The ‘stepping up’ diabetes model seeks to reorient clinical roles to use existing resources in a smarter way to improve patient outcomes and reduce the burden of care. By building the capacity of general practice and practice nurses to deliver intensified diabetes treatment in primary care, the confidence of specialists to discharge patients from clinics may increase and enable clinic access for new patients genuinely requiring specialist intervention.
This project is seeking to test the implementation of the Stepping Up model of care in general practices within the Collaborative catchment.
The problem the model of care seeks to address is the delay in treatment intensification for type 2 diabetes in the primary care setting, despite this being both warranted and demonstrated to be effective. This problem has flow-on effects that result in poorer patient outcomes and higher demand on hospitals.
The model of care allows general practices to work to a fuller capacity and provide their patients with better and more timely care.
What is the project?
The project is a real-world implementation of an existing evidence-based model of care. It is all about new ways of working and building capacity in general practice to deliver more care in the primary care setting.
The aim of the project is to train two registered nurse Credentialed Diabetes Educators (RN-CDEs) based in Merri Health and cohealth to undertake mentoring roles to support practice nurses in their areas to play a more active role in the initiation of insulin and other injectable therapies in general practice.
The model is underpinned by the following components:
A reoriented role for the specialist RN-CDE. They act as a mentor for the practice nurse rather than provide direct patient care.
Case-based training provided by CDEs to GPs and practice nurses
An enhanced role for the practice nurse
Simple algorithms and protocols to guide treatment intensification
The project has been resourced by North Western Melbourne Primary Health Network on behalf of the Collaborative.
$102,166 [ex. GST] for contracting the University of Melbourne for project management and project development
$100,000 [ex. GST] for RN-CDEs (2 x 0.5 FTE roles at both cohealth and Merri Health)
NWMPHN provide contract monitoring, project governance and communications support.
cohealth and Merri Health have undertaken the recruitment and management of project RN-CDEs, practice recruitment, and practice nurse mentoring.
Has it worked (did it address the problem)?
Project timelines were ambitious and the practice recruiting effort has taken longer than intended (was planned to be completed between 15 September and 18 December 2017). As such we are only just starting to get data and feedback from practices that are implementing the model of care.
Through the recruitment process the project group engaged with over 50 practices in the region and had 18 practices consent to the delivery of the model. Time was the most significant barrier faced, as it was quite difficult working with busy practices to find isolated time to deliver the introductory presentation, deliver training, complete data searches, and, finally, commence patient care.
This delay in practice recruitment has been accompanied by delayed recruitment of patients. In part this is due to late commencement in practice, but the patient identification approach has garnered fewer patients than expected. This is most likely due to poor data quality at general practice level and alternative approaches are being considered. Alternatively, though unlikely, the practices that are willing to engage with Stepping Up may already be high performing practices that are delivering quality care to their patients, and do not have a high number of patients that fit the project criteria.
What strategies in place to find more patients?
Practice profile (finding the right practice) readiness tool?
Throughout the project we have developed significant IP that offers opportunities for future scaling or transferring of Stepping Up with significantly reduced project start up time.
Key learnings from the project
Dedicated time to preparing CDEs for delivery of the project
This was a vital aspect of the project as the skills CDEs need to execute in Stepping Up are not natural for most diabetes educators
Recruiting time – longer timelines required (as discussed above)
Translation work is a worthwhile
There is confidence in the model of care that we are implementing, so the question is not “will it work?” but “how do we make it work?”
Engaging an outside party to manage a collaborative project has worked well
Key learnings from working in partnership
Building common language
defining processes, roles and responsibilities among partners is a critical task in project start up. We spent significant energy early on in the project agreeing to what everyone was going to do
Use governance processes for oversight and eliminate organisational boundaries between operational staff
The operational staff, (University of Melbourne and the CDEs from Merri Health and cohealth) bought into the shared goal of the project
Partnership work can be slow but is rewarding
Each organisation has different “constituencies” – partnership work opens doors that may otherwise be closed
Delivery of Stepping Up in practices finishes up in June 2018
Evaluation will follow
At the conclusion of the project there will be further development of resources to support future implementation
Collaborative could consider options for use of intellectual property built through this project