Background: People with low socio-economic status have a greater risk of developing Type 2 Diabetes. For those who do develop Type 2 Diabetes, those with low SES are at higher risk of poor diabetes control and self‐management, greater development of diabetes-associated complications and more avoidable hospitalisations.
Corio, a low SES area of Geelong in regional Victoria, has a very high prevalence of Type 2 diabetes. Limited income and limited access to transport were identified by patients as significant barriers to accessing appropriate multidisciplinary care.
Objective: To improve the attendance of Type 2 diabetes patients at multidisciplinary diabetes care consultations, the co-ordination and consistency of advice provided to patients in order to enhance patient self-management and improve patient outcomes.
Approach: In 2008, a private general practice in regional Victoria in partnership with Barwon Health, the local regional health service, established an Integrated Diabetes Clinic where a credentialed diabetes educator, podiatrist and dietitian work at the general practice in an adjacent diabetes clinic to consult people with Type 2 Diabetes. Appointments are coordinated so that multiple team members can be consulted at the one patient visit. All health professionals record their notes into the same electronic database allowing reinforcement of educational advice from other team members and providing more consistent education and lifestyle and management advice to patients.
Findings: Preliminary analysis of clinical data shows modest improvements in blood pressure, HbA1c, lipid levels and proportion of patients at target HbA1c and on Insulin. Increased patient attendance, patient engagement and reported confidence in self-management were also demonstrated.
Discussion: Further enhancements to the model with the addition of visiting medical specialists are imminent. Ongoing analysis of the model will be continued to assess effectiveness and ultimately whether such an approach leads to improved management, reduced complications and reduction in avoidable hospitalisations.