Jayne James, SESLHD - T2 The Road to Self-Management

T2 The Road to Self Management

Tom Chapman

– SESLHD Chronic Care Redesign Manager

Jayne James

– SESLHD Integrated Diabetes Pathway Manager

South Eastern Sydney Local Health District

SESLHD Region

• 9 Local Government Areas

• Sydney's Central Business District to the Royal National Park Sydney

• 2011 census

– Population 830,000

– Northern Sector 45%

– Southern Sector 55%

South Eastern Sydney Local Health District

SESLHD

• 7 Hospitals

• 2 Medicare Locals

– Eastern Sydney

– South Eastern Sydney

Trends in obesity and inadequate physical

activity

Since 1997, the proportion of overweight or obese residents has increased

by about a third. This is a prime driver for the escalating rate of

hospitalisations for diabetes among our residents. In turn, the increasing

prevalence of diabetes is driving increases in people requiring dialysis for

chronic kidney disease.

0123456789

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Smoothed estimate (%) Actual estimate (%)

Diabetes or high blood glucose, persons ≥16 years, South Eastern Sydney LHD

Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW

Ministry of Health. Available at: www.healthstats.nsw.gov.au. Accessed (08/07/2013).

SESLHD Diabetes population

is increasing ~ 0.3% per year

At this rate in 5 years time 10% of

the population will have Diabetes

or high Blood Glucose

Hospitalisations for Chronic Ambulatory

Care Sensitive Conditions Diabetes is overtaking all

other Chronic Conditions for

hospitalisation rates

In SESLHD every day around 60

residents are

hospitalised with Diabetes as the

principal diagnosis or an

important comorbidity (2011 stats)

Diabetes Complications

Increasing numbers of patients with complications of diabetes due to poor self management and poor glucose

control.

Over the past decade 20,000 amputations have occurred in

Australia due to diabetes1.

In Australia over the past decade, 10,000 people have lost their sight

due to diabetes1.

1: National Diabetes Strategy and Action Plan 2013: Diabetes Australia

Our Community, Our Services…A snapshot (August 2012)

Based on current trends, diabetes, followed by falls, are

expected to have the greatest future impacts on our health

system.

High Priority Initiatives

Establish an integrated,

multidisciplinary diabetes program to

facilitate increased patient knowledge

and skill necessary for both diabetes

self-care and active collaboration with

health care providers, to improve

clinical outcomes and reduce the need

for hospital care.

Integrated Diabetes Project ( Sept. 2012)

SESLHD Integrated

Diabetes Project

Type 1 Type 2

T2 the road to self management

Gestational Adolescent/Tra

nsitional

Project Overview

Improve access to standardised validated education and self-management

support for newly diagnosed type 2 diabetes patients in the Northern sector of

SESLHD.

SESLHD Diabetes population is

increasing ~ 0.3%/ year

Up to 50% of patients with T2DM do

not access education

Diabetes hospitalisations are

escalating

Solution Design Project Initiation &

Start - up

Diagnostics

Solution Design

Implementation

Planning Implementation

Checkpoints

• Post Implementation Evaluation

• Review & Redesign of Unsuccessful Initiatives

• Continuous Cycle of Redesign – Sustainability

• Sharing of Knowledge

• Writing For Publication

• Implement Quick Wins

• Implement all Solutions

• Trouble Shooting

• Coaching & Support

• Monitoring and Reporting

• Implementation Plans for Quick Wins

• Business Cases

• Implementation Teams

• Change Readiness Assessment

• Sponsorship Roles & Responsibilities

• Project, Stakeholder, Communication & Change Management Plans

• Performance Management

• KPI Definition & Measurement Plan

• Piloting Initiatives

• Literature Search for Best Practice Solutions

• Facilitated Problem Solving & Brainstorming

• Solutions Identification

• Cost/Benefit Analysis of Solutions

• Prioritisation of Solutions

• Detailed Solution Statements

• Develop Quick Wins

• Process Mapping

• Diagnostic Tools & Techniques

• Staff Interviews

• Patient Interviews

• Patient Tag Alongs

• Data Collection & Analysis

• Baseline KPI ’ s

• Issues Identification

• Issues Prioritisation

• Root Cause Analysis

• Building the Case For Change

• Project Management

• Project Objectives & Measuring Benefits

• Project Scoping

• Governance & Reporting

• Roles & Responsibilities

• Project Deliverables & Scheduling

• Project Costs

• Risk Management

• Change Management

• Stakeholder Management

• Communications Management

Centre for Healthcare Redesign - Methodology

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

To identify ways to improve the process, share lessons and drive sustainability

To design and prioritise solutions to issues and build stakeholder support

To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change

To develop the project scope and set up project, change, communication and stakeholder management plans

To implement solutions and confirm that benefits are being delivered

To develop a comprehensive plan for implementing solutions and measuring benefits

Diagnostics Project Initiation &

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Project + Change + Stakeholder + Communication Management

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Start - up

Diagnostics

Solution Design

Implementation

Checkpoints

• Business Cases

• Process Mapping

• Project Scoping

• Project Costs

• Risk Management

Implementation

Planning

Evaluation

Sustainability

Knowledge

Sharing

Diagnostics

Project Objectives

1. Establish an integrated clinical framework to support an integrated patient

pathway that provides for newly diagnosed type 2 diabetes patients by

August 2013.

2. To have 10% of GP’s in ESML accessing and implementing this referral

pathway for patients newly diagnosed with type 2 diabetes by March

2014; increasing incrementally to achieve 50% by March 2015

3. To have 20% of newly diagnosed patients with type 2 diabetes following

the established integrated pathway; receiving standardised, validated

diabetes self management education by March 2014; increasing

incrementally to 75% by March 2015

Project Initiation and start-up

Established a steering and working group

SESLHD Integrated

Diabetes Project

Type 1 Type 2

T2 the road to self management

T2 Steering Group

T2 Working group

Gestational Adolescent/Transitional

Key Role Map South Eastern Sydney Local Health District

CE SESLHD

Director of

Medicine

Endocrinologist,

Head of

Endocrinology

Nursing Manager

POW Diabetes

Centre

Diabetes Centre

EducatorsPOW Community

Nurses

Community

Health

Director,

Community Health

Project Team

Jayne James

Tom Chapman

Chronic Care

Integration Unit

Manager

Director of

Ambulatory and

Primary CareDirector of

Operations POW

CEO Eastern

Suburbs

Medicare Local

Manager,

Population

Health

Eastern Suburbs

GP’s

Eastern Suburbs

Practice Nurses

Primary Care

Co-Director

Community Health

and Aged Care

Governance

Management

Patient

Contact

= direct line management

= influence only

Medical

StreamCommunity

HealthAmbulatory and

Primary Care

Co-Director Acute,

Cardiac and

Comm. Care

SESLHD

Redesign Leader

GP & ESML

Board member

POW Nursing Co-

DirectorJenny

Wilson

Northern Network

Executive

Directly

consulted at

some stage

Part of

committees/

working groups

Community

Pharmacy

PATIENTS

Executive

Sponsor

Stakeholder

stakeholders

stakeholder

Stakeholder

Scoping the Project

IN SCOPE Reason

Patient Newly diagnosed Type2 diabetes (within last 12 months)

GP diagnosed Impaired Fasting Glucose or Impaired

Glucose Tolerance

This patient group identified as being

the fastest growing and currently

only 50% receive diabetes

education.

Process Northern sector chosen as the ESML

most able to partner at the time.

SESML still in restructure.

Patient with Type

2 Diabetes

Diabetes Centre

Community Health

Other Health

Specialists

Practice nurse

Stakeholders Surveys File

Patient

Journey

Interviews Mapping Issues

GP’s

Practice

Nurses POW

Diabetes

Centre

Community

Health

Patients

District

Resources

Diagnostics Tools / Methods used

Diagnostics

Key findings Patient Interviews

“Assumed tablets were going to

control it and there wasn’t much to it,

now I realise there is lots to it as far

as eating right and exercise”

“New GP

takes time to

explain things

– it seems

like he really

cares.

I feel more

re-assured

“First doctor

was too

business like

– wouldn’t

talk”

“Initially cut

down sugar in

tea and coffee

and didn’t

really do any

thing else”

Was getting

blackouts – tried

jelly beans, brother

said get treatment

“Nuisance with no car for

shopping and day trips I stay

at home now, I some times

feel depressed’

24 Diagnostics

Mapping Eastern Sydney Medicare Local

93 Solo GP’s 53 Small GP

Practices (2-5)

43 Large GP

Practices 6+

86 Practice

Nurses

• Eastern Sydney Medicare Local has the largest proportion of solo GP

Practices than any other Medicare Local.

• This is significant in that solo GP practices can rarely afford a Practice

Nurse, or have the space for a Practice Nurse to work.

25 Diagnostics

Practice Nurse Distribution in Suburbs

Practices with Practice Nurse's

Number of Practice Nurse's

= lowest socioeconomic suburbs.

These areas are poorly resourced with practice nurses 26

Diagnostics

Summary of Key Diagnostic Data

Nearly 80% of referrals to the POW DEC are made by GP’s

32% of referrals had

all the relevant information

Time from referral to first appointment varied from 1

week to 6 months.

Diagnostics

Process mapping:

GP > Diabetes Centre

Practice Nurse Survey

Only 10% of Practice Nurses

provide diabetes education in a

structured format.

No recognised format was

identified.

No diabetes group education

is provided.

36% do not provide any

diabetes education.

Issues Prioritisation

Impact on patient

Ability to

Influence

Low High

Low Priority

Medium Priority

High Priority

2.Consistent

pt education

3.Education to

reduce

variation in

practice

1.Flexible

pt access

Communication 5. Knowledge

gap of what is

available in

primary care

Current patient Journey

Diabetes Education Pathway

Newly Diagnosed with Type 2 Diabetes

Large variation not only in

where to go but what is

delivered.

Patient diagnosed

with Type 2

Diabetes

Centre

Community

Dietitian Practice

Community

Health

Centre

Internet

Podiatrist

Pharmacist

Endocrinologist

Exercise

Physiologist

Friends

Family ISSUE

Patient options for Diabetes

Self-Management Education

and Support are dependent on

GP connectivity. There is no

standard treatment

Knowledge of current services

both primary and hospital

Diagnostics

Solutions Prioritisation

Description

Ability to Influence Impact

Ease of

Implementation

Cost of

Implementation

Ability to

Influence

Impact on KPI Benefits for

Patients Benefits for Staff

Impact

Scoring System Easy (9)

Moderate (3)

Difficult (1)

Low (9)

Medium (3)

High (1)

previous 2

Positive:

Significant impact

Moderate impact (3)

Low impact (1)

Positive Impact (9)

Neutral Impact (3)

Negative Impact

Positive Impact (9)

Neutral Impact (3)

Negative Impact (1)

forums and events 9 7 16 7 7 9 23

Develop a referral pathway 5 7.5 12.5 7.5 6.5 8 22

Common service directory 4 8 12 8 9 9 26

Standardise correspondence 9 9 18 3 3 3 9

Single point of access 4 4 8 9 9 8 26

Collaborate on one education

package for health staff 4 4 8 7.5 5 9 21.5

Train a broad range of health

care workers from diverse

backgrounds and cultures to

deliver standardised

training/education

4.5 2.5 7 6 9 7.5 22.5

Solution Design

0 13.5 27

Solutions Prioritisation In

Impact (KPI’s + patients + staff)

Common service directory

Develop/enhance networking

forums and events

Develop a

referral

pathway Standardise

correspondence

Collaborate on one

education package

for health staff

Single point of access

Train a broad range of health care

workers from diverse backgrounds

and cultures to deliver

standardised training/education

Solution Design

Will be covered by

the larger Diabetes

Project

Desired patient Journey

Diabetes Education Pathway

Newly Diagnosed with Type 2 Diabetes

Patient diagnosed

with Type 2

Diabetes

Centre

Community

Dietitian

Practice Nurse

Community

Health Centre

Internet

Podiatrist

Pharmacist

Endocrinologis

Exercise

Physiologist

Friends

Family

ComDiab

Generalist

Community based

diabetes self

managament

education.

Those requiring more comprehensive

Diabetes Education. Or more immediate referral.

Triaged by

Access and

referral centre

SOLUTION

Develop a Referral Pathway +

a Single Point of Access

SOLUTION

ComDiab General education

on self management, the

multidisciplinary team and

annual cycle of care.

SOLUTION

Common service directory

available to all sectors

Service Directory

Solution Design

Implementation planning

• Prioritise Actions

• Implementation

• Build Business Case

• Identify KPI’s &

evaluation measures

Plans are nothing -planning is everything (Dwight D. Eisenhower)

Accelerating Implementation

Methodology (AIM) Identify the C.A.S.T

Champion

Sponsor

Target

A.I.M Communication

Strategy

Timing

Newsletter

A.I.M Readiness and

Resistance

‘The path to least resistance

is what makes the river

crooked’(Elbert Hubbard)

A.I.M Assess the Climate

‘Insanity is doing the same

thing over and over again

and expecting different

results’ (Albert Einstein)

Implementation Checkpoints

Implementation checkpoints

2013 Aug Sept Oct Nov Dec 2014 Jan Feb March

Evaluation check points

First ComDiab Sessions

IT links to directory

Book venues

Training complete

Business plan

endorsed

Directory complete

Engage Sponsor

Plan endorsed

Achievements

GP or other Dr diagnoses

Type 2 Diabetes with in last 12

months or Impaired Glucose

Tolerance or Impaired Fasting

Glucose

Is patient appropriate for

ComDiab referral?*

Would ComDiab supplement

GP education for patient to

promote self management?

GP or health

professional provide

patient with referral

information to call

GP calls NNARC

Either ****

Open new referral

in CHIME

And inform Patient

of referral

NO*ComDiab eligibility Criteria

· Diagnosis: Newly diagnosed

T2DMwith last 12 months

· IGT, IFG

· Not on insulin therapy

· Ability to partake in interactive

group session.

· English comprehension ability

· English reading ability

· Or is Carer of above

· Carers welcome to attend

· Can attend existing multicultural

group **POW Diabetes Centre eligibility

Criteria

*** GP working group to define

**** Investigate electronic referral via

GP to NNARC

Does patient meet

criteria for referral to

Diabetes Centre?**

Does patient meet

criteria for ComDiab

referral?*

Contact referral

source for

information

Is referral

information

complete?

Confirmation letter

generated in CHIME and

sent to patient and GP

YESRefer to Diabetes

Centre

Meds check

Private Endo

Private DE

Are there other

options for this

patient?

Meds check

Private Endo

Private DE

Refer back to GP

Pathway approach

Achievements

Networks Relationships & Responsibility

Two Registered Nurses

Complete

• Online training (12 hours)

• 3 day workshop

To do:

Observed and assessed

delivering community sessions.

Ongoing:

Attend an annual review day.

Achievements

Staff trained in

ComDiab

Achievements

Integration &

Collaboration

Australian

Diabetes

Council

Patient

Community

Health

GP’s SESLHD

Chronic

Diabetes

Education

Centre

Practice

Nurses

Challenges

Implementation checkpoints

Where to ….

Solution 1: Co-build a common service directory ESML and SESLHD

Solution 2: Develop a referral pathway with a single point of access

Solution 3: ComDiab General Education on self management, the multidisciplinary team and annual cycle of care

Acknowledgements

Sponsors - Dr Greg Stewart and

Linda Soars

South Eastern Sydney Medicare

Australian Diabetes Council

Prince of Wales Diabetes Centre

Prince of Wales Community Health

Elizabeth Mason – Redesign

Manager

NSW Health Redesign School

Steering Committee

Working Party

Only 15% of the job is

figuring out what to do.

Making it happen – that is

where the action is (F Warren Mcfarlan)

Jayne James, SESLHD - T2 The Road to Self-Management

Health & Medicine

Transcript of Jayne James, SESLHD - T2 The Road to Self-Management