% per year 7.8% 4.7% Smoothed estimate (%) Actual estimate (%) 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Available at: www.healthstats.nsw.gov.au. Accessed (08/07/2013). At this rate in 5 years time 10% of the population will have Diabetes or high Blood Glucose
  6. 6. Hospitalisations for Chronic Ambulatory Care Sensitive Conditions Diabetes is overtaking all other Chronic Conditions for hospitalisation rates In SESLHD every day around 60 residents are hospitalised with Diabetes as the principal diagnosis or an important comorbidity (2011 stats)
  7. 7. Diabetes Complications Increasing numbers of patients with complications of diabetes due to poor self management and poor glucose control. Over the past decade 20,000 amputations have occurred in Australia due to diabetes1. In Australia over the past decade, 10,000 people have lost their sight due to diabetes1. 1: National Diabetes Strategy and Action Plan 2013: Diabetes Australia
  8. 8. Our Community, Our Services…A snapshot (August 2012)  Based on current trends, diabetes, followed by falls, are expected to have the greatest future impacts on our health system.
  9. 9. High Priority Initiatives  Establish an integrated, multidisciplinary diabetes program to facilitate increased patient knowledge and skill necessary for both diabetes self-care and active collaboration with health care providers, to improve clinical outcomes and reduce the need for hospital care.
  10. 10. Integrated Diabetes Project ( Sept. 2012) SESLHD Integrated Diabetes Project Type 1 Type 2 Gestational T2 the road to self management Adolescent/Tra nsitional
  11. 11. Project Overview Aim Improve access to standardised validated education and self-management support for newly diagnosed type 2 diabetes patients in the Northern sector of SESLHD. SESLHD Diabetes population is increasing ~ 0.3%/ year Why? Up to 50% of patients with T2DM do not access education Diabetes hospitalisations are escalating
  12. 12. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  13. 13. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  14. 14. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  15. 15. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  16. 16. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  17. 17. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  18. 18. Centre for Healthcare Redesign - Methodology Diagnostics Purpose Project Initiation & Start-up Diagnostics To develop the project scope and set up project, change, communication and stakeholder management plans To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change • Project Management • Process Mapping • Project Objectives & Measuring Benefits •Diagnostic Tools & Techniques • Project Scoping • Staff Interviews • Governance & Reporting • Roles & Responsibilities • Patient Interviews • Patient Tag Alongs • Data Collection & • Project Deliverables & Analysis Scheduling • Baseline KPI’s • Project Costs • Risk Management • Change Management • Stakeholder Management • Communications Management Solution Design Solution Design To design and prioritise solutions to issues and build stakeholder support To identify ways to improve the process, share lessons and drive sustainability • Literature Search for • Implementation Plans Best Practice Solutions for Quick Wins • Implement Quick Wins • Post Implementation Evaluation • Facilitated Problem Solving & Brainstorming • Implement all Solutions • Review & Redesign of Unsuccessful Initiatives • Trouble Shooting • Continuous Cycle of Redesign – Sustainability • Solutions Identification • Cost/Benefit Analysis of Solutions • Prioritisation of Solutions • Detailed Solution Statements • Issues Prioritisation • Develop Quick Wins • Building the Case For Change Planning To develop a comprehensive plan for implementing solutions and measuring benefits Implementation Checkpoints Evaluation Sustainability Knowledge Sharing To implement solutions and confirm that benefits are being delivered • Issues Identification • Root Cause Analysis Implementation Implementation Planning • Business Cases • Implementation Teams • Change Readiness Assessment • Coaching & Support • Sponsorship Roles & Responsibilities • Monitoring and Reporting • Project, Stakeholder, Communication & Change Management Plans • Performance Management • KPI Definition & Measurement Plan •Piloting Initiatives Project + Change + Stakeholder + Communication Management • Sharing of Knowledge • Writing For Publication
  19. 19. Project Objectives 1. Establish an integrated clinical framework to support an integrated patient pathway that provides for newly diagnosed type 2 diabetes patients by August 2013. 2. To have 10% of GP’s in ESML accessing and implementing this referral pathway for patients newly diagnosed with type 2 diabetes by March 2014; increasing incrementally to achieve 50% by March 2015 3. To have 20% of newly diagnosed patients with type 2 diabetes following the established integrated pathway; receiving standardised, validated diabetes self management education by March 2014; increasing incrementally to 75% by March 2015 Project Initiation and start-up
  20. 20. Established a steering and working group SESLHD Integrated Diabetes Project Type 1 Type 2 Gestational T2 the road to self management T2 Steering Group T2 Working group Project Initiation and start-up Adolescent/ Transitional
  21. 21. Key Stakeholder Key Role Map Primary Care South Eastern Sydney Local Health District CEO Eastern Suburbs Medicare Local SESLHD Redesign Leader CE SESLHD Director of Medicine Director of Operations POW Governance and Management Executive Sponsor Director of Ambulatory and Primary Care Northern Network Executive ESML Manager, Population Health Medical Stream Community Health Co-Director Acute, Cardiac and Comm. Care Head of Endocrinology POW Nursing CoDirectorJenny Wilson Key Stakeholder Patient Contact Ambulatory and Primary Care Chronic Care Integration Unit Manager Co-Director Community Health and Aged Care Project Team Jayne James Tom Chapman Director, Community Health GP & ESML Board member Endocrinologist, POW Nursing Manager POW Diabetes Centre NUM Community Health Key stakeholder Community Pharmacy Eastern Suburbs GP’s Eastern Suburbs Practice Nurses Key stakeholders = direct line management = influence only Project Initiation and start-up Diabetes Centre Educators POW Community Nurses PATIENTS Part of committees/ working groups Directly consulted at some stage
  22. 22. Scoping the Project IN SCOPE Patient Reason Newly diagnosed Type2 diabetes (within last 12 months) Adult GP diagnosed Impaired Fasting Glucose or Impaired Glucose Tolerance Process This patient group identified as being the fastest growing and currently only 50% receive diabetes education. Northern sector chosen as the ESML most able to partner at the time. SESML still in restructure. Diabetes Centre GP Patient with Type 2 Diabetes Practice nurse Community Health Other Health Specialists
  23. 23. Diagnostics Tools / Methods used Stakeholders Surveys GP’s  Practice Nurses File Audit Patient Journey Interviews   Mapping    POW Diabetes Centre   POW Community Health      Patients District Resources Diagnostics  Issues log       
  24. 24. Key findings Patient Interviews “Assumed tablets were going to control it and there wasn’t much to it, now I realise there is lots to it as far as eating right and exercise” “New GP takes time to explain things – it seems like he really cares. I feel more re-assured Diagnostics “First doctor was too business like – wouldn’t talk” Was getting blackouts – tried jelly beans, brother said get treatment “Nuisance with no car for shopping and day trips I stay at home now, I some times feel depressed’ 24 “Initially cut down sugar in tea and coffee and didn’t really do any thing else”
  25. 25. Mapping Eastern Sydney Medicare Local 93 Solo GP’s 53 Small GP Practices (2-5) 43 Large GP Practices 6+ 86 Practice Nurses • Eastern Sydney Medicare Local has the largest proportion of solo GP Practices than any other Medicare Local. • This is significant in that solo GP practices can rarely afford a Practice Nurse, or have the space for a Practice Nurse to work. Diagnostics 25
  26. 26. Practice Nurse Distribution in Suburbs 25 20 15 Practices with Practice Nurse's 10 Number of Practice Nurse's 5 0 = lowest socioeconomic suburbs. These areas are poorly resourced with practice nurses 26 Diagnostics
  27. 27. Summary of Key Diagnostic Data Process mapping: GP > Diabetes Centre Nearly 80% of referrals to the POW DEC are made by GP’s Diagnostics 32% of referrals had all the relevant information Time from referral to first appointment varied from 1 week to 6 months.
  28. 28. Practice Nurse Survey Only 10% of Practice Nurses provide diabetes education in a structured format. No recognised format was identified. No diabetes group education is provided. 36% do not provide any diabetes education. 28
  29. 29. Issues Prioritisation High 3.Education to reduce variation in practice Medium Priority 2.Consistent pt education High Priority 1.Flexible pt access Ability to Influence 5. Knowledge gap of what is available in primary care Low Priority 4.IT/ Communication Medium Priority Low Low Impact on patient 29 High
  30. 30. Current patient Journey Diabetes Education Pathway Newly Diagnosed with Type 2 Diabetes Family Diabetes Centre Internet Friends Dietitian Pharmacist Patient diagnosed with Type 2 Diabetes Community Health Centre Community Nurse Endocrinologist Podiatrist Exercise Physiologist Diagnostics Practice Nurse ISSUE Patient options for Diabetes Self-Management Education and Support are dependent on GP connectivity. There is no standard treatment ISSUE Large variation not only in where to go but what is delivered. ISSUE Knowledge of current services both primary and hospital based
  31. 31. Solution Design Solutions Prioritisation Ability to Influence Description Scoring System Ease of Implementation Easy (9) Moderate (3) Difficult (1) Cost of Implementation Low (9) Medium (3) High (1) Impact Total Ability to Influence Impact on KPI Benefits for Patients Benefits for Staff Total Impact Sum previous 2 Positive: Significant impact (9) Moderate impact (3) Low impact (1) Positive Impact (9) Neutral Impact (3) Negative Impact (1) Positive Impact (9) Neutral Impact (3) Negative Impact (1) Sum previous 3 Develop/enhance networking forums and events 9 7 16 7 7 9 23 Develop a referral pathway 5 7.5 12.5 7.5 6.5 8 22 Common service directory 4 8 12 8 9 9 26 Standardise correspondence 9 9 18 3 3 3 9 Single point of access 4 4 8 9 9 8 26 Collaborate on one education package for health staff 4 4 8 7.5 5 9 21.5 Train a broad range of health care workers from diverse backgrounds and cultures to deliver standardised training/education 4.5 2.5 7 6 9 7.5 22.5
  32. 32. Solutions Prioritisation 18 Develop/enhance networking forums and events Influence (ease + cost of implementation) Standardise correspondence Develop a referral pathway Common service directory Will be covered by the larger Diabetes Project 9 Single point of access Train a broad range of health care workers from diverse backgrounds and cultures to deliver standardised training/education Collaborate on one education package for health staff 0 0 13.5 Impact (KPI’s + patients + staff) Solution Design 27
  33. 33. SOLUTION Desired patient Journey Common service directory Diabetes Education Pathway available to all sectors Newly Diagnosed with Type 2 Diabetes Service Directory Those requiring more comprehensive Diabetes Education. Or more immediate referral. Internet Diabetes Centre Family Dietitian Friends Pharmacist Patient diagnosed with Type 2 Diabetes Triaged by Access and referral centre staff ComDiab Generalist Community based diabetes self managament education. Community Health Centre Podiatrist Practice Nurse Exercise Physiologist SOLUTION Develop a Referral Pathway + a Single Point of Access Solution Design SOLUTION ComDiab General education on self management, the multidisciplinary team and annual cycle of care. Endocrinologis t Community Nurse
  34. 34. Implementation planning • Prioritise Actions • Implementation teams • Build Business Case • Piloting Initiatives • Identify KPI’s & evaluation measures • Change Management Plans are nothing planning is everything (Dwight D. Eisenhower)
  35. 35. Implementation planning Accelerating Implementation Methodology (AIM) Identify the C.A.S.T Champion Agent Sponsor Target
  36. 36. Implementation planning A.I.M Communication Strategy Modes Timing Newsletter
  37. 37. Implementation planning A.I.M Readiness and Resistance ‘The path to least resistance is what makes the river crooked’(Elbert Hubbard)
  38. 38. Implementation planning A.I.M Assess the Climate ‘Insanity is doing the same thing over and over again and expecting different results’ (Albert Einstein)
  39. 39. Implementation Checkpoints 2013 Plan endorsed Aug Engage Sponsor Implementation checkpoints Sept Directory complete Oct Business plan endorsed Nov Training complete Dec 2014 Book venues Jan IT links to directory Feb First ComDiab Sessions held March Evaluation check points
  40. 40. Achievements YES GP or other Dr diagnoses Type 2 Diabetes with in last 12 months or Impaired Glucose Tolerance or Impaired Fasting Glucose GP or health professional provide patient with referral information to call NNARC or GP calls NNARC Or Either **** Is referral information complete? Is patient appropriate for ComDiab referral?* Would ComDiab supplement GP education for patient to promote self management? YES Does patient meet criteria for ComDiab referral?* Contact referral source for information NO YES Open new referral in CHIME And inform Patient of referral NO Confirmation letter generated in CHIME and sent to patient and GP Refer back to GP *ComDiab eligibility Criteria · Diagnosis: Newly diagnosed T2DMwith last 12 months · IGT, IFG · Not on insulin therapy · Ability to partake in interactive group session. · English comprehension ability · English reading ability · Or is Carer of above · Carers welcome to attend · Can attend existing multicultural group NO Does patient meet criteria for referral to Diabetes Centre?** NO **POW Diabetes Centre eligibility Criteria *** GP working group to define **** Investigate electronic referral via GP to NNARC YES Refer to Diabetes Centre Are there other options for this patient? YES NO *** Meds check Private Endo Private DE *** Meds check Private Endo Private DE Pathway approach
  41. 41. Achievements Networks Relationships & Responsibility
  42. 42. Achievements Two Registered Nurses Complete • Online training (12 hours) • 3 day workshop Staff trained in ComDiab To do: Observed and assessed delivering community sessions. Ongoing: Attend an annual review day.
  43. 43. Achievements SESML Australian Diabetes Council Patient Practice Nurses Diabetes Education Centre Community Health Integration & Collaboration SESLHD Chronic Care Team GP’s
  44. 44. Challenges Implementation checkpoints
  45. 45. Where to ….
  46. 46. Where to …. Solution 1: Co-build a common service directory ESML and SESLHD Solution 2: Develop a referral pathway with a single point of access Solution 3: ComDiab General Education on self management, the multidisciplinary team and annual cycle of care
  47. 47. Acknowledgements Steering Committee Sponsors - Dr Greg Stewart and Linda Soars South Eastern Sydney Medicare Local Australian Diabetes Council Prince of Wales Diabetes Centre Prince of Wales Community Health Elizabeth Mason – Redesign Manager NSW Health Redesign School Working Party
  48. 48. Only 15% of the job is figuring out what to do. Making it happen – that is where the action is (F Warren Mcfarlan)

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