Type 2 diabetes is projected to become the leading cause of disease burden by 2023. It is predicted that Type 2 diabetes trends in the City of Whittlesea are among the highest in Victoria. Health care based on a strong primary health care system has been shown be as effective as those centred in tertiary care. A diabetes team-based model at Plenty Valley Community Health has been developed with the intention of reducing the risks of developing acute and chronic complications of diabetes.
This observational study was conducted to assess if the service delivered to patients meets the demand for our growing population with improved primary health care outcome. A review of patients enrolled in our diabetes service was conducted over a 12 month period. Information and data collection was accessed from clients electronic health record (Trakcare) at admission and again at 12 months. Data on pre-specified demographic, clinical and outcome variables, was extracted. Differences between subgroups were tested using univariable regression or the χ2 test, as appropriate.
A total of 67 diabetic patients were follow up during the 12 months of study period. The mean age of the patients was 62.3 years with male patients accounting for 46.3% of all episodes. A mean reduction in HbA1c of greater than 2% was achieved during the one year period. 61% of patients required an Endocrinologist input to maintain the HbA1c reduction. A did Not Attend (DNA) rate of fewer than 10% was achieved across the team.
It has found that a facilitated team-based care model is effective in lowering HbA1c in a catchment with a complex and challenging client cohort. In addition to the clinical outcomes and improved client experience, the service design allows for improved data capture and the administration of a care package that adheres to funding targets and reduces length of stay.