Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.