An integrated model of care was developed by Hunter Alliance Diabetes Workstream, aiming to improve type 2 diabetes patients’ outcomes and experience. Collaborative case consultations and lunchtime training sessions build clinical skills, confidence and capacity of practice staff to better manage diabetes in primary care.

Twenty practices each recruited 30 patients for a case conference with their GP, Practice Nurse, visiting Endocrinologist and Diabetes Educator. In this holistic approach, the specialist team provides expert knowledge and the primary care team provides a clinical, social and psychological history.

Process changes have been implemented by primary care teams as a result of their participation, including establishing recall systems to identify ‘at-risk’ patients and nurse-led clinics to ensure the annual cycle of care is completed. ‘Practice Champions’ have been identified, with protected time to monitor data and develop response processes.   Additionally, weekend Practice Nurse education has been delivered by request (90 participants).  It was identified that resources should be available to integrate diabetes as a specialty within practices. One practice plans to construct a purpose-built Chronic Disease consultation room, specialising in diabetes.

Practice Nurse feedback indicated increased confidence to educate patients and an acknowledgement of “the importance of applying a more thorough review each visit – not just focusing on HbA1c”. The resources supplied and what was learnt during the consultations have been applied to other diabetes patients in the practice.  It was noted that patients like completing the food and BGL diaries.  “It gives them a sense they are part of the process too”.

The Diabetes Educator experience has also been positive, fostering partnerships that facilitate proactive care.  All of the clinicians participating rated the experience as “satisfying /very satisfying” with patients feeling involved, comfortable and supported as a result.  “The collaboration between us practice nurses and the specialist team is invaluable.”