Poster Presentation Australian Diabetes Society and the Australian Diabetes Educators Association Annual Scientific Meeting 2016

Co-designing an integrated patient-centred health service for co-morbid diabetes and chronic kidney disease. (#337)

Clement Lo 1 2 , Helena Teede 1 2 , Peter Kerr 2 , Dragan Ilic 3 , Alan Cass 4 , Gregory Fulcher 5 , Martin Gallagher 6 7 , Greg Johnson 8 , Tim Mathew 9 , Kerry Murphy 3 , Kevan Polkinghorne 2 , Grant Russell 10 , Tim Usherwood 11 , Rowan Walker 12 , Sophia Zoungas 1 2 7
  1. Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
  2. Monash Health, Clayton, VIC, Australia
  3. Department of Epidemiology and Preventive Medicine, School of Public Health and Prevenitve Medicine, Monash University, Melbourne, Victoria, Australia
  4. Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
  5. Department of Diabetes and Endocrinology, The Royal North Shore Hospital, Sydney, New South Wales, Australia
  6. Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
  7. The George Institute of Global Health, Sydney, New South Wales, Australia
  8. Diabetes Australia, Canberra, ACT, Australia
  9. Kidney Health Australia, Adelaide, South Australia, Australia
  10. School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
  11. Department of General Practice, Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  12. Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia

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.