Coordinated Community Care for Diabetes Project

Coordinated Community Care for Diabetes Project (CCC4D)

The coordinated community care for diabetes (CCC4D) project was established in late 2012 and concluded in 2015. The project aimed to improve the journey and outcome for patients with type 2 diabetes (T2D) across acute and primary care.

Key project achievements:

Development of a needs assessment to inform project activities
Implementation of a Diabetes Quality Improvement Project (DQIP) in eight general practices
Education and training events for health care professionals and consumers
Development of consumer resources to support self-management in the community
Development of a suite of diabetes pathways to improve access to clinical and referral guidelines and support coordination of care across settings.

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Key project findings

Establishment of strong partnerships and clear project governance structures ensures key stakeholders are engaged in an effective and meaningful way.
Undertaking a needs assessment is essential to clearly identify the case for change, establish project objectives and inform project activities.
Clinical leadership in quality and service improvement projects is essential to ensure activities are relevant, clinically appropriate and can be realised in practice.
There is varied primary care capacity and systems in place to provide best-practice comprehensive chronic disease management care for patients with T2D.
There is limited access to secondary consultation for primary care clinicians to support delivery of care in the community. In addition, existing funding mechanisms do not readily enable the provision of specialist support to increase primary care capacity.
There was limited access to readily available clinical and local referral guidelines.
There is limited use of eHealth technologies to support delivery of secure and timely communication between providers and with patients.
There is limited access to performance data on the provision of best-practice care and service waiting times.

Key recommendations:

The following key recommendations have been endorsed by the project steering committee to address the identified findings. It is recommended that there be an ongoing focus within each of the organisations and through the Collaborative on:

Increasing workforce capacity across the sector to manage chronic conditions
Strengthening systems to support chronic disease prevention and management
Providing patient information, education and self-management support