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  1. 1. FINAL REPORT The Integrated Diabetes Care Program in Western Australia: An Evaluation October 2001 Produced for General Health Purchasing, Department of Health By Western Research Advisory Services Pty Ltd. Western Research Advisory Services Pty Ltd 4 Laurence Road Innaloo 6018 Western Australia Telephone: (08) 9244 9229 Email: wras@touch88.com.au
  2. 2. Integrated Diabetes Care FINAL REPORT This evaluation was commissioned by the Department of Health (DOH) and contracted to Western Research Advisory Services Pty Ltd. ACKNOWLEDGEMENTS Western Research Advisory Services Pty Ltd wishes to thank the many people who gave their time, knowledge and interest to this evaluation. Your assistance has been invaluable. We also give our special thanks to the Project Committee and the Diabetes Co-ordinators in each pilot region: • Ms Penny Brown (Chair) • Ms Lisa McGinnis • Mr Lindsay France • Dr Jill Rowbottom • Mr Noel Carlin • Ms Emma Ellis • Mr Tim Reid • Ms Maureen Unsworth (Inner City) • Ms Kaye Neylon (Upper and Lower Gt Southern) • Ms Kirsty Boltong (Midwest) Our many thanks also go to the consultancy team: • Lisa Jarman • Chris Worthington • Susan Leeming • Flavia Bises • Jo Hart Limitations Statement The information contained in this report is based on sources believed to be reliable. However, as no independent verification is possible, Western Research Advisory Services Pty Ltd, together with its members and employees, gives no warranty that the said sources are correct, and accepts no responsibility for any resultant errors contained herein and any damage or loss, howsoever caused, suffered by any individual or corporation. The findings and opinions in this report are based on research undertaken by Western Research Advisory Services Pty Ltd as independent consultants and do not purport to be those of the Department of Health. WRAS PTY LTD PAGE 2
  3. 3. Integrated Diabetes Care FINAL REPORT TABLE OF CONTENTS 1. EXECUTIVE SUMMARY..................................................................................................................6 1.1. TERMS OF REFERENCE.........................................................................................................................6 1.2. MAJOR FINDINGS................................................................................................................................6 1.2.1. Overview.................................................................................................................................6 1.2.2. The importance of program ‘fit’ to diabetes and its implications for the IDC Program.......7 1.2.3. Implementation of pilot projects.............................................................................................8 1.2.4. Effectiveness............................................................................................................................9 1.2.5. Sustainability...........................................................................................................................9 1.2.6. Applicability..........................................................................................................................10 2. RECOMMENDATIONS...................................................................................................................11 PRIORITY DEFINITIONS.............................................................................................................................12 3. INTEGRATED DIABETES CARE: OVERVIEW & DISCUSSION.........................................13 3.1. DIABETES AND ITS INFLUENCE ON HEALTH CARE SYSTEMS :......................................................................13 3.1.1. The Open Systems Model and its relevance to the concept of integration...........................13 3.1.2. The NSW Model of IDC........................................................................................................15 3.1.3. Diagnosis of the diabetes service delivery environment.......................................................15 3.2. IMPLEMENTATION OF THE IDC PILOT PROGRAMS IN WESTERN AUSTRALIA................................................16 3.2.1. Background and Program objectives....................................................................................16 3.2.2. Summary of common evaluation themes...............................................................................17 3.2.3. Inner City..............................................................................................................................18 3.2.4. Upper Great Southern...........................................................................................................20 3.2.5. Lower Great Southern...........................................................................................................21 3.2.6. Midwest.................................................................................................................................23 3.3. EFFECTIVENESS OF THE IDC PROGRAM & MODEL....................................................................................26 3.3.1. Summary...............................................................................................................................26 3.3.2. Consistency with national objectives....................................................................................26 3.3.3. Compatibility with other models of service delivery.............................................................26 3.3.4. Level of acceptability............................................................................................................27 3.3.5. Strengths...............................................................................................................................27 3.3.6. Gaps......................................................................................................................................27 3.3.7. Weaknesses...........................................................................................................................28 3.3.8. Barriers.................................................................................................................................28 3.3.9. Duplications..........................................................................................................................28 3.3.10. Unintended consequences...................................................................................................29 3.3.11. Potential impact on health outcomes..................................................................................29 3.4. PROGRAM SUSTAINABILITY..................................................................................................................29 WRAS PTY LTD PAGE 3
  4. 4. Integrated Diabetes Care FINAL REPORT 3.4.1. Summary...............................................................................................................................29 3.4.2. Funding.................................................................................................................................30 3.4.3. Planning................................................................................................................................30 3.4.4. Culture..................................................................................................................................30 3.4.5. Human Resources.................................................................................................................30 3.4.6. Structures..............................................................................................................................31 3.4.7. Measurement systems............................................................................................................32 3.4.8. Technology............................................................................................................................32 3.5. APPLICABILITY...................................................................................................................................32 3.5.1. Capacity to influence other areas of service delivery...........................................................32 3.5.2. Applicability to other regions and program areas...............................................................33 3.6. REFERENCES.....................................................................................................................................33 4. APPENDIX A: METHODOLOGY.................................................................................................34 4.1. TERMS OF REFERENCE.......................................................................................................................34 4.2. ISSUES CONSIDERED IN RESEARCH DESIGN...........................................................................................34 4.3. DATA COLLECTION AND ANALYSIS......................................................................................................35 5. APPENDIX B: LITERATURE REVIEW......................................................................................36 5.1. OVERVIEW OF DIABETES MELLITUS.......................................................................................................36 5.2. DIABETES PREVALENCE IN AUSTRALIA AND WESTERN AUSTRALIA...........................................................37 5.3. DIABETES SERVICE PROVIDERS...........................................................................................................38 5.4. CONCEPTS OF INTEGRATION AND DIFFERENTIATION..................................................................................38 5.5. THE CONCEPT OF INTEGRATION OF HEALTH CARE....................................................................................40 5.6. MODELS OF INTEGRATED DIABETES CARE..............................................................................................41 5.7. EXPERIENCES OF INTEGRATED DIABETES CARE MODELS............................................................................42 5.7.1. General experiences..............................................................................................................42 5.7.2. The NSW Model of Integrated Care......................................................................................44 5.8. OBJECTIVES OF NATIONAL AND WA STRATEGIES..................................................................................45 5.8.1. National Diabetes Objectives (2000-2004)..........................................................................45 5.8.2. Commonwealth Department of Health and Aged Care Objectives 2000-2004 ...................45 5.8.3. The WA Diabetes Strategy 1999...........................................................................................46 5.8.4. Metropolitan Health Plan 2020............................................................................................46 5.8.5. References.............................................................................................................................46 6. APPENDIX C: QUALITATIVE DATA THEMES........................................................................50 6.1. PILOT REGIONS: BACKGROUND AND PROGRESS TO DATE.........................................................................50 6.1.1. Inner City Region..................................................................................................................50 6.1.2. Upper Great Southern Health Locality.................................................................................59 6.1.3. Lower Great Southern Region..............................................................................................65 6.1.4. Midwest Region.....................................................................................................................74 WRAS PTY LTD PAGE 4
  5. 5. Integrated Diabetes Care FINAL REPORT 6.2. THEMES FROM OTHER WESTERN AUSTRALIAN STAKEHOLDERS................................................................84 6.2.1. Implementation of the IDC model.........................................................................................84 6.2.2. Effectiveness of the IDC model.............................................................................................84 6.2.3. Sustainability of the IDC model............................................................................................87 6.3. SUMMARY OF INTERSTATE TRENDS.......................................................................................................89 6.3.1. The Commonwealth Department of Health and Aged Care.................................................89 6.3.2. The New South Wales Experience.........................................................................................90 6.3.3. The Tasmanian Experience...................................................................................................91 6.3.4. The Australian Capital Territory Experience.......................................................................91 6.3.5. The Victorian Experience.....................................................................................................92 6.3.6. The Northern Territory Experience......................................................................................92 6.3.7. The Queensland Experience.................................................................................................92 6.3.8. The South Australian Experience..........................................................................................92 7. APPENDIX D: MONITORING INDICATORS.............................................................................93 ABBREVIATED TERMS ACT Australian Capital Territory NIDDM Non Insulin Dependent Diabetes Mellitus AHW Aboriginal Health Worker NSW New South Wales AMS Aboriginal Medical Service PHU Public Health Unit CGS Central Great Southern RPH Royal Perth Hospital DGP Division of General Practice UGS Upper Great Southern EPC Enhanced Primary Care WA Western Australia GDM Gestational Diabetes Mellitus WADST Western Australian Diabetes Strategy Taskforce GP General Practitioner GRAMS Geraldton Regional Aboriginal Medical Service GSPHU Great Southern Public Health Unit HBF Health Benefit Fund HCP Health Care Professional DOH Department of Health IDC Integrated Diabetes Care IDDM Insulin Dependent Diabetes Mellitus LGS Lower Great Southern LGSHS Lower Great Southern Health Service MWAH Midwest Allied Health NDS National Diabetes Strategy NESB Non English Speaking Background WRAS PTY LTD PAGE 5
  6. 6. Integrated Diabetes Care FINAL REPORT 1. EXECUTIVE SUMMARY 1.1.TERMS OF REFERENCE The Consultant was engaged to conduct an evaluation of the Integrated Diabetes Care (IDC) Program that was implemented in the following four pilot regions of Western Australia (WA) in 1998, Inner City East Perth, Midwest, Lower Great Southern Health Service and Upper Great Southern Health Service. The evaluation was intended to assess the progress, effectiveness, sustainability, and applicability of the Program and was not intended to evaluate individual pilot projects. The aim of the Program is to develop and support an integrated service delivery model that ensures: • Equitable access to a full range of diabetes services. • Health professionals’ access to training and support. • Systems for co-ordinated care. • Systems for ensuring standards. • Systems for monitoring outcomes. • Commitment to the development of a locally appropriate service delivery model. The evaluation was conducted between January and March 2001. Data were collected and collated from centralised DOH records, literature review, qualitative interviews with service providers and stakeholders, focus groups and written submissions. In total, 100 qualitative interviews and 11 focus groups were conducted. 1.2.MAJOR FINDINGS 1.2.1.Overview Diabetes Mellitus is a complex, chronic disease requiring input from a variety of disciplines as well as considerable attention to self-management by the individual. It is a major world-wide health issue with very significant social and economic costs. The prevalence of diabetes is on the increase throughout the world, and its influence on current and future health care systems should not be underestimated. There is a world-wide trend towards the use of integrated models of care in health systems, especially in response to diabetes. More recently, many countries, including Australia have begun integrating diabetes into chronic disease programs because risk factors, education, and treatment overlap with other types of chronic diseases (e.g. cardiovascular, vascular, renal). In 1995, the New South Wales (NSW) Health Department trialled three, two year IDC projects to test the hypothesis that “the impact on the system of chronic disease and its sequelae could be reduced by the provision of well organised care founded on agreed, evidence based guidelines for best practice, which incorporates patient education and early detection of complications” (Boyages, Sheridan & Close, 1999, p85). This population based approach was used as a template for the WA IDC pilots. WRAS PTY LTD PAGE 6
  7. 7. Integrated Diabetes Care FINAL REPORT 1.2.2.The importance of program ‘fit’ to diabetes and its implications for the IDC Program The evaluation applied an ‘Open Systems’ model to the data to diagnose the current functioning of diabetes service delivery in WA, and to identify the elements of the IDC Program requiring change (Cummings & Worley, 1993). When applied to diabetes service delivery, the Open Systems model proposes that programs are only effective and sustainable if they are match or ‘fit’ the needs of the diabetes ‘environment’. The ‘environment’ includes people with or at risk of diabetes, the people who assist them manage or prevent diabetes (e.g. families, health and allied professionals), where they are located, and organisations that compete with diabetes for attention and money. For instance, the NSW model outlined above considers some of the elements by designing its program to incorporate early detection and patient education. It also introduces integration as a means of acknowledging the need for continuous, high quality care. The evaluation’s literature review found that integration is a fundamental principle or ‘force’ that comes from the external environment and drives the design of any program. For instance, in the WA diabetes environment, people are spread out in rural and remote areas across the state, but the number of people with diabetes are low in these areas compared with the metropolitan population. Therefore, any diabetes program must consider available resources, and how they can be integrated to provide a diabetes service to rural and remote areas. One of the ways rural and remote health providers have tried to maximise resources is to have people in health roles with generalist skills, rather than people who only have skills in diabetes. In this instance the integration that has occurred refers to the merging of diabetes knowledge with other health knowledge. There is another fundamental force in the environment that drives programs towards ‘differentiation’ and opposes attempts to integrate. Differentiation refers to the need for a program design that pays attention to individual elements within the environment (Lawrence & Lorsch, 1967). For instance, the WA Diabetes Strategy (1999) emphasises attention to prevention, primary care and specialised care. Each of these elements is differentiated because they are all critical to the reduction of diabetes prevalence in the future. However, the evaluation highlighted that the majority of purchaser and provider effort focuses on specialised care interventions. Therefore, over-attention on this area causes the others to suffer, and prevents the achievement of long term goals. Appropriate levels of attention need to be given to each differentiated element to address diabetes. In the context of program design, forces for differentiation should not be considered ‘good’ or ‘bad’. Rather they should be acknowledged and included in planning processes. The literature on diabetes care refers to a number of problems with integrated models but does not appear to acknowledge the existence of forces for differentiation. The evaluation suggests that differentiation must be also considered in models of diabetes service delivery if they are to be effective and sustainable. The original conception of the IDC Program in WA gave attention to integration systems. It seems that the IDC Program needs to be updated to incorporate attention to a broader set of environmental elements than those conceived by the NSW model. Forces for differentiation should also be acknowledged in future diabetes planning. WRAS PTY LTD PAGE 7
  8. 8. Integrated Diabetes Care FINAL REPORT 1.2.3.Implementation of pilot projects Although each pilot region had its unique features, remarkable similarity was found between regions in the major themes listed below: • Integration was viewed as an acceptable • A co-ordinator is critical, as are their skills model in change management • IDC funding was inadequate • The original submissions were based on the • Access to diabetes services is inequitable NSW pilot • GP acceptance of, and involvement in IDC • Service providers in rural and remote Programs is critical locations have additional challenges relating • Current training provision is inappropriate to isolation, recruitment and retention, for rural and remote service providers access to services, access to professional • There is insufficient planning and support, and competition with generalist monitoring of progress and planning roles There also appeared to be a correlation between the development of structures and systems within pilots and the degree of integration achieved. For instance, the Inner City and Lower Great Southern (LGS) pilots did more planning and had more consistency in co-ordination of the program than the Midwest or Upper Great Southern Pilots. The former pilots also had more success in achieving set goals than the latter. In many ways, the Inner City is further advanced than other pilot regions and is now experiencing a high demand for services. The general theme arising from the Inner City pilot was that services and service integration have improved, with patients behaving differently and demonstrating better understanding of diabetes. The Inner City Pilot was funded a total of $701,500.00 over the three year period this was significantly higher than the other pilots, which received less than this combined total between them. The UGS pilot is co-ordinated by the same co-ordinator as the LGS. Twelve months into the pilot a local area co-ordinator was put in place. This local co-ordinator position has had a history of staff changes and the most recent local co-ordinator is now employed in a more generalist role focusing on chronic disease. General perceptions of service providers were that diabetes care is improving but considerable effort is still needed within the region. The locality is challenged by ongoing issues such as geographical isolation, disagreements between some Aboriginal groups, recruitment and retention of health professionals, and access to service providers (e.g. endocrinologists). The LGS health locality appears to have made significant progress towards the integration of services. The initial business case made few distinctions between the UGS and LGS and this is reflected in reporting of the pilots. The development of the LGS pilot has deviated significantly from its original objectives, but has captured the broader outcomes sought by the IDC Program. Similar to the UGS pilot, the Midwest Region experienced significant challenges to its establishment, including a high frequency in the turnover of co-ordinators, merging of the co-ordinator’s role with a diabetes education role, remote service delivery, and competition between service providers. The general perception of this pilot was that WRAS PTY LTD PAGE 8
  9. 9. Integrated Diabetes Care FINAL REPORT it has not achieved integrated care and will require considerable effort to recover lost ground. 1.2.4.Effectiveness The effectiveness of the pilot projects within the IDC Program has varied considerably. As a whole, diabetes service provision has improved across the pilot regions. Visible changes in consumer behaviour are cited in the LGS and Inner City pilots. Pilots in UGS and Midwest locations have had problems compounded by staff turnover, distance, absence of a critical mass of service providers, and limited access to training. In the case of the Midwest, mini-systems of integration (e.g. where a local GP has made their own unique network of diabetes service providers) have formed in reaction to frustration with the progress of diabetes service delivery. The effectiveness of integration models is supported in literature in other Australian states as well as internationally. Integration of services is also occurring in non-pilot regions of WA. However, the IDC Program in WA has weaknesses and gaps (e.g. absence of planning and monitoring) that make it vulnerable to the external environment. Overall, integration is an appropriate model for WA diabetes service delivery, but the program requires increased sophistication (i.e. attention to a broader set of environmental elements, consideration of differentiation) if it is to maximise its effectiveness. The primary elements of the IDC model applied by WA are similar to those implemented by the Commonwealth Department of Aged Care, NSW and the ACT, although each of these states have now moved to models of chronic disease integration. The Victorian Department of Health Services has recently introduced a model of Integrated Disease Management, which incorporates broader elements in its definition of integration. Western Australia has a unique environment due to its relative isolation and broad set of environmental elements impacting diabetes service delivery. Application of the NSW model to the IDC Program was a sound starting point for service delivery change but is no longer a satisfactory model for WA diabetes care. 1.2.5.Sustainability It is acknowledged that the IDC Program is in its infancy, and is an appropriate model for diabetes service delivery in Western Australia. The IDC pilot projects do not seem to be sustainable in their current form. However, attention to the elements listed below seems highly likely to generate future sustainability within the IDC Program: • Enhancement of the profile of diabetes as a major health issue in Western Australia • Increased resources to support expansions in service delivery around a framework of IDC • Development of a framework for a state-wide IDC Program • Implementation of further structures within the IDC Program • Enhancement of general knowledge of diabetes for people in health related roles • Increased consumer involvement in the IDC Program WRAS PTY LTD PAGE 9
  10. 10. Integrated Diabetes Care FINAL REPORT 1.2.6.Applicability The IDC model has the capacity to influence other areas of service delivery, and other regions but it is not necessarily applicable to all forms of health care programs. Diabetes is a natural choice for integration because of its complexity, duration, commonalities with other chronic diseases, and innate requirement for contributions from a variety of disciplines. WRAS PTY LTD PAGE 10
  11. 11. Integrated Diabetes Care FINAL REPORT 2. RECOMMENDATIONS The prevalence of diabetes is on the increase throughout the world and its social and economic impact should not be underestimated by health systems. Diabetes is particularly suited to integrated models of care because it requires input from a variety of disciplines as well as considerable attention to self-management by the individual. There is a world-wide trend towards the application of IDC models, and the evaluation suggests this approach is appropriate for the WA health system. However, diabetes service delivery in WA has unique challenges that are not adequately addressed by the model devised by New South Wales, which was applied to the pilot projects. Therefore, although an IDC Program appears effective and sustainable in the longer term, there is now a need to move beyond the application of pilot projects and develop a state-wide, systematic approach to IDC. Furthermore, if the WA Diabetes Strategy (1999) is to be successful in tackling diabetes issues in the future, it needs to be supported by a sustained commitment to diabetes funding. It is recommended that: 2.1 The profile of diabetes is enhanced: 2.1.1 Through reinforcement from the DOH that diabetes is a major health issue which demands high priority attention (Priority = Short Term). 2.1.2 Through promotion of the WA Diabetes Strategy to health services and diabetes service providers (Priority = Short Term). 2.1.3 Through the development of a state-wide image for the IDC Program (Priority = Short Term). 2.2 Increases in resources are sought to support expansion in service delivery around a framework of IDC: 2.2.1 For the DOH to develop a purchasing plan that supports an integrated model of diabetes service delivery with the DOH (Priority = Short Term). 2.2.2 To encourage application of the IDC Program to health localities not currently applying integrated approaches to diabetes care, and improve IDC Programs already in place (Priority = Short to Medium Term). 2.3 A framework for a state-wide IDC Program is developed: 2.3.1 Through the organisation of an ongoing IDC forum, which brings together diabetes stakeholders from throughout WA. It would be the intention of this forum to promote discussion of common and unique issues in IDC, conduct strategic IDC planning, develop action plans, and identify common performance indicators (Priority = Short Term). 2.3.2 That considers all the integrated and differentiated elements of the diabetes service delivery environment (Priority = Short Term). 2.33 That manages the change to IDC in a manner likely to promote long term behavioural change (Priority = Short Term). WRAS PTY LTD PAGE 11
  12. 12. Integrated Diabetes Care FINAL REPORT 2.3.4 That acknowledges the importance of strategies integrating diabetes with other chronic diseases (Priority = Long Term). 2.3.5 That investigates ways to increase the application of information systems (e.g. registers), collation of the diabetes databases, and use of information technology within the IDC Program (Priority = Medium Term). 2.3.6 That incorporates the development of standardised measurement instruments that target service providers and consumers. It is also recommended that regional data collected by these instruments is centrally collated and analysed (Priority = Short Term). 2.4 Existing and new health localities applying the IDC Program implement the following structures: 2.4.1 Annual strategic planning (Priority = Short Term). 2.4.2 A clearly defined IDC Co-ordinator role (Priority = Short Term). 2.4.3 Training for IDC Co-ordinators and advisory committees in change management (Priority = Short Term). 2.4.4 Networking structures for the IDC Co-ordinator to maintain relationships with other IDC Co-ordinators (Priority = Short Term). 2.4.5 Collection of baseline data against standardised performance indicators, with monitoring on an annual basis (Priority = Short Term). 2.4.6 Systems to retain corporate knowledge (e.g. plans, policies, contact lists, processes) (Priority = Medium Term). 2.4.7 Registers of service providers (Priority = Medium Term). 2.4.8 The application of the standardised measurement instrument developed by the DOH (Priority = Short Term). 2.5 General knowledge of diabetes is enhanced: 2.5.1 Through the development of strategies to increase the number of people, who work in health related roles in rural and remote areas, who have generalist knowledge of diabetes (Priority = Medium Term). 2.5.2 Through development of accessible and affordable training courses for people in rural and remote areas, which have an emphasis on generalist diabetes knowledge (Priority = Short Term). 2.5.3 Through continued acknowledgment of the importance of specialist diabetes training courses (Priority = Short Term). 2.6 Strategies are developed to increase diabetes consumer involvement in the IDC Program: 2.6.1 Through the encouragement of community integration networks for people with diabetes and their families (e.g. buddy systems) (Priority = Medium Term). Priority Definitions • Short Term: To be undertaken in the next 12 months. • Medium Term: To be undertaken in the next 1 to 3 years. • Long Term: To be undertaken in the next 3 to 5 years WRAS PTY LTD PAGE 12
  13. 13. Integrated Diabetes Care FINAL REPORT 3. INTEGRATED DIABETES CARE: OVERVIEW & DISCUSSION 3.1.DIABETES AND ITS INFLUENCE ON HEALTH CARE SYSTEMS : Diabetes Mellitus is a complex, chronic disease requiring input from a variety of disciplines as well as considerable attention to self-management by the individual. It is a major world-wide health issue with very significant social and economic costs. The prevalence of diabetes is on the increase throughout the world, and its influence on current and future health care systems should not be underestimated. There is a world-wide trend towards the use of integrated models of care in health systems, especially in response to diabetes. More recently, many countries, including Australia have begun integrating diabetes into chronic disease programs because risk factors, education, and treatment overlap with other types of chronic diseases (e.g. cardiovascular, vascular, renal). 3.1.1.The Open Systems Model and its relevance to the concept of integration The evaluation applied an ‘Open Systems Model’ to the data to diagnose the current functioning of diabetes service delivery in WA, and to identify the elements of the IDC Program requiring change (Cummings & Worley, 1993). Figure 1. Primary format of an open system model Environment INPUTS TRANSFORMATIONS OUTPUTS • Strategy • People and work relationships • Finished • Resources goods (e.g. • Tools, techniques, methods of production • Services human, • Ideas informatio n, Feedback The open systems model is based on systems theory, which describes the properties and behaviours of things called ‘systems’ – people, groups or organisations. Systems are viewed as unitary wholes comprised of parts or sub-systems. The system serves to integrate the parts into a functioning unit. For example, the Health Department of WA is divided into a number of units, such as Public Relations and General Health Purchasing. WRAS PTY LTD PAGE 13
  14. 14. Integrated Diabetes Care FINAL REPORT Systems can vary in how open they are to the outside environment. ‘Open systems’ exchange information and resources with their environment. They cannot completely control their own behaviour and are partially influenced by environmental conditions. An understanding of how these external forces affect an organisation is critical to designing organisational systems properly. Figure 1 shows the key components of an open system: inputs, transformations, outputs, and feedback. If an organisation is likely to produce the right outputs and sustain its existence, these elements should be designed in consideration of the elements of the external environment. When applied to diabetes service delivery, the open systems model proposes that programs are only effective and sustainable if they match or ‘fit’ the needs of the diabetes ‘environment’. The ‘environment’ includes people with or at risk of diabetes, the people who assist them to manage or prevent diabetes (e.g. families, health and allied professionals), where they are located, and organisations that compete with diabetes for attention and money. For instance, the NSW model in the next section considers some of the elements by designing its program to incorporate early detection and patient education. It also introduces integration as a means of acknowledging the need for continuous, high quality care. The evaluation’s literature review found that integration is a fundamental principle or ‘force’ that comes from the external environment and drives the design of any program. For instance, in the WA diabetes environment, people are spread out in rural and remote areas across the state, but the number of people with diabetes are low in these areas compared with the metropolitan population. Therefore, any diabetes program must consider available resources, and how they can be integrated to provide a diabetes service to rural and remote areas. One of the ways rural and remote health providers have tried to maximise resources is to have people in health roles with generalist skills, rather than people who only have skills in diabetes. In this instance the integration that has occurred refers to the merging of diabetes knowledge with other health knowledge. There is another fundamental force in the environment, which drives programs towards ‘differentiation’ and opposes attempts to integrate. Differentiation refers to the need for a program design that pays attention to individual elements within the environment (Lawrence & Lorsch, 1967). For instance, the WA Diabetes Strategy (1999) emphasises attention to prevention, primary care and specialised care. Each of these elements is differentiated because they are all critical to the reduction of diabetes prevalence in the future. However, the evaluation highlighted that the majority of funder, purchaser and provider effort focuses on specialised care interventions. Therefore, over-attention on this area causes the others to suffer, and prevents the achievement of long term goals. Appropriate levels of attention need to be given to each differentiated element to address diabetes. In the context of program design, forces for differentiation should not be considered ‘good’ or ‘bad’. Rather they should be acknowledged and included in planning processes. The literature on diabetes care refers to a number of problems with integrated models but does not appear to acknowledge the existence of forces for differentiation. The evaluation suggests that differentiation must be also considered in models of diabetes service delivery if they are to be effective and sustainable. The original conception of the IDC Program in WA gave attention to integration systems. It seems that the IDC WRAS PTY LTD PAGE 14
  15. 15. Integrated Diabetes Care FINAL REPORT Program needs to be updated to incorporate attention to a broader set of environmental elements than those conceived by the NSW model. Forces for differentiation should also be acknowledged in future diabetes planning. 3.1.2.The NSW Model of IDC In 1995, the NSW Health Department trialled three, two year IDC projects to test the hypothesis that “the impact on the system of chronic disease and its sequelae could be reduced by the provision of well organised care founded on agreed, evidence based guidelines for best practice, which incorporates patient education and early detection of complications” (Boyages, Sheridan & Close, 1999, p85). This population based approach was used as a template for the WA IDC pilots. The term “Integrated Diabetes Care” has been defined as “the organised participation of practitioners, other medical and non-medical clinicians, government and non- government agencies, and consumers, in the provision and use of a full range of client focused diabetes services, using agreed standards of care” (Sheridan & Boyages, 1996). Boyages Sheridan and Close (1999) note that in the NSW Model, integrated care consists of: • Established systems for communication between service providers. • Co-operation between service providers in providing care and in the planning of health services. • Agreed guidelines and standards of care, and adequate professional training. • The implementation of an agreed set of policies and procedures. This model was evaluated through biochemical, clinical, psychological and economic outcomes. 3.1.3.Diagnosis of the diabetes service delivery environment As previously noted, diabetes is a complex disease, and the service delivery environment has distinct elements requiring consideration. Table 1 (over the page) identifies the elements within this environment and diagnoses them according to: • Forces for integration • Forces for differentiation Table 1. The diabetes service delivery environment Forces for integration Forces for differentiation These are elements that require integration in These are elements that require individual order to promote good outputs of products, attention to promote flexible, high quality diabetes services and ideas: care. • Service providers forming a • Individual professions multidisciplinary team around the individual (ie. Medical and non-medical, specialists and generalists) • Health care as core business • Aboriginal and other cultures working across core businesses (e.g. health, education, social, housing, socio-economic structures) • System solutions that are focused on • Solutions focused on sub-populations and diabetes as a whole individuals WRAS PTY LTD PAGE 15
  16. 16. Integrated Diabetes Care FINAL REPORT • Geographical proximity • Remote locations • Continuum of care • Disease episodes • Active consumers who self-manage • Passive consumers who are reliant upon the system • Accountability, information technology • Relative autonomy (decision support systems, intelligent information systems) • Limited resources requiring focus across • Resources focusing on individual elements primary, secondary and tertiary prevention such as Tertiary care • Focus across primary, secondary and tertiary • Competition between generalist and service providers specialist ideology • Guidelines, protocols and care paths • Therapeutic freedom • Relatively objective, evidence based • Professional judgement treatment (outcomes assessment, economic evaluation) • Monitoring and evaluation • Focus on delivery • Chronic disease focus • Diabetes focus Source: modified from a table presented by Primary Care Partnerships, Integrated Disease Management: Interim Policy Directions and Guidelines, Victorian Government Publishing Service, 2001. The evaluation confirms that all these elements exist within the WA diabetes service delivery environment. See section 6, Table 15 for reference to the Pilot Programs and the existence of the forces of integration and differentiation within each. 3.2.IMPLEMENTATION OF THE IDC PILOT PROGRAMS IN WESTERN AUSTRALIA 3.2.1.Background and Program objectives In 1997/98 the DOH developed a reinvestment strategy for purchasing diabetes services. The focus of the strategy is to develop and support an integrated service delivery model that ensured: • Equitable access to a full range of diabetes services. • Health professionals’ access to training and support. • Systems for co-ordinated care. • Systems for ensuring standards. • Systems for monitoring outcomes. • Commitment to the development of a locally appropriate service delivery model. The key objective is to create an informed community that practices positive diabetes prevention and control. The introduction of IDC commenced in 1998, with the purchasing of four pilot projects by the DOH. Each project was based on the NSW model, but was developed to reflect local needs and priorities as each region has different geographic and demographic profiles. The projects are located in: • Inner City health locality • Upper Great Southern health locality • Lower Great Southern health locality • Midwest health zone. The pilots are due for completion in June 2001. The sections following provide summarised findings and outline achievements of the pilot projects against anticipated WRAS PTY LTD PAGE 16
  17. 17. Integrated Diabetes Care FINAL REPORT program and project outcomes. Details of individual projects are located in the appendix to this report. 3.2.2.Summary of common evaluation themes Although each pilot region had its unique features, remarkable similarity was found between regions in major themes. • Integration was viewed as an acceptable model that has the potential to be applied across a broad range of health systems. • Perceptions that IDC funding was inadequate to meet the demand for services from the population with diabetes. • Access to diabetes services is inequitable. This issue is particularly evident amongst Aboriginal and gestational populations. However, a related theme was the need for a model of diabetes service delivery that incorporates, primary, secondary and tertiary prevention. • GP acceptance of, and involvement in IDC Programs is critical to the progress of integration. Meeting other members of the multi-disciplinary team is critical to networking and referral processes. • Rural and remote service providers are particularly concerned about the focus of the current Curtin University training program in diabetes, which is viewed as expensive, difficult to attend, and not relevant to the development of generalist skills. • A co-ordinator’s position is critical to program implementation and maintenance, however the position does not have sufficient authority to implement change quickly. • The pilots were generally viewed as consistent with the NSW model of IDC but understanding of integration varied considerably. • Skills in change management are critical for diabetes co-ordinators. Even after programs have been established, negotiations with service providers are a part of daily work. • Guidelines and protocols for quality diabetes care are perceived as sufficient. • There is insufficient planning and monitoring of progress and planning. • Adolescents with diabetes who have moved from tertiary centres in the Perth metropolitan area have no transition to adult programs. • There are tensions with Silver Chain service providers in rural locations. • Service providers in rural and remote locations have additional challenges relating to isolation, recruitment and retention, access to services, access to professional support, and competition with generalist roles. There also appeared to be a correlation between the development of structures and systems within pilots and the degree of integration achieved. The Inner City and Lower Great Southern (LGS) pilots did more planning and had more consistency in co-ordination of the program than the Midwest or Upper Great Southern Pilots. The former pilots also had more success in achieving set goals than the latter. Although it was not within the scope of the evaluation to form a judgement on the success of individual pilots, it could be argued that planning and people are key features of effective integration and have had a direct impact on the pilots’ progress. WRAS PTY LTD PAGE 17
  18. 18. Integrated Diabetes Care FINAL REPORT 3.2.3.Inner City In many ways, the Inner City is further advanced than other pilot regions and is now experiencing a high demand for services. The general theme arising from the pilot is that there are now improved services and service integration, with patients behaving differently and demonstrating better understanding of diabetes. However, the pilot now faces the challenge of being unable to provide services to meet demands. Its metropolitan location has meant that the project’s focus has had to incorporate a variety of NESB populations. The Inner City health locality project has a number of features likely to enhance program effectiveness and sustainability including: • Metropolitan location • Continuity of committee members • Comparatively higher funding • Access to local tertiary centres • Quarterly and annual reporting of progress against its business case. There was a strong match between the common themes generated across all regions and the major issues of importance within the Inner City region. Over the page, Table 3 and 4 show the outcomes cited in reports to the DOH. Table 3. Achievement of projects against original submission INNER CITY OBJECTIVES REPORTED OUTCOMES 1. Provide community based education services • 1998 - 250 people attended training to 480 people with NIDDM and their partners • 1999 – 340 people attended training per year in the inner city • 2000 – 70 in first 5 months 2. Conduct a needs assessment and pilot • 1998 - Needs assessment and pilot programs programs to identify appropriate services and established with focus on Italian and service locations for people with diabetes Vietnamese from NESB • 2000 – these programs were expanded to include other Health Services 3. Implement at least 4 programs targeting high • 1998 – 2 day workshop held for strategic risk groups that will increase diagnosis and planning focusing on diabetes prevention reduce modifiable risks for developing • 2000 – first risk reduction program diabetes commenced for GDM 4. Implement systems for co-ordinated care, • 1998 – RPH provided practical placements quality standards of care, health professional for local podiatrists training and support, and systems of • GP registrations for diabetes education monitoring of health outcomes training with Perth DGP • Co-ordinator attended diabetes education training • Logo, generic referral form/ foot assessment and ophthalmologist assessment form developed • Systems for co-ordination of podiatry services under development • Local Area Co-ordination Committee meets quarterly – ongoing to 2001 • 2000 – Expansion to include other regions, DGP, hospitals DGP in program for discharge processes • Steering committee terms of reference WRAS PTY LTD PAGE 18
  19. 19. Integrated Diabetes Care FINAL REPORT developed for eye check program and GDM • Working party focusing on community podiatry in place Table 4 . Performance against outcomes sought through the application of the IDC model OUTCOMES SOUGHT THROUGH IDC GENERAL THEMES IDENTIFIED THROUGH THE EVALUATION PROCESS 1. Equitable access to a full range of diabetes • Emphasis on podiatry and optometry/ services ophthalmology services • Project officer appointed to progress continued community education • Majority of perceptions suggested access to services was not equitable. Lower risk patients now ‘clogging’ system. • Social and psychological services needed • Privately insured viewed as a gap in service 2. Health professionals’ access to training and • Training emphasis in 1998 support • Mixed responses received 3. Systems for co-ordinated care • Systems for co-ordinating podiatry services exist • Continuity of steering committee • Clarity of direction of steering and committee • Cultural barriers and practices between service providers identified, especially with AHW and Community HW • Multiple complex system development cited as a problem • Heavy reliance on co-ordinator 4. Systems for ensuring standards • RPH assisted with training of podiatrists • Pilot eye-check program 5. Systems for monitoring outcomes • Insufficient data collection and monitoring • Quality improvement processes not built in • Evaluation of strategic plan absent 6. Commitment to the development of a locally • Initial focus on inner city area only with appropriate service delivery model expansion in 2000 to incorporate other metropolitan stakeholders • Identification of needs within NESB populations • Evaluation of pilot diabetes clinic at AMS and pilot community diabetes programs in 1998 • High level of acceptability amongst service providers WRAS PTY LTD PAGE 19
  20. 20. Integrated Diabetes Care FINAL REPORT 3.2.4.Upper Great Southern The original business case submission did not segment between UGS and LGS, and very similar indicators were developed for both regions. The UGS pilot had a history of staff changes and the most recent local co-ordinator is now employed in more generalist role focusing on chronic disease. General perceptions of service providers were that diabetes care is improving but considerable effort is still needed within the region. The locality is challenged by ongoing issues such as: • Geographical isolation • Disagreements between some Aboriginal groups • Recruitment and retention of health professionals • Access to service providers (e.g. endocrinologists). The objectives for the pilot are almost identical to those of the LGS health locality, with the exception of those areas reported in Table 5 below. Where reported outcomes for this region exist, they have been combined with those of the LGS health locality. Table 5. Objectives unique to the UGS pilot project UNIQUE UGS OBJECTIVES REPORTED OUTCOMES 1. 1998 – 1999 To develop a co-ordinated • Currently working with primary health and diabetes assessment and education plan for Family Futures. Opportunistic, ad-hoc the adult Aboriginal population strategy. Examined community based education programs. 2. 1999-2000 To identify defined access to • Primary health expanded services to diabetes education, podiatry and dietetic outlying towns. Senior dietician mapped services in each health service needs and obtained second dietician. More lifestyle programs, focus on diagnosed and undiagnosed. 3. 2000-2001 To register 95% of expected • Reported at a regional level only 79% of known people with diabetes who attend a GP target (>1000 people registered) WRAS PTY LTD PAGE 20
  21. 21. Integrated Diabetes Care FINAL REPORT Table 6 . Performance against outcomes sought through the application of the IDC model OUTCOMES SOUGHT THROUGH IDC GENERAL THEMES IDENTIFIED THROUGH THE EVALUATION PROCESS 1. Equitable access to a full range of diabetes • The majority of respondents suggested there services is not equity of access • No community education occurs • Consumers cited problems with accessing local services • No services for GDM 2. Health professionals’ access to training and • Educational barriers were cited as an area of support particular concern • Hospital and community service staff (e.g. police) require training 3. Systems for co-ordinated care • Problems with retention of staff has interrupted program continuity • Current local co-ordinator is highly respected and has an integrated role with other chronic diseases • Political issues between health services were also highlighted • A referral process exists between GPs and the co-ordinator, for diabetes education 4. Systems for ensuring standards • Service duplication is occurring between GPs, Aboriginal services and diabetes education services. 5. Systems for monitoring outcomes • Highlighted as an area of weakness • More systems for accessing patient records are needed • No planning is apparent for IDC 6. Commitment to the development of a locally • High acceptability amongst service appropriate service delivery model providers and patients, with the exception of difficulties relating to GPs • Move towards integration with chronic disease seems positive 3.2.5.Lower Great Southern The LGS health locality appears to have made significant progress towards the integration of services. The initial business case made few distinctions between the UGS and LGS and this is reflected in reporting of the pilots. In the first year of funding strategic planning was conducted for the entire region, and included the Central Great Southern (CGS) Health Service. The outcome of this planning was the formation of advisory committees in each health locality, including CGS. The development of the LGS pilot has deviated significantly from its original objectives, but is captured in the broader outcomes sought by the IDC Program. It could be argued that this development has occurred in response to the environmental demands within the health locality and the region. The major features of the LGS pilot include: • Involvement of GPs WRAS PTY LTD PAGE 21
  22. 22. Integrated Diabetes Care FINAL REPORT • Development of recall and referral systems and the use of a diabetes register (although this is restricted to the Division of GP) • Behavioural changes such as increased participation in programs, reduced inpatient time, increased screening, interdisciplinary support, increased awareness of diabetes, and increased motivation amongst people with diabetes. The information reported in Table 7 was obtained directly from reports supplied by the LGS health locality to the DOH and discussions with the pilot Co-ordinator. Table 7. Achievement of projects against original submission LGS OBJECTIVES REPORTED OUTCOMES 1998-1999 1. To implement an integrated diabetes service 1. Steering committee established in the LGSHS area 2. To register 80% of expected known people 2. 79% of target registration achieved with diabetes 3. 87% of General Practitioners registering 3. To register 100% of newly diagnosed people patients on diabetes database with NIDDM 4. Development of standards for diabetes 4. To increase by 50% patient access to quality education program. Major focus of program diabetes education programs time devoted to a variety of initiatives 5. To provide podiatry education, assessment 5. RPH contracted, local training for service and treatment services providers on podiatry 6. To identify an appropriate diabetes hand held 6. Planned but not implemented as focus on passport register instead 1999-2000 1. To register 90% of expected known people 1. Endorsement of GS Diabetes Policy with diabetes 2. Standards for Diabetes Education programs 2. To implement the patient held passport accepted 3. To formalise the roles of diabetes service 3. Identification of roles and referral pathways providers for diabetes education providers 2000-2001 1. To register 90% of expected known people 1. 87% target registration achieved with diabetes • No other progress against objectives 2 - 4 2. To identify the number of elderly people in recorded the population with diabetes 3. To identify the number of IDDM registered >15 years of age 4. To implement the diabetes prevention programs for first degree relatives WRAS PTY LTD PAGE 22
  23. 23. Integrated Diabetes Care FINAL REPORT Table 8 . Performance against outcomes sought through the application of the IDC model OUTCOMES SOUGHT THROUGH IDC GENERAL THEMES IDENTIFIED THROUGH THE EVALUATION PROCESS 1. Equitable access to a full range of diabetes • Inequity of access focuses on Aboriginal services populations and remote communities 2. Health professionals’ access to training and • Educational barriers were cited as an area support of particular concern • Informal education is occurring between disciplines due to integration 3. Systems for co-ordinated care • A number of examples, including referral processes, committee meetings, diabetes register, shared community education • Some problems with Silver Chain due to decreased attendance at education sessions • Diabetes policy developed • Management participating • More integration needed with AHW’s 4. Systems for ensuring standards • Standard guidelines for community education, referral forms 5. Systems for monitoring outcomes • Clinically focused • Audits of diabetes education occurring • Register used by GPs but some problems • General perception that monitoring is not sufficient 6. Commitment to the development of a locally • Acceptability is generally high for service appropriate service delivery model providers and patients 3.2.6.Midwest The business case for the Midwest was prepared by staff from the Great Southern Public Health Unit. Similar to the UGS pilot, the Midwest Region experienced significant challenges to its establishment, including: • Turnover of diabetes co-ordinators and the position change from full-time to part-time • Merging of the co-ordinators’ role with that of diabetes education • Changes in fund holders from the Midwest PHU to the Geraldton Health Service • Management of co-ordination processes by volunteer committee members during times of vacancy (the position was vacant for a total of one year of the 3 year pilot) • Competition with Aboriginal services and between health services • Problems associated with managing health service delivery in rural and remote areas. This general perception of this pilot was that it has not achieved integrated care and will require considerable effort to recover lost ground. More details are reported in Tables 9 and 10 on the next page. WRAS PTY LTD PAGE 23
  24. 24. Integrated Diabetes Care FINAL REPORT Table 9. Achievement of projects against original submission MIDWEST OBJECTIVES REPORTED OUTCOMES 1998-1999 1. To establish a co-operative forum to 1. Established a Midwest steering committee – implement integrated diabetes service in the continued to 2001 Midwest Region 2. To identify the appropriate health service 2. Needs Analysis commenced capacity to meet consumer needs in Geraldton 3. To increase diabetes training for health 3. Training implemented for service providers, professionals including AHWs 4. To improve access to quality diabetes 4. Diabetes awareness week and a remote education programs promotion day established 5. To establish a diabetes register and recall 5. Register initiatives commenced, support for system in Geraldton DGP and separate register for PHU. 17 out of 50 GPs used the system with over 300 patients registered 1999-2000 1. To identify the appropriate health service 1. Needs analysis completed, which included capacity to meet consumer needs in the training needs of health professionals Midwest and Murchison areas 2. To maintain ongoing diabetes training 2. Study days introduced in Geraldton and education programs for health professionals Meekatharra 3. To extend the diabetes register and recall 3. Big drop in use of register, 2 out of 50 GPs system throughout the Midwest Region used the system 4. To improve primary prevention and 4. Diabetes awareness and some community promotion activities in the Midwest Region education programs 2000-2001 1. To maintain and increase diabetes education 1. Some local service providers including prevention and promotion activities in the chemist, HBF held promotions. Web site Midwest Region currently being developed 2. To increase to 90% the number of GPs 2. No progress reported referring to the register and recall system 3. To incorporate into the integrated service 3. No progress reported model people with a history of GDM once a national consensus on diagnosis of this group has been achieved. WRAS PTY LTD PAGE 24
  25. 25. Integrated Diabetes Care FINAL REPORT Table 10 . Performance against outcomes sought through the application of the IDC model OUTCOMES SOUGHT THROUGH IDC GENERAL THEMES IDENTIFIED THROUGH THE EVALUATION PROCESS 1. Equitable access to a full range of diabetes • Aboriginal and remote communities services feature very strongly on the list of sectors lacking access to services • A web-site is in development • Perceptions that access to basics such as insulin and test strips is limited to one distributor in Geraldton • Remote communities rely on the goodwill of local people who remain with communities to provide diabetes services 2. Health professionals’ access to training and • Although training programs were support implemented in 1998 and 1999, there is little evidence of ongoing training • Educational barriers were cited as an area of particular concern 3. Systems for co-ordinated care • Mini-systems of integrated care are being established by service providers (e.g. GPs), but they have no relationship to the pilot • Interpersonal and interdisciplinary conflicts • Role of co-ordinator has changed • Tenuous partnerships not supported by formal structures • Focus of committee is on service provision in Geraldton • No integration with Aboriginal service providers • Automatic referral between GPs and Silver Chain occurring • No integration between the Midwest Health Services Planning Committee and the steering committee 4. Systems for ensuring standards • Duplication of services for Aboriginal people, and by community education, GPs and health services 5. Systems for monitoring outcomes • No planning or monitoring processes evident 6. Commitment to the development of a locally • Commitment evident in first year of appropriate service delivery model implementation, with problems arising after this time. Current focus is on Geraldton only. WRAS PTY LTD PAGE 25
  26. 26. Integrated Diabetes Care FINAL REPORT 3.3.EFFECTIVENESS OF THE IDC PROGRAM & MODEL This section focuses on assessment of effectiveness of the program implemented within Western Australia as well as effectiveness of the IDC model as the means of achieving the program outcomes and objectives. 3.3.1.Summary The effectiveness of the pilot projects within the IDC Program has varied considerably. As a whole, diabetes service provision has improved across the pilot regions. Visible changes in consumer behaviour are cited in the Lower Great Southern and Inner City pilots. Pilots in UGS and Midwest locations have had problems compounded by staff turnover, distance, absence of a critical mass of service providers, and limited access to training. In the case of the Midwest, mini- systems of integration (e.g. where a local GP has set up a unique network of diabetes service providers) have formed in reaction to frustrations with the progress of diabetes service delivery. The effectiveness of integration models is supported in literature in other Australian states as well as internationally. Integration of services is also occurring in non-pilot regions of WA. However, the IDC Program in WA has weaknesses and gaps (e.g. absence of planning and monitoring) that make it vulnerable to the external environment. Overall, integration is an appropriate model for WA diabetes service delivery, but the pilot projects need to be merged with an IDC Program that incorporates attention to a broader set of environmental elements than those conceived by the NSW model. Forces for differentiation should also be acknowledged in future diabetes planning if the IDC Program is to maximise its effectiveness and sustainability. 3.3.2.Consistency with national objectives The major themes emerging from state and commonwealth health agencies are: • A solid trend towards application of integrated care models in every state of Australia. • A trend towards integration of chronic disease services, rather than diabetes specific integration. • A trend towards integration models which incorporate primary prevention, early intervention, and quality management of diabetes. 3.3.3.Compatibility with other models of service delivery The primary elements of the IDC model applied by WA is similar to that implemented by the Commonwealth Department of Aged Care, NSW and the ACT, although each of these states have now moved to models of chronic disease integration. The Victorian Department of Health Services has recently introduced a model of Integrated Disease Management, which incorporates broader elements in its definition of integration. Western Australia has a unique environment due to its relative isolation and broad set of environmental elements impacting diabetes service delivery. Application of the WRAS PTY LTD PAGE 26
  27. 27. Integrated Diabetes Care FINAL REPORT NSW model to the IDC Program was a sound starting point for service delivery change but is no longer a satisfactory model for WA diabetes care. 3.3.4.Level of acceptability The evaluation also sought respondents’ perceptions on the acceptability of the IDC Program amongst service providers, patients and at-risk groups and found that: • Amongst service providers, acceptability of the IDC Program was high. • Amongst patients, acceptability of the IDC Program was medium to high, with the exception of remote consumers who do not have access to services. • Amongst at-risk populations, acceptability of the IDC Program was low. Reasons included lack of service, non-compliance and non-understanding, poor management, language, cultural or disability barriers, and poverty. These perceptions were generally consistent across all pilot regions. Increased acceptance of the model of IDC was related to issues including: • Continuity of funding • Professionalism in the approach to change • Continuity of people involved in the management program and information • Acceptance of differentiation forces • Clarity of direction and models of good • Visible services and changes in consumer practice behaviour • Improved communication and decreased conflict 3.3.5.Strengths Integrated models of health care are a good match for the needs of diabetes, and have the potential for high levels of effectiveness and sustainability. Where they are working well in WA the following strengths are reported: • Changes in client behaviour and motivation • Improved knowledge of diabetes by service • Access to new populations providers, consumers and community • Identification of previously undiagnosed • Cost efficiencies consumers • Improved management practices • Reduction in hospital admissions • Increased continuity, interchange and back- • Development of health indicators up of care and information • Increased range of services • Increased quality of care • Better relationships between health • Decreased duplication of services professionals • Enhanced responsiveness to environment 3.3.6.Gaps Although the current IDC pilots in WA have a number of weaknesses, it is the gaps in the IDC Program that have the greatest impact on program effectiveness and sustainability. These gaps come from unmet environmental needs and major themes include: • Perceptions of funding inadequacy and • Consideration of forces for differentiation inconsistency of funding objectives • Consideration of the issues innately • Strategic planning, including definition of impacting rural and remote service provision integration and vision • Incentives for changes in service delivery • Knowledge of change management • Access to services for sub-populations • Data collection and monitoring • Policy development to support processes • Absence of a common program identity or image WRAS PTY LTD PAGE 27
  28. 28. Integrated Diabetes Care FINAL REPORT 3.3.7.Weaknesses A broad variety of weaknesses were highlighted by respondents to the evaluation. Many of these themes were consistent with findings in national and international literature: • Professional differences in philosophy, • Increased expectations but insufficient approach and expected outcomes services to respond to increased demand • Competing priorities (e.g. GP attention, • Insufficient number of professionals (e.g. direction of programs, other health issues) endocrinologists, rural areas) • Short term commitments to funding • Inadequacy in current training delivery • Lack of continuity of personnel between • Inadequate co-ordinator training, knowledge funder, purchaser and provider groups of change management, role clarity, support • Poor capacity to adapt to meet changing • Disjointed feedback on progress environmental demands • Reliance on co-ordinator • Emphasis on tertiary care 3.3.8.Barriers As previously noted in this section, the major barriers encountered by the Program appear to relate to forces for differentiation. The core problems with discounting these forces are the inability of the Program to plan for resistance and identify appropriate priorities. Furthermore, some of the barriers identified below are associated with gaps occurring in the Program, which causes innate problems for program effectiveness: Barriers in common with gaps: Other barriers: • Perceptions of funding inadequacy, conflicts • Strength of existing medical model between the objectives of funding sources, • Financial survival of service providers (e.g. problems with funding application Silver Chain) processes, and perceived lack of continuity • Conflict of new systems with existing of funding business processes and structures • Strategic planning, including WA definition • Primary problems with terminology, of integration and vision standards and measurement tools • Data collection and monitoring surrounding diabetes integration • Absence of a common program identity or • Professional and interpersonal conflicts image • Continuity of staff and awareness of • Consideration of the issues innately diabetes service providers in WA impacting rural and remote service provision • Rural economies of scale • Incentives for changes in service delivery • Lack of community awareness of diabetes (e.g. to cope with time and service level • Cost of services to consumers demands) • Cultural barriers • Access to services for sub-populations • Policy development to support processes 3.3.9.Duplications The major duplication currently occurring within the state is the development of integration models. At local and regional levels, duplication of service delivery is reduced as integration increases. WRAS PTY LTD PAGE 28
  29. 29. Integrated Diabetes Care FINAL REPORT 3.3.10.Unintended consequences Unintended consequences have been both positive and negative: Positive Negative • Increased cross-fertilisation of information • Consumer dependence on services and education between health professionals • Generation of expectations without being • Increased community awareness, interest able to meet demand and education • Service providers forced to act alone when • Non-participating services and regions have integration processes break down commenced integration of care • Silver Chain marginalised • Better regional services • Low risk patients ‘clogging’ services and • Support for integration of services within preventing access for high risk patients other chronic disease programs • Resistance where integration has failed • Access to community diabetes experts has • Additional workloads for allied health led to reinforcement of consumer behaviour professionals without GP incentives and increased motivation amongst consumers • Knowledge of diabetes has improved quality of treatment in other chronic disease areas 3.3.11.Potential impact on health outcomes The potential impact of the IDC Program is a co-ordinated, cost-effective service that facilitates access to ongoing diabetes services across a range of sub-populations. Respondents’ overall view of the potential impact of integration was very positive, with the capacity to decrease the social and economic impact of diabetes, and other chronic diseases in WA. 3.4.PROGRAM SUSTAINABILITY 3.4.1.Summary It is acknowledged that the IDC Program is in its infancy, and is an appropriate model for diabetes service delivery in Western Australia. The IDC pilot projects do not seem to be sustainable in their present form. However, attention to the elements listed below seems highly likely to generate future sustainability within the IDC Program: • Enhancement of the profile of diabetes as a major health issue in Western Australia • Increased resources to support expansions in service delivery around a framework of IDC • Development of a framework for a state-wide IDC Program • Implementation of further structures within the IDC Program • Enhancement of general knowledge of diabetes for people in health related roles • Increased consumer involvement in the IDC Program WRAS PTY LTD PAGE 29
  30. 30. Integrated Diabetes Care FINAL REPORT 3.4.2.Funding Funding is a primary force for ensuring sustainability. At present funding is problematic and issues raised through the evaluation include: • Perceived inadequacy of funding, particularly in the primary and secondary prevention elements of diabetes service delivery. • Perceptions that there is always an emphasis on short term funding, giving the impression that diabetes services may be discontinued at whim. Co-ordinators were also concerned about the frequency and timing of funding submissions, which often place additional burdens upon their time and attention to other matters. • Diversity of diabetes funding sources at a commonwealth and state level. This diversity has generated conflicts of objectives that impact upon sustainability and the time devoted to reporting requirements. • Conflict between service providers about control of funding. • Diabetes consumers bear a proportionally high burden of medical expenses, and can be discouraged from access to a range of health services because they cannot afford to attend. The sustainability of the program is not assisted by barriers preventing access. 3.4.3.Planning Little planning is conducted in the current IDC projects. This finding is of major concern to future sustainability, and is partly due to the absence of baseline or monitoring data for diabetes services. It seems clear that comprehensive planning is required if the IDC Program is to succeed in the future. As noted previously, planning must consider all elements of the diabetes service environment, and program effectiveness can be maximised if all stakeholders contribute to the development of a strategic, state-wide integration plan. It has been suggested by respondents that the DOH should allocate resources to assist in the co-ordination of a diabetes planning forum. A forum would have significant advantages in acting as a catalyst for change, networking, and integration. A state-wide approach would also have advantages in the establishment of a strong diabetes image and vision for the future. 3.4.4.Culture To be sustainable, an IDC model must lead to enhancement in relationships between and within funder, purchaser and provider groups. The literature highlights that professional and interpersonal conflicts are common in integrated care models. However, it seems that a positive culture of collaboration and co-operation can be attained if: • Attention is given to both integration and differentiation elements during planning. • Change management is approached professionally, through the application of appropriate facilitation and feedback skills. 3.4.5.Human Resources Human resource planning and management are critical elements to sustainability and attention needs to be paid to a number of distinct elements, including: WRAS PTY LTD PAGE 30

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