Background: Multi-morbidity is a growing global challenge for health services with single disease focuses. To address this challenge, we co-designed an integrated model of care for diabetes and chronic kidney disease (CKD) informed by the needs of health-care providers and patients and their perceived enablers and barriers to optimal health-care.
Methods: Participants, including patients with co-morbid diabetes and CKD, care-givers and primary and tertiary health professionals were purposively recruited from 4 tertiary health services across Melbourne and Sydney. Twelve focus groups were conducted with 58 patients, with a further 6 focus group performed with 65 health professionals. Semi-structured interviews were conducted with 8 care-givers and 8 heads of specialist units. Discussions were audio-taped, transcribed and independently analysed thematically by 2 researchers. Emergent key themes informed the co-design of a new health-care model, with a committee of key stake-holders including diabetologists, nephrologists, GPs and representatives from Diabetes Australia and Kidney Health Australia.
Results: The co-designed health-care model is patient-centred with an emphasis on empowerment and education to facilitate self- management. The GP remains the coordinator of care with an integrated diabetes-kidney service providing ancillary support. Communication is enhanced between primary and specialist care and between health professionals and patients via a diabetes-kidney care plan given to the patient after each clinical review. The care plan is used for patient education and to facilitate self-management. The integrated diabetes-kidney service provides continuity of care, screens for psychological morbidity and has a phone advice line accessible to both patients and GPs. It also upskills GPs.
Conclusions: We have co-designed a comprehensive Australian model of care for co-morbid diabetes and CKD, specifically tailored to meet the needs of patients and health providers. Implementation and evaluation of the model of care is underway at Monash Health.