Evaluation of Shared Care Community Diabetes (SCC) Clinics: A clinical microsystem approach

Background
The prevalence of type 2 diabetes is reaching pandemic proportions globally and in Australia with devastating effect on morbidity, mortality and cost.1 More than 880,000 Australians aged over 25 years are affected and at risk of acute and chronic micro and macro vascular complications, including retinopathy, nephropathy, neuropathy, peripheral vascular disease, coronary heart disease and stroke; as well as mental health problems.2 It has been demonstrated that these complications can be significantly reduced with rigorous glycaemic control.2 

Most people with type 2 diabetes in Australia receive the majority of their care from their GP. Askew et al (2010) suggests around 5% of diabetes consultations lead to the GP referring patients for specialist care. Most commonly, these are to an already stretched specialist outpatient clinic which reinforces the need to consider the way services are delivered such as shifted or outreach specialist models.1, 2

The Model
A newly established model of specialist care in the primary sector has been implemented in five general practices within SCDGP. This service, underpinned by a multi-intervention framework to implement change and enhance type 2 diabetes management in the primary sector has led the approach taken in the Shared Care Community Clinics. This is a multi-faceted specialist diabetes service model with the central tenets being a) a focus on improving access for patients with complex needs, b) improving health care provider clinical knowledge, c) building a team culture, and c) enhancing practice based processes to systematically manage their patients with diabetes.

It is an outreach service with a view to increasing the accessibility and effectiveness of specialist services and integration with primary care services.5 The model is a shared care arrangement with the idea that it will improve quality and coordination of care and improve communications between health sectors.4 The model features an educative component to up-skill primary providers, both GPs and practice nurses with the view to maximising the skills and strengths of primary care providers.3, 6 The model provides support for practices to adopt systems improvements and a team approach in the management of their patients with diabetes. The model is located in a familiar environment for the patient with a view to improving attendance rates and build self-management capacity.

A diabetes specialist team comprising of Diabetes Specialist and Endocrinologist and Diabetes Educator visit one of the five general practices each month to do either a morning or afternoon session. The referral criteria include items such as those patients with poor glycaemic control and significant associated co-morbidities. Patients with type 2 diabetes mellitus are the focus however type 1 diabetes mellitus and other endocrine disorders are also seen.

The sessions involve the Diabetes Educator supporting the practice nurse to undertake screening measures using a dedicated assessment tool and to ensure each client has been “worked-up” sufficiently to gain maximum advantage of the specialist time. The nursing team also identify patient’s capacity to self-manage, focusing on areas such as knowledge of their illness, device management, foot care and glucose monitoring. The patient then has a consultation with the GP and diabetes specialist team combined. Further diabetes education support such as insulin management is available. If other allied health professional support is needed, patients are referred to external local providers.

Systems improvement support includes items such as clinical data integrity, maintaining a register of patients with diabetes, developing quality reminder systems, deciding billing arrangements and encouraging the team approach to diabetes care. The important role the administration personnel provide is highlighted through their key involvement in appointment scheduling, managing billing items and supporting patient flow.

Each practice visit by the specialist team includes a learning session over a light breakfast or lunch. Case studies or other topics of interest are discussed. GPs from each practice are encouraged to undertake diabetes clinical fellow training with a partner university. Nurses are also encouraged to undertake diabetes management professional development.

A number of print and electronic resources have been sourced, developed and made available to practices as part of this model such as the previously mentioned assessment tool, referral for ambulatory insulin stabilisation, clinical audit extraction tool, foot assessment tool, role descriptions and scheduling templates.

Research Question
What are the factors that contribute to or limit the effectiveness of the SCC clinics, following the clinical microsystem approach?

Methods
This study has used a mixed methods approach. Patients and health care professionals (GPs, Nurses, Diabetes Specialist) were invited to complete a self-administered structured questionnaire guided by the domains of the clinical microsystem framework. Additional patient clinical outcome measures as early indicators in diabetes management are also being investigated.

This evaluation has been funded by PHC RED (Primary Health Care Research, Evaluation and Development) grant and is being conducted by Jenny Morcom as part of a partnership arrangement between University of Queensland and SCDGP. This evaluation would not have been possible without the contributions from patients consenting to participate, practice staff and members of the specialist team.

References
1. Zimmet, p., The burden of type 2 diabetes: are we doing enough? Diabetes & Metabolism, 2003. 29(4): p. 6S9-6S18.
2. Askew, D.A., et al., Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care. BMC Health Serv Res, 2010. 10: p. 134.
3. Jackson, C., et al., GPs with special interests - impacting on complex diabetes care. Aust Fam Physician, 2010. 39(12): p. 972-4.
4. Smith, S.M., S. Allwright, and T. O'Dowd, Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev, 2007(3): p. CD004910.
5. Gruen RL, W.T., Knight SE, Bailie RS., Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database of Systematic Reviews, 2003. Art. No.: CD003798. DOI: 10.1002/14651858.CD003798.pub2(4).
6. Renders, C.M., et al., Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev, 2001(1): p. CD001481.