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Chronic Disease Diabetes Model of Care Redesign

13 June 2017

The project involved redesigning the existing Chronic Disease Diabetes Model of Care to align with the MSH Service Plan. The project objectives were:

To embed a connected and enhanced model of care to improve the patient journey and to build capacity through improved system efficiencies to appropriately manage diabetes across the spectrum of the disease.
To decrease clinical variation – everyone working towards the same goal.
To develop a clear understanding of the current service provision, identify changes required and opportunities to improve.

Aims & Goals:

To improve the capacity of primary care services to prevent and manage diabetes and its complications
Develop an efficient interface between general practice (GP), community-based diabetes prevention and management services and acute services
Improve efficiencies within the acute care setting, by identifying current gaps in service
Improve work flow process – scope of practice, defined work roles
Create clear referral pathways for inpatient/outpatient services and improve patient flow
Reduce avoidable hospital admissions/presentation.

Evaluation/outcomes:

This project met the planned objectives:

Develop referral pathway for Cat 3 and 4 low risk services to primary care and community based prevention programs to the Diabetes Queensland DESMOND and SMARTS program
Transitioned Cat 3 and 4 low risk services from the MSHHS What Now group programs to primary care and community based prevention programs

Implementation of the QAS-MSHHS Diabetes Service referral pathway to identify diabetic patients who frequently use the QAS service and present to the hospital for non-acute care
Provide a direct referral from QAS to the MSHHS Diabetes Service for clinically appropriate patients to decrease the number of hospital presentations and non-acute service episodes for QAS
Provision of MSHHS Diabetes Service to support patient access to knowledge and self-management of their chronic condition

Improve adolescence/paediatric services Logan contract in place with Mater Young Adults Outpatient Clinics for patients to access services

Improvements to workflow, patient journey and SOPD waitlist – process change to ARMS for direct options for Beacon Clinic and Nurse Practitioner clinics
Development of Nurse Practitioner discharge criteria to decrease duplication and service variation

Lead Service / Stream:

Keywords:

Diabetes, Chronic Disease, Model of Care

Last updated 12 December 2018