FINAL REPORT
The Integrated Diabetes Care Program in Western
Australia:
An Evaluation
October 2001
Produced for General Health Purchasing,
Department of Health
By Western Research Advisory Services Pty Ltd.
Western Research Advisory Services Pty Ltd
4 Laurence Road Innaloo 6018 Western Australia
Telephone: (08) 9244 9229
Email: wras@touch88.com.au
Integrated Diabetes Care
FINAL REPORT
This evaluation was commissioned by the Department of Health (DOH) and contracted to Western
Research Advisory Services Pty Ltd.
ACKNOWLEDGEMENTS
Western Research Advisory Services Pty Ltd wishes to thank the many people who gave their time,
knowledge and interest to this evaluation. Your assistance has been invaluable. We also give our
special thanks to the Project Committee and the Diabetes Co-ordinators in each pilot region:
 Ms Penny Brown (Chair)
 Ms Lisa McGinnis
 Mr Lindsay France
 Dr Jill Rowbottom
 Mr Noel Carlin
 Ms Emma Ellis
 Mr Tim Reid
 Ms Maureen Unsworth (Inner City)
 Ms Kaye Neylon (Upper and Lower Gt Southern)
 Ms Kirsty Boltong (Midwest)
Our many thanks also go to the consultancy team:
 Lisa Jarman
 Chris Worthington
 Susan Leeming
 Flavia Bises
 Jo Hart
Limitations Statement
The information contained in this report is based on sources believed to be reliable. However, as no independent
verification is possible, Western Research Advisory Services Pty Ltd, together with its members and employees,
gives no warranty that the said sources are correct, and accepts no responsibility for any resultant errors contained
herein and any damage or loss, howsoever caused, suffered by any individual or corporation. The findings and
opinions in this report are based on research undertaken by Western Research Advisory Services Pty Ltd as
independent consultants and do not purport to be those of the Department of Health.
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TABLE OF CONTENTS
1.
EXECUTIVE SUMMARY ........................................................................................................... 6
1.1.
TERMS OF REFERENCE ............................................................................................................. 6
1.2.
MAJOR FINDINGS ..................................................................................................................... 6
1.2.1.
Overview ............................................................................................................................. 6
1.2.2.
The importance of program ‘fit’ to diabetes and its implications for the IDC Program .... 7
1.2.3.
Implementation of pilot projects ......................................................................................... 8
1.2.4.
Effectiveness ....................................................................................................................... 9
1.2.5.
Sustainability ...................................................................................................................... 9
1.2.6.
Applicability...................................................................................................................... 10
2.
RECOMMENDATIONS............................................................................................................. 11
3.
INTEGRATED DIABETES CARE: OVERVIEW & DISCUSSION .................................... 13
3.1.
DIABETES AND ITS INFLUENCE ON HEALTH CARE SYSTEMS : .................................................. 13
3.1.1.
The Open Systems Model and its relevance to the concept of integration ........................ 13
3.1.2.
The NSW Model of IDC .................................................................................................... 15
3.1.3.
Diagnosis of the diabetes service delivery environment ................................................... 15
3.2.
IMPLEMENTATION OF THE IDC PILOT PROGRAMS IN WESTERN AUSTRALIA .......................... 16
3.2.1.
Background and Program objectives................................................................................ 16
3.2.2.
Summary of common evaluation themes ........................................................................... 17
3.2.3.
Inner City .......................................................................................................................... 17
3.2.4.
Upper Great Southern ...................................................................................................... 20
3.2.5.
Lower Great Southern ...................................................................................................... 21
3.2.6.
Midwest ............................................................................................................................. 23
3.3.
EFFECTIVENESS OF THE IDC PROGRAM & MODEL ................................................................... 26
3.3.1.
Summary ........................................................................................................................... 26
3.3.2.
Consistency with national objectives ................................................................................ 26
3.3.3.
Compatibility with other models of service delivery ......................................................... 26
3.3.4.
Level of acceptability ........................................................................................................ 27
3.3.5.
Strengths ........................................................................................................................... 27
3.3.6.
Gaps .................................................................................................................................. 27
3.3.7.
Weaknesses ....................................................................................................................... 28
3.3.8.
Barriers ............................................................................................................................. 28
3.3.9.
Duplications...................................................................................................................... 28
3.3.10.
Unintended consequences ............................................................................................ 29
3.3.11.
Potential impact on health outcomes ........................................................................... 29
3.4.
PROGRAM SUSTAINABILITY ................................................................................................... 29
3.4.1.
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3.4.2.
Funding............................................................................................................................. 30
3.4.3.
Planning ........................................................................................................................... 30
3.4.4.
Culture .............................................................................................................................. 30
3.4.5.
Human Resources ............................................................................................................. 30
3.4.6.
Structures .......................................................................................................................... 31
3.4.7.
Measurement systems ....................................................................................................... 32
3.4.8.
Technology........................................................................................................................ 32
3.5.
3.5.1.
Capacity to influence other areas of service delivery ....................................................... 32
3.5.2.
Applicability to other regions and program areas............................................................ 33
3.6.
4.
5.
REFERENCES .......................................................................................................................... 33
APPENDIX A: METHODOLOGY ........................................................................................... 34
4.1.
TERMS OF REFERENCE ........................................................................................................... 34
4.2.
ISSUES CONSIDERED IN RESEARCH DESIGN ........................................................................... 34
4.3.
DATA COLLECTION AND ANALYSIS ....................................................................................... 35
APPENDIX B: LITERATURE REVIEW ................................................................................ 36
5.1.
OVERVIEW OF DIABETES MELLITUS ....................................................................................... 36
5.2.
DIABETES PREVALENCE IN AUSTRALIA AND WESTERN AUSTRALIA ...................................... 37
5.3.
DIABETES SERVICE PROVIDERS ............................................................................................. 38
5.4.
CONCEPTS OF INTEGRATION AND DIFFERENTIATION .............................................................. 38
5.5.
THE CONCEPT OF INTEGRATION OF HEALTH CARE .................................................................. 40
5.6.
MODELS OF INTEGRATED DIABETES CARE ............................................................................. 41
5.7.
EXPERIENCES OF INTEGRATED DIABETES CARE MODELS ........................................................ 42
5.7.1.
General experiences ......................................................................................................... 42
5.7.2.
The NSW Model of Integrated Care ................................................................................. 44
5.8.
6.
APPLICABILITY ....................................................................................................................... 32
OBJECTIVES OF NATIONAL AND WA STRATEGIES ................................................................. 45
5.8.1.
National Diabetes Objectives (2000-2004) ...................................................................... 45
5.8.2.
Commonwealth Department of Health and Aged Care Objectives 2000-2004 ................ 45
5.8.3.
The WA Diabetes Strategy 1999 ....................................................................................... 46
5.8.4.
Metropolitan Health Plan 2020 ........................................................................................ 46
5.8.5.
References ......................................................................................................................... 47
APPENDIX C: QUALITATIVE DATA THEMES .................................................................. 50
6.1.
PILOT REGIONS: BACKGROUND AND PROGRESS TO DATE ...................................................... 50
6.1.1.
Inner City Region.............................................................................................................. 50
6.1.2.
Upper Great Southern Health Locality............................................................................. 59
6.1.3.
Lower Great Southern Region .......................................................................................... 65
6.1.4.
Midwest Region ................................................................................................................ 74
6.2.
THEMES FROM OTHER WESTERN AUSTRALIAN STAKEHOLDERS ........................................... 84
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6.2.1.
Implementation of the IDC model ..................................................................................... 84
6.2.2.
Effectiveness of the IDC model ......................................................................................... 84
6.2.3.
Sustainability of the IDC model ........................................................................................ 87
6.3.
7.
SUMMARY OF INTERSTATE TRENDS........................................................................................ 89
6.3.1.
The Commonwealth Department of Health and Aged Care ............................................. 89
6.3.2.
The New South Wales Experience .................................................................................... 90
6.3.3.
The Tasmanian Experience ............................................................................................... 91
6.3.4.
The Australian Capital Territory Experience ................................................................... 91
6.3.5.
The Victorian Experience ................................................................................................. 92
6.3.6.
The Northern Territory Experience .................................................................................. 92
6.3.7.
The Queensland Experience ............................................................................................. 92
6.3.8.
The South Australian Experience ..................................................................................... 92
APPENDIX D: MONITORING INDICATORS ....................................................................... 93
ABBREVIATED TERMS
ACT
Australian Capital Territory
NIDDM
AHW
AMS
CGS
DGP
EPC
GDM
Aboriginal Health Worker
Aboriginal Medical Service
Central Great Southern
Division of General Practice
Enhanced Primary Care
Gestational Diabetes Mellitus
NSW
PHU
RPH
UGS
WA
WADST
GP
GRAMS
General Practitioner
Geraldton Regional Aboriginal
Medical Service
Great Southern Public Health
Unit
Health Benefit Fund
Health Care Professional
Department of Health
Integrated Diabetes Care
Insulin Dependent Diabetes
Mellitus
Lower Great Southern
Lower Great Southern Health
Service
Midwest Allied Health
National Diabetes Strategy
Non English Speaking
Background
GSPHU
HBF
HCP
DOH
IDC
IDDM
LGS
LGSHS
MWAH
NDS
NESB
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Non Insulin Dependent Diabetes
Mellitus
New South Wales
Public Health Unit
Royal Perth Hospital
Upper Great Southern
Western Australia
Western Australian Diabetes Strategy
Taskforce
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1. EXECUTIVE SUMMARY
1.1.
TERMS OF REFERENCE
The Consultant was engaged to conduct an evaluation of the Integrated Diabetes
Care (IDC) Program that was implemented in the following four pilot regions of
Western Australia (WA) in 1998, Inner City East Perth, Midwest, Lower Great
Southern Health Service and Upper Great Southern Health Service. The evaluation
was intended to assess the progress, effectiveness, sustainability, and applicability of
the Program and was not intended to evaluate individual pilot projects. The aim of
the Program is to develop and support an integrated service delivery model that
ensures:
 Equitable access to a full range of diabetes services.
 Health professionals’ access to training and support.
 Systems for co-ordinated care.
 Systems for ensuring standards.
 Systems for monitoring outcomes.
 Commitment to the development of a locally appropriate service delivery model.
The evaluation was conducted between January and March 2001. Data were
collected and collated from centralised DOH records, literature review, qualitative
interviews with service providers and stakeholders, focus groups and written
submissions. In total, 100 qualitative interviews and 11 focus groups were
conducted.
1.2.
MAJOR FINDINGS
1.2.1. Overview
Diabetes Mellitus is a complex, chronic disease requiring input from a variety of
disciplines as well as considerable attention to self-management by the individual. It
is a major world-wide health issue with very significant social and economic costs.
The prevalence of diabetes is on the increase throughout the world, and its influence
on current and future health care systems should not be underestimated.
There is a world-wide trend towards the use of integrated models of care in health
systems, especially in response to diabetes. More recently, many countries, including
Australia have begun integrating diabetes into chronic disease programs because risk
factors, education, and treatment overlap with other types of chronic diseases (e.g.
cardiovascular, vascular, renal).
In 1995, the New South Wales (NSW) Health Department trialled three, two year IDC
projects to test the hypothesis that “the impact on the system of chronic disease and its
sequelae could be reduced by the provision of well organised care founded on agreed,
evidence based guidelines for best practice, which incorporates patient education and
early detection of complications” (Boyages, Sheridan & Close, 1999, p85). This
population based approach was used as a template for the WA IDC pilots.
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1.2.2. The importance of program ‘fit’ to diabetes and its implications for the IDC
Program
The evaluation applied an ‘Open Systems’ model to the data to diagnose the current
functioning of diabetes service delivery in WA, and to identify the elements of the
IDC Program requiring change (Cummings & Worley, 1993). When applied to
diabetes service delivery, the Open Systems model proposes that programs are only
effective and sustainable if they are match or ‘fit’ the needs of the diabetes
‘environment’. The ‘environment’ includes people with or at risk of diabetes, the
people who assist them manage or prevent diabetes (e.g. families, health and allied
professionals), where they are located, and organisations that compete with diabetes
for attention and money. For instance, the NSW model outlined above considers
some of the elements by designing its program to incorporate early detection and
patient education. It also introduces integration as a means of acknowledging the
need for continuous, high quality care.
The evaluation’s literature review found that integration is a fundamental principle or
‘force’ that comes from the external environment and drives the design of any
program. For instance, in the WA diabetes environment, people are spread out in
rural and remote areas across the state, but the number of people with diabetes are low
in these areas compared with the metropolitan population. Therefore, any diabetes
program must consider available resources, and how they can be integrated to provide
a diabetes service to rural and remote areas. One of the ways rural and remote health
providers have tried to maximise resources is to have people in health roles with
generalist skills, rather than people who only have skills in diabetes. In this instance
the integration that has occurred refers to the merging of diabetes knowledge with
other health knowledge.
There is another fundamental force in the environment that drives programs towards
‘differentiation’ and opposes attempts to integrate. Differentiation refers to the need
for a program design that pays attention to individual elements within the
environment (Lawrence & Lorsch, 1967). For instance, the WA Diabetes Strategy
(1999) emphasises attention to prevention, primary care and specialised care. Each
of these elements is differentiated because they are all critical to the reduction of
diabetes prevalence in the future. However, the evaluation highlighted that the
majority of purchaser and provider effort focuses on specialised care interventions.
Therefore, over-attention on this area causes the others to suffer, and prevents the
achievement of long term goals. Appropriate levels of attention need to be given to
each differentiated element to address diabetes. In the context of program design,
forces for differentiation should not be considered ‘good’ or ‘bad’. Rather they
should be acknowledged and included in planning processes.
The literature on diabetes care refers to a number of problems with integrated models
but does not appear to acknowledge the existence of forces for differentiation. The
evaluation suggests that differentiation must be also considered in models of diabetes
service delivery if they are to be effective and sustainable. The original conception of
the IDC Program in WA gave attention to integration systems. It seems that the IDC
Program needs to be updated to incorporate attention to a broader set of
environmental elements than those conceived by the NSW model. Forces for
differentiation should also be acknowledged in future diabetes planning.
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1.2.3. Implementation of pilot projects
Although each pilot region had its unique features, remarkable similarity was found
between regions in the major themes listed below:
 Integration was viewed as an acceptable
model
 IDC funding was inadequate
 Access to diabetes services is inequitable
 GP acceptance of, and involvement in IDC
Programs is critical
 Current training provision is inappropriate
for rural and remote service providers
 There is insufficient planning and
monitoring of progress and planning

A co-ordinator is critical, as are their skills
in change management
 The original submissions were based on the
NSW pilot
 Service providers in rural and remote
locations have additional challenges relating
to isolation, recruitment and retention,
access to services, access to professional
support, and competition with generalist
roles
There also appeared to be a correlation between the development of structures and
systems within pilots and the degree of integration achieved. For instance, the Inner
City and Lower Great Southern (LGS) pilots did more planning and had more
consistency in co-ordination of the program than the Midwest or Upper Great
Southern Pilots. The former pilots also had more success in achieving set goals than
the latter.
In many ways, the Inner City is further advanced than other pilot regions and is now
experiencing a high demand for services. The general theme arising from the Inner
City pilot was that services and service integration have improved, with patients
behaving differently and demonstrating better understanding of diabetes. The Inner
City Pilot was funded a total of $701,500.00 over the three year period this was
significantly higher than the other pilots, which received less than this combined total
between them.
The UGS pilot is co-ordinated by the same co-ordinator as the LGS. Twelve months
into the pilot a local area co-ordinator was put in place. This local co-ordinator
position has had a history of staff changes and the most recent local co-ordinator is
now employed in a more generalist role focusing on chronic disease. General
perceptions of service providers were that diabetes care is improving but considerable
effort is still needed within the region. The locality is challenged by ongoing issues
such as geographical isolation, disagreements between some Aboriginal groups,
recruitment and retention of health professionals, and access to service providers (e.g.
endocrinologists).
The LGS health locality appears to have made significant progress towards the
integration of services. The initial business case made few distinctions between the
UGS and LGS and this is reflected in reporting of the pilots. The development of the
LGS pilot has deviated significantly from its original objectives, but has captured the
broader outcomes sought by the IDC Program.
Similar to the UGS pilot, the Midwest Region experienced significant challenges to
its establishment, including a high frequency in the turnover of co-ordinators, merging
of the co-ordinator’s role with a diabetes education role, remote service delivery, and
competition between service providers. The general perception of this pilot was that
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it has not achieved integrated care and will require considerable effort to recover lost
ground.
1.2.4. Effectiveness
The effectiveness of the pilot projects within the IDC Program has varied
considerably. As a whole, diabetes service provision has improved across the pilot
regions. Visible changes in consumer behaviour are cited in the LGS and Inner City
pilots. Pilots in UGS and Midwest locations have had problems compounded by staff
turnover, distance, absence of a critical mass of service providers, and limited access
to training. In the case of the Midwest, mini-systems of integration (e.g. where a local
GP has made their own unique network of diabetes service providers) have formed in
reaction to frustration with the progress of diabetes service delivery.
The effectiveness of integration models is supported in literature in other Australian
states as well as internationally. Integration of services is also occurring in non-pilot
regions of WA. However, the IDC Program in WA has weaknesses and gaps (e.g.
absence of planning and monitoring) that make it vulnerable to the external
environment. Overall, integration is an appropriate model for WA diabetes service
delivery, but the program requires increased sophistication (i.e. attention to a broader
set of environmental elements, consideration of differentiation) if it is to maximise its
effectiveness.
The primary elements of the IDC model applied by WA are similar to those
implemented by the Commonwealth Department of Aged Care, NSW and the ACT,
although each of these states have now moved to models of chronic disease
integration. The Victorian Department of Health Services has recently introduced a
model of Integrated Disease Management, which incorporates broader elements in its
definition of integration.
Western Australia has a unique environment due to its relative isolation and broad set
of environmental elements impacting diabetes service delivery. Application of the
NSW model to the IDC Program was a sound starting point for service delivery
change but is no longer a satisfactory model for WA diabetes care.
1.2.5. Sustainability
It is acknowledged that the IDC Program is in its infancy, and is an appropriate model
for diabetes service delivery in Western Australia. The IDC pilot projects do not seem
to be sustainable in their current form. However, attention to the elements listed
below seems highly likely to generate future sustainability within the IDC Program:
 Enhancement of the profile of diabetes as a major health issue in Western Australia
 Increased resources to support expansions in service delivery around a framework of
IDC
 Development of a framework for a state-wide IDC Program
 Implementation of further structures within the IDC Program
 Enhancement of general knowledge of diabetes for people in health related roles
 Increased consumer involvement in the IDC Program
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1.2.6. Applicability
The IDC model has the capacity to influence other areas of service delivery, and other
regions but it is not necessarily applicable to all forms of health care programs.
Diabetes is a natural choice for integration because of its complexity, duration,
commonalities with other chronic diseases, and innate requirement for contributions
from a variety of disciplines.
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2. RECOMMENDATIONS
The prevalence of diabetes is on the increase throughout the world and its social and
economic impact should not be underestimated by health systems. Diabetes is
particularly suited to integrated models of care because it requires input from a variety
of disciplines as well as considerable attention to self-management by the individual.
There is a world-wide trend towards the application of IDC models, and the
evaluation suggests this approach is appropriate for the WA health system. However,
diabetes service delivery in WA has unique challenges that are not adequately
addressed by the model devised by New South Wales, which was applied to the pilot
projects. Therefore, although an IDC Program appears effective and sustainable in
the longer term, there is now a need to move beyond the application of pilot projects
and develop a state-wide, systematic approach to IDC. Furthermore, if the WA
Diabetes Strategy (1999) is to be successful in tackling diabetes issues in the future, it
needs to be supported by a sustained commitment to diabetes funding.
It is recommended that:
2.1
The profile of diabetes is enhanced:
2.1.1 Through reinforcement from the DOH that diabetes is a major health issue
which demands high priority attention (Priority = Short Term).
2.1.2 Through promotion of the WA Diabetes Strategy to health services and
diabetes service providers (Priority = Short Term).
2.1.3 Through the development of a state-wide image for the IDC Program (Priority
= Short Term).
2.2
Increases in resources are sought to support expansion in service delivery
around a framework of IDC:
2.2.1 For the DOH to develop a purchasing plan that supports an integrated model
of diabetes service delivery with the DOH (Priority = Short Term).
2.2.2 To encourage application of the IDC Program to health localities not
currently applying integrated approaches to diabetes care, and improve IDC
Programs already in place (Priority = Short to Medium Term).
2.3
A framework for a state-wide IDC Program is developed:
2.3.1 Through the organisation of an ongoing IDC forum, which brings together
diabetes stakeholders from throughout WA. It would be the intention of this
forum to promote discussion of common and unique issues in IDC, conduct
strategic IDC planning, develop action plans, and identify common
performance indicators (Priority = Short Term).
2.3.2 That considers all the integrated and differentiated elements of the diabetes
service delivery environment (Priority = Short Term).
2.33 That manages the change to IDC in a manner likely to promote long term
behavioural change (Priority = Short Term).
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2.3.4 That acknowledges the importance of strategies integrating diabetes with
other chronic diseases (Priority = Long Term).
2.3.5 That investigates ways to increase the application of information systems (e.g.
registers), collation of the diabetes databases, and use of information
technology within the IDC Program (Priority = Medium Term).
2.3.6 That incorporates the development of standardised measurement instruments
that target service providers and consumers. It is also recommended that
regional data collected by these instruments is centrally collated and analysed
(Priority = Short Term).
2.4
Existing and new health localities applying the IDC Program implement
the following structures:
2.4.1 Annual strategic planning (Priority = Short Term).
2.4.2 A clearly defined IDC Co-ordinator role (Priority = Short Term).
2.4.3 Training for IDC Co-ordinators and advisory committees in change
management (Priority = Short Term).
2.4.4 Networking structures for the IDC Co-ordinator to maintain relationships with
other IDC Co-ordinators (Priority = Short Term).
2.4.5 Collection of baseline data against standardised performance indicators, with
monitoring on an annual basis (Priority = Short Term).
2.4.6 Systems to retain corporate knowledge (e.g. plans, policies, contact lists,
processes) (Priority = Medium Term).
2.4.7 Registers of service providers (Priority = Medium Term).
2.4.8 The application of the standardised measurement instrument developed by the
DOH (Priority = Short Term).
2.5
General knowledge of diabetes is enhanced:
2.5.1
Through the development of strategies to increase the number of people, who work in
health related roles in rural and remote areas, who have generalist knowledge of
diabetes (Priority = Medium Term).
2.5.2 Through development of accessible and affordable training courses for people
in rural and remote areas, which have an emphasis on generalist diabetes
knowledge (Priority = Short Term).
2.5.3 Through continued acknowledgment of the importance of specialist diabetes
training courses (Priority = Short Term).
2.6
Strategies are developed to increase diabetes consumer involvement in the
IDC Program:
2.6.1 Through the encouragement of community integration networks for people
with diabetes and their families (e.g. buddy systems) (Priority = Medium
Term).
Priority Definitions
 Short Term:
To be undertaken in the next 12 months.
 Medium Term: To be undertaken in the next 1 to 3 years.
 Long Term:
To be undertaken in the next 3 to 5 years
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3. INTEGRATED DIABETES CARE: OVERVIEW &
DISCUSSION
3.1.
DIABETES AND ITS INFLUENCE ON HEALTH CARE SYSTEMS :
Diabetes Mellitus is a complex, chronic disease requiring input from a variety of
disciplines as well as considerable attention to self-management by the individual. It
is a major world-wide health issue with very significant social and economic costs.
The prevalence of diabetes is on the increase throughout the world, and its influence
on current and future health care systems should not be underestimated.
There is a world-wide trend towards the use of integrated models of care in health
systems, especially in response to diabetes. More recently, many countries, including
Australia have begun integrating diabetes into chronic disease programs because risk
factors, education, and treatment overlap with other types of chronic diseases (e.g.
cardiovascular, vascular, renal).
3.1.1. The Open Systems Model and its relevance to the concept of integration
The evaluation applied an ‘Open Systems Model’ to the data to diagnose the current
functioning of diabetes service delivery in WA, and to identify the elements of the
IDC Program requiring change (Cummings & Worley, 1993).
Figure 1. Primary format of an open system model
Environment
INPUTS
 Strategy
 Resources
(e.g. human,
information,
materials)
TRANSFORMATIONS
 People and work relationships
 Tools, techniques, methods of production
OUTPUTS
 Finished
goods
 Services
 Ideas
Feedback
The open systems model is based on systems theory, which describes the properties
and behaviours of things called ‘systems’ – people, groups or organisations. Systems
are viewed as unitary wholes comprised of parts or sub-systems. The system serves to
integrate the parts into a functioning unit. For example, the Health Department of
WA is divided into a number of units, such as Public Relations and General Health
Purchasing.
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Systems can vary in how open they are to the outside environment. ‘Open systems’
exchange information and resources with their environment. They cannot completely
control their own behaviour and are partially influenced by environmental conditions.
An understanding of how these external forces affect an organisation is critical to
designing organisational systems properly. Figure 1 shows the key components of an
open system: inputs, transformations, outputs, and feedback. If an organisation is
likely to produce the right outputs and sustain its existence, these elements should be
designed in consideration of the elements of the external environment.
When applied to diabetes service delivery, the open systems model proposes that
programs are only effective and sustainable if they match or ‘fit’ the needs of the
diabetes ‘environment’. The ‘environment’ includes people with or at risk of
diabetes, the people who assist them to manage or prevent diabetes (e.g. families,
health and allied professionals), where they are located, and organisations that
compete with diabetes for attention and money. For instance, the NSW model in the
next section considers some of the elements by designing its program to incorporate
early detection and patient education. It also introduces integration as a means of
acknowledging the need for continuous, high quality care.
The evaluation’s literature review found that integration is a fundamental principle or
‘force’ that comes from the external environment and drives the design of any
program. For instance, in the WA diabetes environment, people are spread out in
rural and remote areas across the state, but the number of people with diabetes are low
in these areas compared with the metropolitan population. Therefore, any diabetes
program must consider available resources, and how they can be integrated to provide
a diabetes service to rural and remote areas. One of the ways rural and remote health
providers have tried to maximise resources is to have people in health roles with
generalist skills, rather than people who only have skills in diabetes. In this instance
the integration that has occurred refers to the merging of diabetes knowledge with
other health knowledge.
There is another fundamental force in the environment, which drives programs
towards ‘differentiation’ and opposes attempts to integrate. Differentiation refers to
the need for a program design that pays attention to individual elements within the
environment (Lawrence & Lorsch, 1967). For instance, the WA Diabetes Strategy
(1999) emphasises attention to prevention, primary care and specialised care. Each
of these elements is differentiated because they are all critical to the reduction of
diabetes prevalence in the future. However, the evaluation highlighted that the
majority of funder, purchaser and provider effort focuses on specialised care
interventions. Therefore, over-attention on this area causes the others to suffer, and
prevents the achievement of long term goals. Appropriate levels of attention need to
be given to each differentiated element to address diabetes. In the context of program
design, forces for differentiation should not be considered ‘good’ or ‘bad’. Rather
they should be acknowledged and included in planning processes.
The literature on diabetes care refers to a number of problems with integrated models
but does not appear to acknowledge the existence of forces for differentiation. The
evaluation suggests that differentiation must be also considered in models of diabetes
service delivery if they are to be effective and sustainable. The original conception of
the IDC Program in WA gave attention to integration systems. It seems that the IDC
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Program needs to be updated to incorporate attention to a broader set of
environmental elements than those conceived by the NSW model. Forces for
differentiation should also be acknowledged in future diabetes planning.
3.1.2. The NSW Model of IDC
In 1995, the NSW Health Department trialled three, two year IDC projects to test the
hypothesis that “the impact on the system of chronic disease and its sequelae could be
reduced by the provision of well organised care founded on agreed, evidence based
guidelines for best practice, which incorporates patient education and early detection
of complications” (Boyages, Sheridan & Close, 1999, p85). This population based
approach was used as a template for the WA IDC pilots.
The term “Integrated Diabetes Care” has been defined as “the organised participation
of practitioners, other medical and non-medical clinicians, government and nongovernment agencies, and consumers, in the provision and use of a full range of client
focused diabetes services, using agreed standards of care” (Sheridan & Boyages,
1996).
Boyages Sheridan and Close (1999) note that in the NSW Model, integrated care
consists of:
 Established systems for communication between service providers.
 Co-operation between service providers in providing care and in the planning of
health services.
 Agreed guidelines and standards of care, and adequate professional training.
 The implementation of an agreed set of policies and procedures.
This model was evaluated through biochemical, clinical, psychological and economic
outcomes.
3.1.3. Diagnosis of the diabetes service delivery environment
As previously noted, diabetes is a complex disease, and the service delivery
environment has distinct elements requiring consideration. Table 1 (over the page)
identifies the elements within this environment and diagnoses them according to:
 Forces for integration
 Forces for differentiation
Table 1. The diabetes service delivery environment
Forces for integration
Forces for differentiation
These are elements that require integration in
order to promote good outputs of products,
services and ideas:
 Service providers forming a
multidisciplinary team around the individual
(ie. Medical and non-medical, specialists
and generalists)
 Health care as core business
 System solutions that are focused on
diabetes as a whole
 Geographical proximity
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These are elements that require individual
attention to promote flexible, high quality
diabetes care.
 Individual professions
 Aboriginal and other cultures working across
core businesses (e.g. health, education,
social, housing, socio-economic structures)
 Solutions focused on sub-populations and
individuals
 Remote locations
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 Continuum of care
 Active consumers who self-manage
 Disease episodes
 Passive consumers who are reliant upon the
system
 Relative autonomy
 Accountability, information technology
(decision support systems, intelligent
information systems)
 Limited resources requiring focus across
 Resources focusing on individual elements
primary, secondary and tertiary prevention
such as Tertiary care
 Focus across primary, secondary and tertiary
 Competition between generalist and
service providers
specialist ideology
 Guidelines, protocols and care paths
 Therapeutic freedom
 Relatively objective, evidence based
 Professional judgement
treatment (outcomes assessment, economic
evaluation)
 Monitoring and evaluation
 Focus on delivery
 Chronic disease focus
 Diabetes focus
Source: modified from a table presented by Primary Care Partnerships, Integrated Disease
Management: Interim Policy Directions and Guidelines, Victorian Government Publishing Service,
2001.
The evaluation confirms that all these elements exist within the WA diabetes service
delivery environment. See section 6, Table 15 for reference to the Pilot Programs and
the existence of the forces of integration and differentiation within each.
3.2.
IMPLEMENTATION OF THE IDC PILOT PROGRAMS IN WESTERN AUSTRALIA
3.2.1. Background and Program objectives
In 1997/98 the DOH developed a reinvestment strategy for purchasing diabetes
services. The focus of the strategy is to develop and support an integrated service
delivery model that ensured:
 Equitable access to a full range of diabetes services.
 Health professionals’ access to training and support.
 Systems for co-ordinated care.
 Systems for ensuring standards.
 Systems for monitoring outcomes.
 Commitment to the development of a locally appropriate service delivery model.
The key objective is to create an informed community that practices positive diabetes
prevention and control. The introduction of IDC commenced in 1998, with the
purchasing of four pilot projects by the DOH. Each project was based on the NSW
model, but was developed to reflect local needs and priorities as each region has
different geographic and demographic profiles. The projects are located in:
 Inner City health locality
 Upper Great Southern health locality
 Lower Great Southern health locality
 Midwest health zone.
The pilots are due for completion in June 2001. The sections following provide
summarised findings and outline achievements of the pilot projects against anticipated
program and project outcomes. Details of individual projects are located in the
appendix to this report.
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3.2.2. Summary of common evaluation themes
Although each pilot region had its unique features, remarkable similarity was found
between regions in major themes.
 Integration was viewed as an acceptable model that has the potential to be applied
across a broad range of health systems.
 Perceptions that IDC funding was inadequate to meet the demand for services
from the population with diabetes.
 Access to diabetes services is inequitable. This issue is particularly evident
amongst Aboriginal and gestational populations. However, a related theme was
the need for a model of diabetes service delivery that incorporates, primary,
secondary and tertiary prevention.
 GP acceptance of, and involvement in IDC Programs is critical to the progress of
integration. Meeting other members of the multi-disciplinary team is critical to
networking and referral processes.
 Rural and remote service providers are particularly concerned about the focus of
the current Curtin University training program in diabetes, which is viewed as
expensive, difficult to attend, and not relevant to the development of generalist
skills.
 A co-ordinator’s position is critical to program implementation and maintenance,
however the position does not have sufficient authority to implement change
quickly.
 The pilots were generally viewed as consistent with the NSW model of IDC but
understanding of integration varied considerably.
 Skills in change management are critical for diabetes co-ordinators. Even after
programs have been established, negotiations with service providers are a part of
daily work.
 Guidelines and protocols for quality diabetes care are perceived as sufficient.
 There is insufficient planning and monitoring of progress and planning.
 Adolescents with diabetes who have moved from tertiary centres in the Perth
metropolitan area have no transition to adult programs.
 There are tensions with Silver Chain service providers in rural locations.
 Service providers in rural and remote locations have additional challenges
relating to isolation, recruitment and retention, access to services, access to
professional support, and competition with generalist roles.
There also appeared to be a correlation between the development of structures and
systems within pilots and the degree of integration achieved. The Inner City and
Lower Great Southern (LGS) pilots did more planning and had more consistency in
co-ordination of the program than the Midwest or Upper Great Southern Pilots. The
former pilots also had more success in achieving set goals than the latter. Although it
was not within the scope of the evaluation to form a judgement on the success of
individual pilots, it could be argued that planning and people are key features of
effective integration and have had a direct impact on the pilots’ progress.
3.2.3. Inner City
In many ways, the Inner City is further advanced than other pilot regions and is now
experiencing a high demand for services. The general theme arising from the pilot is
that there are now improved services and service integration, with patients behaving
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differently and demonstrating better understanding of diabetes. However, the pilot
now faces the challenge of being unable to provide services to meet demands. Its
metropolitan location has meant that the project’s focus has had to incorporate a
variety of NESB populations.
The Inner City health locality project has a number of features likely to enhance
program effectiveness and sustainability including:
 Metropolitan location
 Continuity of committee members
 Comparatively higher funding
 Access to local tertiary centres
 Quarterly and annual reporting of progress against its business case.
There was a strong match between the common themes generated across all regions
and the major issues of importance within the Inner City region. Over the page, Table
3 and 4 show the outcomes cited in reports to the DOH.
Table 3. Achievement of projects against original submission
INNER CITY OBJECTIVES
1. Provide community based education services
to 480 people with NIDDM and their partners
per year in the inner city
2. Conduct a needs assessment and pilot
programs to identify appropriate services and
service locations for people with diabetes
from NESB
3.
4.
Implement at least 4 programs targeting high
risk groups that will increase diagnosis and
reduce modifiable risks for developing
diabetes
Implement systems for co-ordinated care,
quality standards of care, health professional
training and support, and systems of
monitoring of health outcomes
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REPORTED OUTCOMES
 1998 - 250 people attended training
 1999 – 340 people attended training
 2000 – 70 in first 5 months
 1998 - Needs assessment and pilot programs
established with focus on Italian and
Vietnamese
 2000 – these programs were expanded to
include other Health Services
 1998 – 2 day workshop held for strategic
planning focusing on diabetes prevention
 2000 – first risk reduction program
commenced for GDM
 1998 – RPH provided practical placements
for local podiatrists
 GP registrations for diabetes education
training with Perth DGP
 Co-ordinator attended diabetes education
training
 Logo, generic referral form/ foot assessment
and ophthalmologist assessment form
developed
 Systems for co-ordination of podiatry
services under development
 Local Area Co-ordination Committee meets
quarterly – ongoing to 2001
 2000 – Expansion to include other regions,
DGP, hospitals DGP in program for
discharge processes
 Steering committee terms of reference
developed for eye check program and GDM
 Working party focusing on community
podiatry in place
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Table 4 . Performance against outcomes sought through the application of the IDC
model
OUTCOMES SOUGHT THROUGH IDC
1.
Equitable access to a full range of diabetes
services
2.
3.
Health professionals’ access to training and
support
Systems for co-ordinated care
4.
Systems for ensuring standards
5.
Systems for monitoring outcomes
6.
Commitment to the development of a locally
appropriate service delivery model
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GENERAL THEMES IDENTIFIED
THROUGH THE EVALUATION PROCESS
 Emphasis on podiatry and optometry/
ophthalmology services
 Project officer appointed to progress
continued community education
 Majority of perceptions suggested access to
services was not equitable. Lower risk
patients now ‘clogging’ system.
 Social and psychological services needed
 Privately insured viewed as a gap in service
 Training emphasis in 1998
 Mixed responses received
 Systems for co-ordinating podiatry services
exist
 Continuity of steering committee
 Clarity of direction of steering and
committee
 Cultural barriers and practices between
service providers identified, especially with
AHW and Community HW
 Multiple complex system development cited
as a problem
 Heavy reliance on co-ordinator
 RPH assisted with training of podiatrists
 Pilot eye-check program
 Insufficient data collection and monitoring
 Quality improvement processes not built in
 Evaluation of strategic plan absent
 Initial focus on inner city area only with
expansion in 2000 to incorporate other
metropolitan stakeholders
 Identification of needs within NESB
populations
 Evaluation of pilot diabetes clinic at AMS
and pilot community diabetes programs in
1998
 High level of acceptability amongst service
providers
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3.2.4. Upper Great Southern
The original business case submission did not segment between UGS and LGS, and
very similar indicators were developed for both regions. The UGS pilot had a history
of staff changes and the most recent local co-ordinator is now employed in more
generalist role focusing on chronic disease. General perceptions of service providers
were that diabetes care is improving but considerable effort is still needed within the
region. The locality is challenged by ongoing issues such as:




Geographical isolation
Disagreements between some Aboriginal groups
Recruitment and retention of health professionals
Access to service providers (e.g. endocrinologists).
The objectives for the pilot are almost identical to those of the LGS health locality,
with the exception of those areas reported in Table 5 below. Where reported
outcomes for this region exist, they have been combined with those of the LGS health
locality.
Table 5. Objectives unique to the UGS pilot project
UNIQUE UGS OBJECTIVES
1. 1998 – 1999 To develop a co-ordinated
diabetes assessment and education plan for
the adult Aboriginal population
2.
1999-2000 To identify defined access to
diabetes education, podiatry and dietetic
services in each health service
3.
2000-2001 To register 95% of expected
known people with diabetes who attend a GP
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REPORTED OUTCOMES
 Currently working with primary health and
Family Futures. Opportunistic, ad-hoc
strategy. Examined community based
education programs.
 Primary health expanded services to outlying
towns. Senior dietician mapped needs and
obtained second dietician. More lifestyle
programs, focus on diagnosed and
undiagnosed.
 Reported at a regional level only 79% of
target (>1000 people registered)
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Table 6 . Performance against outcomes sought through the application of the IDC
model
OUTCOMES SOUGHT THROUGH IDC
1.
Equitable access to a full range of diabetes
services
2.
Health professionals’ access to training and
support
3.
Systems for co-ordinated care
4.
Systems for ensuring standards
5.
Systems for monitoring outcomes
6.
Commitment to the development of a locally
appropriate service delivery model
GENERAL THEMES IDENTIFIED
THROUGH THE EVALUATION PROCESS
 The majority of respondents suggested there
is not equity of access
 No community education occurs
 Consumers cited problems with accessing
local services
 No services for GDM
 Educational barriers were cited as an area of
particular concern
 Hospital and community service staff (e.g.
police) require training
 Problems with retention of staff has
interrupted program continuity
 Current local co-ordinator is highly
respected and has an integrated role with
other chronic diseases
 Political issues between health services were
also highlighted
 A referral process exists between GPs and
the co-ordinator, for diabetes education
 Service duplication is occurring between
GPs, Aboriginal services and diabetes
education services.
 Highlighted as an area of weakness
 More systems for accessing patient records
are needed
 No planning is apparent for IDC
 High acceptability amongst service providers
and patients, with the exception of
difficulties relating to GPs
 Move towards integration with chronic
disease seems positive
3.2.5. Lower Great Southern
The LGS health locality appears to have made significant progress towards the
integration of services. The initial business case made few distinctions between the
UGS and LGS and this is reflected in reporting of the pilots. In the first year of
funding strategic planning was conducted for the entire region, and included the
Central Great Southern (CGS) Health Service. The outcome of this planning was the
formation of advisory committees in each health locality, including CGS. The
development of the LGS pilot has deviated significantly from its original objectives,
but is captured in the broader outcomes sought by the IDC Program. It could be
argued that this development has occurred in response to the environmental demands
within the health locality and the region.
The major features of the LGS pilot include:
 Involvement of GPs
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
Development of recall and referral systems and the use of a diabetes register
(although this is restricted to the Division of GP)
 Behavioural changes such as increased participation in programs, reduced
inpatient time, increased screening, interdisciplinary support, increased
awareness of diabetes, and increased motivation amongst people with diabetes.
The information reported in Table 7 was obtained directly from reports supplied by
the LGS health locality to the DOH and discussions with the pilot Co-ordinator.
Table 7. Achievement of projects against original submission
LGS OBJECTIVES
1998-1999
1. To implement an integrated diabetes service
in the LGSHS area
2. To register 80% of expected known people
with diabetes
3. To register 100% of newly diagnosed people
with NIDDM
4. To increase by 50% patient access to quality
diabetes education programs
5. To provide podiatry education, assessment
and treatment services
6. To identify an appropriate diabetes hand held
passport
1999-2000
1. To register 90% of expected known people
with diabetes
2. To implement the patient held passport
3. To formalise the roles of diabetes service
providers
2000-2001
1. To register 90% of expected known people
with diabetes
2. To identify the number of elderly people in
the population with diabetes
3. To identify the number of IDDM registered
>15 years of age
4. To implement the diabetes prevention
programs for first degree relatives
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REPORTED OUTCOMES
1.
Steering committee established
2.
3.
79% of target registration achieved
87% of General Practitioners registering
patients on diabetes database
Development of standards for diabetes
education program. Major focus of program
time devoted to a variety of initiatives
RPH contracted, local training for service
providers on podiatry
Planned but not implemented as focus on
register instead
4.
5.
6.
1.
2.
Endorsement of GS Diabetes Policy
Standards for Diabetes Education programs
accepted
Identification of roles and referral pathways
for diabetes education providers
3.
1.

87% target registration achieved
No other progress against objectives 2 - 4
recorded
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Table 8 . Performance against outcomes sought through the application of the IDC
model
OUTCOMES SOUGHT THROUGH IDC
1.
2.
Equitable access to a full range of diabetes
services
Health professionals’ access to training and
support
3.
Systems for co-ordinated care
4.
Systems for ensuring standards
5.
Systems for monitoring outcomes
6.
Commitment to the development of a locally
appropriate service delivery model
GENERAL THEMES IDENTIFIED
THROUGH THE EVALUATION PROCESS

Inequity of access focuses on Aboriginal
populations and remote communities

Educational barriers were cited as an area
of particular concern

Informal education is occurring between
disciplines due to integration

A number of examples, including referral
processes, committee meetings, diabetes
register, shared community education

Some problems with Silver Chain due to
decreased attendance at education sessions

Diabetes policy developed

Management participating

More integration needed with AHW’s

Standard guidelines for community
education, referral forms

Clinically focused

Audits of diabetes education occurring

Register used by GPs but some problems

General perception that monitoring is not
sufficient

Acceptability is generally high for service
providers and patients
3.2.6. Midwest
The business case for the Midwest was prepared by staff from the Great Southern
Public Health Unit. Similar to the UGS pilot, the Midwest Region experienced
significant challenges to its establishment, including:
 Turnover of diabetes co-ordinators and the position change from full-time to
part-time
 Merging of the co-ordinators’ role with that of diabetes education
 Changes in fund holders from the Midwest PHU to the Geraldton Health Service
 Management of co-ordination processes by volunteer committee members
during times of vacancy (the position was vacant for a total of one year of the 3
year pilot)
 Competition with Aboriginal services and between health services
 Problems associated with managing health service delivery in rural and remote
areas.
This general perception of this pilot was that it has not achieved integrated care and
will require considerable effort to recover lost ground. More details are reported in
Tables 9 and 10 on the next page.
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Table 9. Achievement of projects against original submission
MIDWEST OBJECTIVES
1998-1999
1. To establish a co-operative forum to
implement integrated diabetes service in the
Midwest Region
2. To identify the appropriate health service
capacity to meet consumer needs in
Geraldton
3. To increase diabetes training for health
professionals
4. To improve access to quality diabetes
education programs
5. To establish a diabetes register and recall
system in Geraldton
1999-2000
1. To identify the appropriate health service
capacity to meet consumer needs in the
Midwest and Murchison areas
2. To maintain ongoing diabetes training
education programs for health professionals
3. To extend the diabetes register and recall
system throughout the Midwest Region
4. To improve primary prevention and
promotion activities in the Midwest Region
2000-2001
1. To maintain and increase diabetes education
prevention and promotion activities in the
Midwest Region
2. To increase to 90% the number of GPs
referring to the register and recall system
3. To incorporate into the integrated service
model people with a history of GDM once a
national consensus on diagnosis of this group
has been achieved.
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REPORTED OUTCOMES
1.
Established a Midwest steering committee –
continued to 2001
2.
Needs Analysis commenced
3.
Training implemented for service providers,
including AHWs
Diabetes awareness week and a remote
promotion day established
Register initiatives commenced, support for
DGP and separate register for PHU. 17 out of
50 GPs used the system with over 300
patients registered
4.
5.
1.
Needs analysis completed, which included
training needs of health professionals
2.
Study days introduced in Geraldton and
Meekatharra
Big drop in use of register, 2 out of 50 GPs
used the system
Diabetes awareness and some community
education programs
3.
4.
1.
2.
Some local service providers including
chemist, HBF held promotions. Web site
currently being developed
No progress reported
3.
No progress reported
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Table 10 . Performance against outcomes sought through the application of the IDC
model
OUTCOMES SOUGHT THROUGH IDC
1.
Equitable access to a full range of diabetes
services
2.
Health professionals’ access to training and
support
3.
Systems for co-ordinated care
4.
Systems for ensuring standards
5.
Systems for monitoring outcomes
6.
Commitment to the development of a locally
appropriate service delivery model
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GENERAL THEMES IDENTIFIED
THROUGH THE EVALUATION PROCESS

Aboriginal and remote communities
feature very strongly on the list of sectors
lacking access to services

A web-site is in development

Perceptions that access to basics such as
insulin and test strips is limited to one
distributor in Geraldton

Remote communities rely on the goodwill
of local people who remain with
communities to provide diabetes services

Although training programs were
implemented in 1998 and 1999, there is
little evidence of ongoing training

Educational barriers were cited as an area
of particular concern

Mini-systems of integrated care are being
established by service providers (e.g. GPs),
but they have no relationship to the pilot

Interpersonal and interdisciplinary
conflicts

Role of co-ordinator has changed

Tenuous partnerships not supported by
formal structures

Focus of committee is on service provision
in Geraldton

No integration with Aboriginal service
providers

Automatic referral between GPs and Silver
Chain occurring

No integration between the Midwest
Health Services Planning Committee and
the steering committee

Duplication of services for Aboriginal
people, and by community education, GPs
and health services

No planning or monitoring processes
evident

Commitment evident in first year of
implementation, with problems arising
after this time. Current focus is on
Geraldton only.
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3.3.
EFFECTIVENESS OF THE IDC PROGRAM & MODEL
This section focuses on assessment of effectiveness of the program implemented
within Western Australia as well as effectiveness of the IDC model as the means of
achieving the program outcomes and objectives.
3.3.1. Summary
The effectiveness of the pilot projects within the IDC Program has varied
considerably. As a whole, diabetes service provision has improved across the pilot
regions. Visible changes in consumer behaviour are cited in the Lower Great
Southern and Inner City pilots. Pilots in UGS and Midwest locations have had
problems compounded by staff turnover, distance, absence of a critical mass of
service providers, and limited access to training. In the case of the Midwest, minisystems of integration (e.g. where a local GP has set up a unique network of diabetes
service providers) have formed in reaction to frustrations with the progress of diabetes
service delivery.
The effectiveness of integration models is supported in literature in other Australian
states as well as internationally. Integration of services is also occurring in non-pilot
regions of WA. However, the IDC Program in WA has weaknesses and gaps (e.g.
absence of planning and monitoring) that make it vulnerable to the external
environment. Overall, integration is an appropriate model for WA diabetes service
delivery, but the pilot projects need to be merged with an IDC Program that
incorporates attention to a broader set of environmental elements than those conceived
by the NSW model. Forces for differentiation should also be acknowledged in future
diabetes planning if the IDC Program is to maximise its effectiveness and
sustainability.
3.3.2. Consistency with national objectives
The major themes emerging from state and commonwealth health agencies are:
 A solid trend towards application of integrated care models in every state of
Australia.
 A trend towards integration of chronic disease services, rather than diabetes
specific integration.
 A trend towards integration models which incorporate primary prevention, early
intervention, and quality management of diabetes.
3.3.3. Compatibility with other models of service delivery
The primary elements of the IDC model applied by WA is similar to that implemented
by the Commonwealth Department of Aged Care, NSW and the ACT, although each
of these states have now moved to models of chronic disease integration. The
Victorian Department of Health Services has recently introduced a model of
Integrated Disease Management, which incorporates broader elements in its definition
of integration.
Western Australia has a unique environment due to its relative isolation and broad set
of environmental elements impacting diabetes service delivery. Application of the
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NSW model to the IDC Program was a sound starting point for service delivery
change but is no longer a satisfactory model for WA diabetes care.
3.3.4. Level of acceptability
The evaluation also sought respondents’ perceptions on the acceptability of the IDC
Program amongst service providers, patients and at-risk groups and found that:
 Amongst service providers, acceptability of the IDC Program was high.
 Amongst patients, acceptability of the IDC Program was medium to high, with
the exception of remote consumers who do not have access to services.
 Amongst at-risk populations, acceptability of the IDC Program was low.
Reasons included lack of service, non-compliance and non-understanding, poor
management, language, cultural or disability barriers, and poverty.
These perceptions were generally consistent across all pilot regions.
acceptance of the model of IDC was related to issues including:
 Continuity of funding
 Continuity of people involved in the
program and information
 Clarity of direction and models of good
practice
 Improved communication and decreased
conflict
Increased
 Professionalism in the approach to change
management
 Acceptance of differentiation forces
 Visible services and changes in consumer
behaviour
3.3.5. Strengths
Integrated models of health care are a good match for the needs of diabetes, and have
the potential for high levels of effectiveness and sustainability. Where they are
working well in WA the following strengths are reported:
 Changes in client behaviour and motivation
 Access to new populations
 Identification of previously undiagnosed
consumers
 Reduction in hospital admissions
 Development of health indicators
 Increased range of services
 Better relationships between health
professionals
 Improved knowledge of diabetes by service
providers, consumers and community
 Cost efficiencies
 Improved management practices
 Increased continuity, interchange and backup of care and information
 Increased quality of care
 Decreased duplication of services
 Enhanced responsiveness to environment
3.3.6. Gaps
Although the current IDC pilots in WA have a number of weaknesses, it is the gaps in the
IDC Program that have the greatest impact on program effectiveness and sustainability.
These gaps come from unmet environmental needs and major themes include:
 Perceptions of funding inadequacy and
inconsistency of funding objectives
 Strategic planning, including definition of
integration and vision
 Knowledge of change management
 Data collection and monitoring
 Absence of a common program identity or
image
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

Consideration of forces for differentiation
Consideration of the issues innately
impacting rural and remote service provision
 Incentives for changes in service delivery
 Access to services for sub-populations
 Policy development to support processes
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3.3.7. Weaknesses
A broad variety of weaknesses were highlighted by respondents to the evaluation.
Many of these themes were consistent with findings in national and international
literature:
 Professional differences in philosophy,
approach and expected outcomes
 Competing priorities (e.g. GP attention,
direction of programs, other health issues)
 Short term commitments to funding
 Lack of continuity of personnel between
funder, purchaser and provider groups
 Poor capacity to adapt to meet changing
environmental demands
 Emphasis on tertiary care
 Increased expectations but insufficient
services to respond to increased demand
 Insufficient number of professionals (e.g.
endocrinologists, rural areas)
 Inadequacy in current training delivery
 Inadequate co-ordinator training, knowledge
of change management, role clarity, support
 Disjointed feedback on progress
 Reliance on co-ordinator
3.3.8. Barriers
As previously noted in this section, the major barriers encountered by the Program
appear to relate to forces for differentiation. The core problems with discounting
these forces are the inability of the Program to plan for resistance and identify
appropriate priorities. Furthermore, some of the barriers identified below are
associated with gaps occurring in the Program, which causes innate problems for
program effectiveness:
Barriers in common with gaps:
 Perceptions of funding inadequacy, conflicts
between the objectives of funding sources,
problems with funding application
processes, and perceived lack of continuity
of funding
 Strategic planning, including WA definition
of integration and vision
 Data collection and monitoring
 Absence of a common program identity or
image
 Consideration of the issues innately
impacting rural and remote service provision
 Incentives for changes in service delivery
(e.g. to cope with time and service level
demands)
 Access to services for sub-populations
 Policy development to support processes
Other barriers:
 Strength of existing medical model
 Financial survival of service providers (e.g.
Silver Chain)
 Conflict of new systems with existing
business processes and structures
 Primary problems with terminology,
standards and measurement tools
surrounding diabetes integration
 Professional and interpersonal conflicts
 Continuity of staff and awareness of
diabetes service providers in WA
 Rural economies of scale
 Lack of community awareness of diabetes
 Cost of services to consumers
 Cultural barriers
3.3.9. Duplications
The major duplication currently occurring within the state is the development of
integration models. At local and regional levels, duplication of service delivery is
reduced as integration increases.
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3.3.10. Unintended consequences
Unintended consequences have been both positive and negative:
Positive
 Increased cross-fertilisation of information
and education between health professionals
 Increased community awareness, interest
and education
 Non-participating services and regions have
commenced integration of care
 Better regional services
 Support for integration of services within
other chronic disease programs
 Access to community diabetes experts has
led to reinforcement of consumer behaviour
and increased motivation amongst
consumers
 Knowledge of diabetes has improved
quality of treatment in other chronic disease
areas
Negative
 Consumer dependence on services
 Generation of expectations without being
able to meet demand
 Service providers forced to act alone when
integration processes break down
 Silver Chain marginalised
 Low risk patients ‘clogging’ services and
preventing access for high risk patients
 Resistance where integration has failed
 Additional workloads for allied health
professionals without GP incentives
3.3.11. Potential impact on health outcomes
The potential impact of the IDC Program is a co-ordinated, cost-effective service that
facilitates access to ongoing diabetes services across a range of sub-populations.
Respondents’ overall view of the potential impact of integration was very positive,
with the capacity to decrease the social and economic impact of diabetes, and other
chronic diseases in WA.
3.4.
PROGRAM SUSTAINABILITY
3.4.1. Summary
It is acknowledged that the IDC Program is in its infancy, and is an appropriate model
for diabetes service delivery in Western Australia. The IDC pilot projects do not
seem to be sustainable in their present form. However, attention to the elements
listed below seems highly likely to generate future sustainability within the IDC
Program:
 Enhancement of the profile of diabetes as a major health issue in Western
Australia
 Increased resources to support expansions in service delivery around a framework
of IDC
 Development of a framework for a state-wide IDC Program
 Implementation of further structures within the IDC Program
 Enhancement of general knowledge of diabetes for people in health related roles
 Increased consumer involvement in the IDC Program
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3.4.2. Funding
Funding is a primary force for ensuring sustainability. At present funding is
problematic and issues raised through the evaluation include:
 Perceived inadequacy of funding, particularly in the primary and secondary
prevention elements of diabetes service delivery.
 Perceptions that there is always an emphasis on short term funding, giving the
impression that diabetes services may be discontinued at whim. Co-ordinators
were also concerned about the frequency and timing of funding submissions,
which often place additional burdens upon their time and attention to other
matters.
 Diversity of diabetes funding sources at a commonwealth and state level. This
diversity has generated conflicts of objectives that impact upon sustainability and
the time devoted to reporting requirements.
 Conflict between service providers about control of funding.
 Diabetes consumers bear a proportionally high burden of medical expenses, and
can be discouraged from access to a range of health services because they cannot
afford to attend. The sustainability of the program is not assisted by barriers
preventing access.
3.4.3. Planning
Little planning is conducted in the current IDC projects. This finding is of major
concern to future sustainability, and is partly due to the absence of baseline or
monitoring data for diabetes services. It seems clear that comprehensive planning is
required if the IDC Program is to succeed in the future. As noted previously, planning
must consider all elements of the diabetes service environment, and program
effectiveness can be maximised if all stakeholders contribute to the development of a
strategic, state-wide integration plan. It has been suggested by respondents that the
DOH should allocate resources to assist in the co-ordination of a diabetes planning
forum. A forum would have significant advantages in acting as a catalyst for change,
networking, and integration. A state-wide approach would also have advantages in
the establishment of a strong diabetes image and vision for the future.
3.4.4. Culture
To be sustainable, an IDC model must lead to enhancement in relationships between
and within funder, purchaser and provider groups. The literature highlights that
professional and interpersonal conflicts are common in integrated care models.
However, it seems that a positive culture of collaboration and co-operation can be
attained if:
 Attention is given to both integration and differentiation elements during
planning.
 Change management is approached professionally, through the application of
appropriate facilitation and feedback skills.
3.4.5. Human Resources
Human resource planning and management are critical elements to sustainability and
attention needs to be paid to a number of distinct elements, including:
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 Continuity of staff. Turnover is common between the general groups of
funders, purchasers and providers. Therefore it is important to develop systems
that retain the knowledge of initiatives and networks (e.g. directories, policies,
plans, monitoring) when people change roles. One of the major weaknesses of
the current IDC Program is its vulnerability to co-ordinator turnover.
 Recruitment and retention. This element refers to employees as well as service
providers recruited to the IDC Program. A tremendous amount of work is
devoted to identifying and negotiating with individuals, and if they are to remain
with the program, attention must also to be given to processes of support and
acknowledgement. This issue is particularly pertinent to rural and remote areas,
where turnover is high. The evaluation highlighted some innovative methods
(e.g. Therapy Assistants) used in remote areas, where members of the local
community are given generalist training to cope with basic health issues.
 Support. One of the major gaps in the IDC Program is lack of common
knowledge or skills in organisational change management amongst co-ordinators
and steering groups. Training, knowledge sharing, and opportunities for
reflection are all critical elements to developing change strategies that are
effective and sustainable.
 Acknowledgement. The IDC Program competes for attention with a variety of
different health initiatives. One of the reasons diabetes has been integrated with
other chronic diseases is because integration reduces workload. The Enhanced
Primary Care (EPC) incentives have also acknowledged the demands upon GPs
time and have been successful in shifting additional time and attention to diabetes
service delivery. However, increased integration has also placed additional
demands on the time of other health professionals, who do not have financial
incentives to support diabetes service delivery.
 Diabetes training. One of the major themes emerging from the evaluation was
the mismatch between training needs of rural and remote service providers, and
the content of the formalised diabetes training. The importance of specialised
diabetes knowledge can not be underestimated, but this form of training is not
accessible, affordable or relevant to rural and remote communities needing
generalist skills. At present, a generalist training course is under development
and appears highly relevant to this issue.
 Networking. The development of diabetes networks appears to be a core
element of referral and knowledge sharing. Networks are also currently
expanding to include psychological and social support. However, these networks
do not need to be restricted to service providers, and people with diabetes
suggested that consumer networks were just as important to sustaining selfmanagement as ongoing professional care.
3.4.6. Structures
As noted in the section above, the sustainability of the IDC Program is influenced by the
continuity of human resources. As turnover is generally high, systems must be generated to
retain knowledge of initiatives and networks. Recall and registration systems have been
identified as effective and efficient structures, but sustainability will be enhanced through
increased focus on:
 Plans
 Policies
 Directories
 Monitoring
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

Role clarity
Integrating processes.
Furthermore, the majority of respondents perceived there were adequate protocols and
standards of care in place for diabetes. However this finding was not consistent with the
literature and perceptions of interstate stakeholders who believed that conflicting terminology,
standards and measurement tools are applied in integrated care models.
3.4.7. Measurement systems
Measurement and monitoring is a major gap in the current IDC Program. Feedback is
critical to program effectiveness and sustainability. More information collection
tools, such as standardised surveys, need to be developed. The IDC pilots in their
business case identified a wide range of indicators. Very few outcomes were reported
against these indicators, as there has been no actual method of measurement put in
place. The indicators have therefore been redundant. Appendix D contains the draft
monitoring indicators researched by the NSW Health Department, and which are
intended for collection during funding application and monitoring processes. These
indicators provide a useful starting point for the development of indicators for the WA
IDC Program.
3.4.8. Technology
The centralised collation of information through diabetes registers is critical to
continuity of patient care and monitoring. Access to diabetes databases appears to be
restricted to the GP population, and other forms of records, such as hand-held
‘passports’ have not been sustainable in the program. Furthermore, survey
respondents noted that the diabetes registers were also under review as problems with
reporting tools had been identified. It seems that registers are a sound way to promote
continuity amongst some diabetes communities, further investigation is needed on
their effectiveness and sustainability.
Respondents also suggested that sustainability would be enhanced if:
 GPs and hospitals were linked via Intranet or Internet.
 Teleconferencing and telehealth initiatives were applied more frequently within
diabetes services located in rural and remote areas.
3.5.
APPLICABILITY
3.5.1. Capacity to influence other areas of service delivery
The general perception of respondents was that the IDC model has the capacity to
influence other health service programs, including:
 Chronic diseases where early intervention, self management and the right
treatment mix are key factors.
 Other health service delivery areas such as mental health.
 Specific examples included: Asthma, arthritis, cardiovascular disease, cervical
screening, hypertension, obesity, renal disease, palliative care, continence care,
eye and ear programs.
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3.5.2. Applicability to other regions and program areas
As previously noted in other sections, integrated care is already occurring in other
regions as well as other program areas (e.g. primary prevention). However,
integrated care is not necessarily applicable to all forms of health care programs.
Diabetes is a natural choice for integration because of its complexity, duration, and
innate requirement for contributions from a variety of disciplines.
3.6.
REFERENCES
Please refer to page 53 for references.
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4. APPENDIX A: METHODOLOGY
4.1.
TERMS OF REFERENCE
The DOH developed a reinvestment strategy for purchasing diabetes services in
1997/1998. The focus of this strategy is to develop and support an integrated delivery
model that ensures:
 Equitable access to a full range of diabetes services
 Health professionals’ access to training and support
 Systems for co-ordinated care
 Systems for ensuring standards
 Systems for monitoring outcomes
 Commitment to the development of a locally appropriate service delivery model.
Four pilot projects were implemented in 1998 and are located in:
 East Metro (Inner City) health locality
 Lower Great Southern health locality
 Upper Great Southern health locality
 Midwest Health Zone.
The focus of the evaluation sought information on:
 Implementation of the model
 Program effectiveness
 Program sustainability
 Applicability of the model.
4.2.
ISSUES CONSIDERED IN RESEARCH DESIGN
There were a number of issues impacting upon the Consultant’s ability to provide
‘neat’ results in this project:
 Definition of outcomes. The NSW model of integrated care, upon which the
pilot projects were designed, evaluated their program through biochemical,
clinical, psychological and economic outcomes. However, in view of the short
period the pilot projects have been operating in Western Australia, it seems
unlikely that results in terms of clinical and biochemical outcomes could be
identified at this stage. Therefore, where individual pilot projects had
information on these categories, it is reported. Outcomes, such as psychological,
structural and economic results, are also reported where they are available.
 Quantitative data collection. Although a quantitative survey was originally
planned as part of the data collection process, discussions with the project
evaluation committee determined that the pre-validated questionnaires applied
within the NSW evaluation would not be a good match for measurement of the
IDCP. Therefore, this component of data collection was omitted.
 Clarifying the boundaries of the IDC evaluation with evaluations already
underway within pilot regions. The focus of the evaluation is on the
effectiveness of the IDC model, as opposed to an evaluation of each pilot
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program or service provider. In addition, it is understood that, although the
pilots were based upon the IDC model they were developed to reflect local needs.
The evaluation sought to distinguish the alternate implementation actions
undertaken in each pilot and make a comparison of their strengths and
weaknesses.
 Causality: establishing links between strategies and outcomes.
The
evaluation aims to determine whether the extent to which the IDC Program has
been effective. Although this seems straightforward at first glance, establishing
the argument for a link between a strategy and its outcome must include control
for ‘extraneous variables’ (i.e. factors which may influence results). However,
there are a number of issues impacting on determination of causality for this
project:
Other organisational strategies, or processes may have had an influence
at a philosophical or practical level amongst participants. It is difficult
to make a clear link between these systemic influences and the IDCP.
 Participants. A sample of participants who represent the range of people
consuming services, as well as those planning and providing services to people
with diabetes was included in the evaluation.
4.3.
DATA COLLECTION AND ANALYSIS
Data were collected during January, February and March 2001 using 5 qualitative
methods, which were subsequently analysed through triangulation procedures:
 Literature review of national and international literature on models of integrated
care.
 A review of DOH records pertaining to the pilot projects.
 60 semi-structured telephone interviews with service providers working in pilot
regions. Sampling was stratified and random, with the exception of the UGS,
which had a new committee of service providers who were individually targeted.
 11 Focus groups (i.e. IDCP committees, IDCP co-ordinators, Aboriginal service
providers, people with diabetes).
 40 Semi-structured interviews with other stakeholders involved in diabetes
service delivery (e.g. interstate agencies, non-pilot regions, co-ordinators, WA
stakeholders).
 A request for written submissions, which was advertised in community papers in
each of the pilot regions – 6 submissions were received.
At risk groups are defined as:











Aboriginals
Diagnosed non-compliant people with diabetes
Ethnic groups eg. Italians
The 15 – 25 age bracket who may get lost between child and adult services
Undiagnosed people with diabetes
People with complications from diabetes
People with diabetes from low socio-economic backgrounds
Elderly, immobile patients
People with gestational diabetes
Patients not being referred by the GPs
People with diabetes in geographically isolated towns with few services
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5. APPENDIX B: LITERATURE REVIEW
This review focuses on Australian and international literature published over the last
decade (i.e. 1991-2001) and is comprised of the following sub-sections:
 Overview of diabetes mellitus
 Diabetes prevalence in Australia and Western Australia
 Diabetes service providers
 Concepts of integration and differentiation
 The concept of integration of health care
 Models of integrated diabetes care
 Experiences of integrated diabetes care models.
5.1.
OVERVIEW OF DIABETES MELLITUS
Diabetes mellitus (commonly referred to as diabetes), is a group of closely related
diseases characterized by hyperglycemia (high blood glucose) resulting from
problems with insulin action, insulin secretion, or both (de Courten, Hodge, Dowse,
King, Vickery and Zimmet, 1998). Insulin, a hormone produced by the pancreas, is
essential for regulating glucose (sugar) levels in the blood and for taking glucose into
body cells. Without insulin, or the ability to use insulin, the body’s main source of
energy becomes unavailable to cells (D’Cunha, 1999).
Diabetes mellitus is a collection of closely related diseases, which are classified into a
number of clinical categories:
 Type 1 diabetes, or insulin-dependent diabetes mellitus (IDDM), is characterized
by absolute insulin deficiency. Approximately 10 to 15 % of people diagnosed
with diabetes in Australia come under this classification. Almost all children
diagnosed with diabetes are in this classification.
 Type 2 diabetes, or non-insulin dependent diabetes mellitus (NIDDM),
encompasses approximately 85 to 90% of all diabetes cases and is characterized
by insufficient insulin secretion and/ or resistance to its action. The Australian
Aboriginal population appears to be highly susceptible to Type 2 diabetes and
incidence is also increasing in adolescents.
 Impaired glucose tolerance (IGT), or impaired fasting glucose (IFG), is
characterized by elevated but not yet diabetic glucose levels. IGT is more
common in obese than non-obese people.
 Gestational diabetes occurs during pregnancy and is prevalent in approximately 4
to 6% of women who have not previously had diabetes. Women who develop
gestational diabetes usually return to normal glucose levels after pregnancy but
have an increased risk of developing diabetes later in life. Gestational diabetes is
also associated with the risk of birth defects.
 Other types of diabetes account for less than 5% of all adult cases of diabetes,
such as diabetes associated with certain syndromes or conditions, including:
Abnormalities of insulin or its receptors;
Some genetic syndromes;
Pancreatic disease;
Drug-induced or chemical-induced conditions;
Disease of hormonal aetiology (de Courten et al, 1998).
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Although environmental and genetic factors can cause diabetes, risk factors are also
lifestyle-related and include physical inactivity and obesity (Commonwealth
Department of Health and Aged Care and Australian Institute of Health and Welfare,
1999).
Persistent hyperglycemia can lead to long term damage of the kidneys, heart, eyes,
gastrointestinal system and nervous system. Diabetes causes kidney failure, heart
disease, blindness and poor circulation in the lower extremities, often leading to
amputations.
People with poorly controlled Type 1 or 2 diabetes can experience excessive thirst,
frequent urination, and weight loss. Type 2 diabetes is also associated with recurring
bladder, skin or gum infections; tingling sensations in hands and feet; and cuts and
bruises that are slow to heal. In many instances, it is difficult to recognise the
symptoms of diabetes in its early stages. Furthermore, where insulin is taken as part
of a treatment program, hypoglycemia (low blood sugar) can occur suddenly if the
insulin dosage is not adjusted according to changing needs. For instance,
hypoglycemia can occur if the person accidentally takes too much insulin, exercises
too much or does not eat at the appropriate time. Hypoglycemia can have symptoms
of drowsiness, pale complexion, loss of attention, confusion, lack of coordination,
sweating, trembling, dizziness, headache, moodiness and hunger.
In addition to the above physical symptoms and complications, diabetes can cause
significant emotional strain. Numerous lifestyle changes are required of people with
diabetes including regular use of insulin or drugs, alteration to eating and exercise
habits, self-monitoring, shifting eating schedules, varying family routines and social
outings, and developing coping strategies.
The management of diabetes is demanding, and a person with diabetes can experience
lowered quality of life. This is especially relevant where people with diabetes have
inadequate social supports, experience constant stress, or have health beliefs that are
inconsistent with the treatment program. It is estimated that 25% of people with
diabetes suffer from depression, anxiety or eating disorders. Emotional distress can
interfere with a person’s capacity to self-manage, to work, to study, and to maintain
relationships (D’Cunha, 1999).
5.2.
DIABETES PREVALENCE IN AUSTRALIA AND WESTERN AUSTRALIA
The results of the AusDiab study released by the International Diabetes Institute in
2001 highlighted that the number of people with diabetes has trebledin the last 20
years. This study indicated that nearly 25% of Australian adults has either diabetes or
impaired glucose metabolism and highlighted that:
 23.6% of Australians over 75 years have diabetes
 7.5% of Australians over 25 years have diabetes, with an additional 16% suffering
from impaired glucose metabolism
 In the last 20 years, the average weight of adults in Australia has increased by 5
kilograms
Diabetes has become a major health issue in Australia, with an estimated 80,000
Western Australians being affected. As a sole diagnosis, diabetes accounted for more
than $5 million in Western Australian hospital services in 1997 and 1998 (Western
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Australian Diabetes Services Taskforce [WADST], 1999). Both diagnosed and
undiagnosed diabetes are strong risk factors for chronic disease and significant
morbidity and mortality. In Canada it is estimated that diabetes, coupled with chronic
diseases, consumes 1 in every 7 health dollars (Hertzel, Gerstein and Meltzer, 1999).
The social and economic costs of diabetes are especially evident amongst the
Aboriginal population in Australia. It is estimated that between 10 and 30% of
Aboriginals have Type 2 diabetes. However, diabetes is only one element of an
interactive set of health, dispossession and socioeconomic problems facing the
Aboriginal population. Recent reports suggest that diabetes can only be addressed in
this population if social, cultural, economic, and education issues are radically
improved (de Courten et al, 1998). In 1996, Aboriginal males and females in Western
Australia were hopitalised for diabetes and diabetes complications 12 and 10% times
more, respectively, than non-Aboriginal males and females (DOH, 1999).
5.3.
DIABETES SERVICE PROVIDERS
Although the majority of day-to-day care of diabetes is managed by patients and their
families (Toobert, Hampson and Glasgow, 2000), diabetes is the eighth most frequent
reason for general practice visits (Veale, 2000). A variety of health professionals
provide services to people with diabetes and studies in the United States have
indicated that co-involvement with the medical care team, the patient, and their
family, are critical to the effective management of diabetes (Harris, 2000). The WA
Diabetes Strategy (1999) provides the following definitions of provider groups:
 Primary health care providers include GPs, nurses, and Aboriginal Health
Workers (AHW’s). These people are considered to be the first point of contact for
people with diabetes.
 Allied health professionals (also referred to as secondary providers) delivering
diabetes services typically include diabetes nurse educators, dieticians, podiatrists,
pharmacists, and optometrists, and may also include physiotherapists, clinical
psychologists and social workers.
 Specialist medical health care providers (also referred to as tertiary providers)
include physicians, endocrinologists, renal physicians, cardiologists, neurologists,
ophthalmologists, gerontologists and vascular surgeons.
In some Aboriginal communities, specialised care services are provided by trained
AHW’s working in liaison with specialised care clinicians and services.
5.4.
CONCEPTS OF INTEGRATION AND DIFFERENTIATION
In organisational theory, change programs often use interventions focusing on the
technology and structures of organisation – ‘technostructural interventions’. These
programs redesign the division of work and then coordinate tasks to achieve overall
effectiveness. One theory of change by Lawrence and Lorsch (1967), proposes an
organisation’s groups and functions should be designed to match or ‘fit’
environmental conditions. This change program suggests organisations should be
divided according to the amount of integration and differentiation in the environment.
Lawrence and Lorsch suggest that functions should be individually designed
(differentiation) and co-ordinated (integration) according to the amount of
organisational uncertainty facing the organisation. The concepts of integration and
differentiation appear to bear close relationships with integration models applied to
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diabetes and other chronic diseases, and can also be defined according to an IDC
Program, whereby:

When a program is designed for an environment that has a high level of complex
information to consider, the program must have a high level of differentiation in
its elements to meet the needs of the environment (Lawrence & Dyer, 1983).
Differentiation is crucial because it leads to innovation, and advances in
knowledge about how to best meet the needs of individual elements. For instance,
the diabetes environment has many elements that require consideration (e.g.
primary to tertiary prevention, geographical location, diabetes classifications,
culture, type of service provision).

Where resources (e.g. human, equipment, funding) are scarce, a program needs to
be efficient and integrate its elements to be able to respond to its environment.
For instance, AHW’s in the Lower Great Southern region have a generalist role,
which incorporates the management of issues with health (including diabetes),
housing, transport and counselling, because people and support funds need to be
pooled.
Therefore, in diabetes environments, information complexity exerts pressures towards
differentiation while resource scarcity pushes towards efficiency and integration.
These contradictory pressures are highlighted in Figure 2.
Figure 2: Opposing forces towards integration and differentiation in diabetes
Diabetes
Program
INTEGRATION
DIFERENTIATION
programs
Literature on integration models highlights the importance of:
a) Recognition of interdependence
b) Willingness to pursue integration at the potential cost of professional and
organisational autonomy (Hardy et al, 1999).
However, this interpretation of integration does not highlight the fundamental
importance of differentiation to program design. Specifically, the sustainability of
diabetes programs is dependent upon acceptance of differentiation and integration
elements as well as planning for both. The consultants were unable to locate
specific references to the element of differentiation in models of integrated care.
Rather, the integration models were broadened to include elements that had strong
resemblance to differentiation (e.g. primary, secondary and tertiary prevention [White
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and Nanan, 1999]; targeting populations [Victorian Government Department of
Human Services, 2000]). It is the consultant’s hypothesis that integration models
used throughout the world have been more successful when they have included
differentiation elements in their definition of integrated care. For example Bodeker’s
(2001) review of worldwide integration highlighted the importance of:
 Acceptance of each profession’s contribution in multidisciplinary teams, and

Investment into distinct sectors to improve the standard of care.
In conclusion, the success of integration models appears to depend as strongly on
acceptance of difference, as it does on identifying ways to integrate. One of the
strongest barriers to integration is the ‘political infighting’ that occurs when one
element attempts to dominate or compete with others rather than acknowledge a place
for all in overall program delivery.
5.5.
THE CONCEPT OF INTEGRATION OF HEALTH CARE
As noted in previous sections, diabetes seems to naturally lend itself to team based
models of care because:

It is complex to manage

It incorporates a variety of disciplines

It requires self-management and daily decision-making by people with
diabetes (Anderson, 1982).
Results from the Diabetes Control and Complications Trial (DCCT, 1993) in the
United States suggested that more intensive treatment regimens delayed the onset and
slowed the progression of diabetic conditions in patients with IDDM. This study,
along with others focusing on increased accountability (Mazze, 1994), appears to
coincide with rejuvenation of team concepts and definition of team member roles in
models of diabetes care (Mitchell-Funnell, 1996).
There appear to be two distinct types of health care teams, which often have confused
definitions, but are distinct in their relationship to models of integrated care:

Multidisciplinary teams. This view of teamwork is often cited as the
‘traditional’ approach to health care and is characterized by clearly defined
leadership, retention of distinct professional identities, representation of
individual professional disciplines, and consultative relationships. Efforts are
also divided according to speciality. Multidisciplinary teams evolved from
acute-care medical models of health care delivery and are generally
compatible with inpatient care of diabetes (Fisher et al, 1993).

Interdisciplinary teams, which lead to integrated care. This view of
teamwork appears to have evolved from the trend for chronic illness to be
treated in the outpatient arena. It endeavors to counter problems associated
with moving from the centralised and controlled inpatient climate to
decentralised and disparate outpatient environment. The characteristics of
interdisciplinary teams include: shared leadership, identity and goals;
negotiated roles and collaboration (Mazze, 1980; Wylie-Rosett & Villeneuve,
1989). Hardy et al (1999) suggest the key variables to interdisciplinary teams
are (a) the recognition of interdependence in team relationships; and (b)
willingness to pursue integration at the potential cost of professional and
organisational autonomy.
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Integrated care focuses on product (the patient) rather than functional lines (Fisher et
al, 1993). When this patient-centred and goal-directed approach is used, patients
receive care, education and psychosocial support from each member of the
interdisciplinary team. In theory, patients subsequently receive high quality metabolic
care and learn to be more informed, self-management experts (Mitchell-Funnell,
1996).
5.6.
MODELS OF INTEGRATED DIABETES CARE
There are a number of models of integrated diabetes care:
 Shared Care. This model has several definitions in the literature. Dunning et al
(1993) describe a definition focusing on the use of GPs as the point of first
contact, with diabetes clinics acting as a consultative/ education service. MitchellFunnell (1996) suggests shared care consists of a two-step process, whereby
patients receive an annual evaluation in a diabetes care Centre, with follow-up
care delivered by a primary care physician and integrated team. The Centre for
Nursing Research and Development (CNRD, 1998) use a definition more in line
with the concept of integrated care and have recommended this model for cancer
care in Western Australia.
 Management between the primary care physician and the patient. This model
has the advantage of reimbursement to patients, and is widely accepted. However
it is not necessarily compatible to intensive therapies, which require dietary and
exercise treatment, and does not provide for all the elements of integrated care.
 Integrated care teams comprising the primary care physician and local
diabetes experts. This model has similarities to the shared care definition
provided by CNRD and has the advantage of increasing access to integrated care
on a local level. Reimbursement may be available for some of these services (e.g.
podiatry), but not for other elements (e.g. diabetes education) (Mitchell-Funnell,
1996).
 Case management or care co-ordination. In this model, an identified person is
assigned to individual patients as a case manager. The case manager then
integrates, co-ordinates and advocates for people needing extensive health-care
services. This approach can be labour intensive (CNRD, 1998) but can also be
crucial in the maximisation of team interaction and quality of diabetes care
(Mitchell-Funnell, 1996).
 Collaborative practice and collaborative practice clinics. The collaborative
practice model shares responsibility for a group of patients between an advanced
practice nurse with expertise in diabetes and a physician (Mundinger, 1994). The
model has some concerns because reimbursement can be limited, prescriptions
restricted and skilled nurses hard to find (Fisher et al, 1993). In collaborative
clinics, different health care personnel work together, using independent or joint
judgement when planning health care for patients. However, difficulties have
been found in the sharing of roles and responsibilities within this situation
(CNRD, 1998).
 Diabetes Centres. An alternate model by Watkins et al (1996) proposes that an
area in or near a hospital be set aside for diabetes care. Such a Centre could
provide education for patients and staff, give advice, act as a central point for a
diabetes register, and act as a central point for organisation of district diabetes
schemes.
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With increases in popularity of integrated care models in health systems throughout
the world (Rees & Weil, 2001), a variety of hybrid models comprised of combinations
of the models listed above, have appeared in the literature. Some of these models, as
well as their outcomes with regard to integrated diabetes care are described in the
subsequent section.
5.7.
EXPERIENCES OF INTEGRATED DIABETES CARE MODELS
5.7.1. General experiences
As noted previously the successful findings of the 1993 study by the DCCT research
group generated a great deal of interest in intensive treatment approaches. Results
reported by Naji (1994) in the United Kindom (UK) supported the application of
integrated care for diabetes. Naji found that integrated care was effective for Type 1
and 2 patients; patients had more regular visits; and costs to patients were lower in
integrated care than conventional care. In this project, integrated care included
protocols for clinical examinations, prompts to practitioners, and computer generated
reminder letters to patients.
An approach to Managed Care submitted by Sidorov (1996) suggested that, at a
minimum, integrated care could include consideration to: patient education, patient
self-report surveys, consumer satisfaction, a diabetes database, telephone medicine,
guidelines, professional education, a team approach, cost of medical supplies,
research and pharmacy support.
A comparison of integrated care in the UK and Australia highlighted a number of
similarities between the health care systems of the two countries. Identified trends
included (Gold & Baines, 1998):
 A focus on primary care, with emphasis on integration and incremental change
 The development of incentives
 Sustainability depended upon GPs ability to delegate to professionals who are
better placed to deal with some activities
 Increasing patterns of quality management
 New skill development in GPs
 Increased consumer involvement in health system development
 Emphasis on continuity of care
A comparison of integrated care models between England and the Netherlands
indicated fundamental differences in design. In the Netherlands there is emphasis on
negotiation in a health system that is not hierarchical. In England, hierarchies, and the
interaction between these systems and more fluid networks and markets are important.
However, the success of integration in both countries appears dependent upon
recognition of interdependence and a willingness to pursue integration at the cost of
autonomy (Hardy et al, 1999).
A 1999 study by the WHO highlighted wide acceptance of the integrated program
model in the Americas. Within these continents, diabetes is placed within
noncommunicable disease programs rather than being a freestanding program. Well-
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trained health care teams and education of patients and the public are viewed as
crucial. In addition, integrated programs focus on :
 Primary prevention, which is aimed at reducing the incidence of disease
 Secondary prevention, which involves early detection and prompt and effective
intervention
 Tertiary prevention, which focuses on reduction and elimination of long term
impairments or disabilities, minimising suffering due to poor health, and
promoting adjustment.
More recent literature into chronic disease management also highlights a trend
towards the involvement of patient care teams in primary service provision (Wagner,
2000; Davis, Wagner & Groves, 2000).
There has also been considerable attention on integrated teams, and the role of GPs in
integrated care. Hirsch (1998) suggested that many GPs were uncomfortable with the
involvement of other disciplines in diabetes management. Kinmonth et al (1998)
reported that GPs needed to learn to negotiate behavioural change with patients during
consultation if the risk of diabetes was to decrease. These authors found that nurses
had better listening skills than doctors but did not necessarily negotiate behavioural
change with patients either. A recently reported meta-analysis of GP contributions to
diabetes care suggested that prompted GP care of people with uncomplicated diabetes
can be as good as or better than hospital outpatient care (Aged, Community and
Mental Health, 2000).
Bayless (1998) reviewed the concept of the interdisciplinary team and encouraged a
model of collaboration incorporating:
 A core membership reflecting the basic requirements of diabetes treatment (e.g.
nutrition, medication, self-monitoring) as well as specialist skills (e.g. podiatrists,
psychologists)
 Clear leadership, roles and functions, with the physician acting as ‘team builder’,
registered diabetes nurses acting as care coordinators, dieticians acting as
educators, and behavioural scientists assisting with behaviour modification
 A collaborative focus with each member of the team respecting each discipline’s
unique input and matching care accordingly
 Monitoring via periodic reviews, and reflective practice.
Van den Arend et al (2000) compared four models of care including:
1. Primary care teams following written protocols, accurate disease management,
recall and case-evaluation
2. A GP recall system and GP training
3. A GP recall system and training supported by a diabetes education course
(lectures and group discussion)
4. An integrated care program including primary and secondary providers in a
collaborative team, and diabetes education involving families and patients.
These authors found that model 3 (above) was the most successful program, followed
by model 4. They concluded that diabetes education was critical to the sustainability
of care.
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Other authors have focused on the importance of collaborative clinics (also called
mini-clinics) in improving diabetes care. Sturmberg and Overend (1999) gave a
positive account of GP mini-clinics in NSW where patients were initially seen by a
GP, a diabetes educator and a dietician. They suggested these clinics saved clinical
time, reduced waiting times, reduced costs to patients, and increased access to
services. Rose et al (2000) also found that specialised treatment facilities improved
the knowledge of Type 2 people with diabetes due to access to more intensive therapy
and structured training.
Diabetes information management systems have come to the fore in the literature in
recent years. Bonney et al (2000) have suggested that information management
systems are an integral component to structured care when they encompass elements
of registration, recall and prompts for appropriate care from GPs. However, these
systems are not without difficulties and barriers to the use of information systems
including: difficulty in data collection; time available for completion; lack of
remuneration for time outside consultation; and confidentiality concerns.
Leichter (2000) has also highlighted that information systems do not necessarily
support diabetes care management because of problems with:
 Confidentiality issues
 The comparatively low quality of diabetes software
 Management of patients by GPs who have not yet seen or examined them
 Registration issues.
Aboriginal populations have required unique approaches to integrated care. Lee et al
(2000) used a number of strategies in the NSW pilot including:
 Diabetes clinics not requiring advance bookings
 Diabetes camps
 Diabetes complications games
 Literature and brochures
 Diabetes talks
 An Aboriginal diabetes educator
 Attention to related social problems such as poor housing, lack of refrigeration,
lack of transport and electricity.
The South Australian pilot conducted by these authors used alternate strategies. Issues
with AHW retention, knowledge and skills were identified as barriers to the project:
 An advisory committee
 A diabetes database
 AHW training
 Home and community based health service delivery
 Community education.
5.7.2. The NSW Model of Integrated Care
In 1995, the NSW Health Department and Commonwealth Department of Health and
Family Services initiated a two year pilot encompassing 3 pilot sites. The key
strategies of the pilot projects were building partnerships and integrating services
across public and private health sectors and across clinical specialties, providing
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effective patient management based on agreed guidelines and ensuring people with
diabetes have access to a range of quality health services (Sheridan, 2000). Expected
deliverables included:
 Demonstrated commitment to local collaboration
 System for monitoring and feeding information into clinical practice operations
 GP application of Guidelines and Principles of Care
 Demonstrated enhanced communication mechanisms in place
 Participation in the Accounting for Health Component.
The originally expected benefits included (Diabetes Integrated Care Pilot Project
Evaluation Committee, 1995):
 Establishment of models of integrated care, which can be generalised to other
geographical areas and other services
 Improved quality of care experienced by people with diabetes
 Improved health outcomes of people with diabetes, psychological and
physiological
 Identification of indicators of quality of care and outcomes for state-wide
monitoring
 Identify efficiencies associated with integrated diabetes care
 Implementation of best practice guidelines for service providers in NSW.
5.8.
OBJECTIVES OF NATIONAL AND WA STRATEGIES
5.8.1. National Diabetes Objectives (2000-2004)
The goals of the National Diabetes Strategy (2000-2004) include:
1. Improve the capacity of the health system to deliver, manage and monitor services
for the prevention of diabetes and the care of people with or at risk of diabetes
2. Prevent or delay the development of Type 2 diabetes
3. Improve health related quality of life and reduce complications and premature
mortality in people with Type 1 and Type 2 diabetes
4. Achieve long term maternal and child outcomes for gestational diabetes and for
women with pre-existing diabetes equivalent to those of non-diabetic pregnancies
5. Advance knowledge and understanding about the prevention, delay, early
detection, care and cure of Type 1, Type 2 and gestational diabetes.
5.8.2. Commonwealth Department of Health and Aged Care Objectives 2000-2004
The focus of this program is on Chronic Disease prevention, its key objectives are to:
1. Improve the health related quality of life for people with chronic disease,
particularly those with comorbidities
2. Help people with chronic disease to use the health care system more effectively
3. Achieve effective collaboration between individuals, their families and health care
professionals in the management of chronic conditions (National Public Health
Partnership, 2001).
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5.8.3. The WA Diabetes Strategy 1999
The Strategy focuses on prevention, care by primary service providers and care by
specialist service providers. A number of objectives are identified under each level of
intervention:
Prevention
 Ensure prevention
programs cover entire state
population
 Increase identification of
health risk factors
 Increase awareness/
understanding of Type 2
 Improve collaboration/
communication amongst
diabetes service providers,
agencies and consumers
 Ensure prevention is a
health priority
 Increase community
capacity to reduce risk
factors
Primary Care
 Ensure coverage of Type 1
and Type 2 populations
 Minimise morbidity from
diabetes
 Improve service
integration
 Increase early diagnosis
 Monitor prevalence,
morbidity and mortality
 Ensure skills match selfcare needs
 Encourage diabetes
management as a health
priority
 Ensure a range of
information sources are
available and accessible
Specialised Care
 Work through primary
health providers to ensure
access to services
 Ensure ongoing
communication
 Ensure links are
established between
specialist care centres and
primary health providers
 Ensure continuity of
patient records
 Ensure regular updating of
skills of providers
 Ensure access to culturally
secure care for Aboriginal
 Make diabetes a priority
5.8.4. Metropolitan Health Plan 2020
Key themes for change:
 Integration of diverse parts of the health sector to improve coordination between
services
 Reconfiguration to improve access to hospital and health services
 Development of services to the highest quality to best meet future health needs.
5.8.5. References
Aged Community and Mental Health (2000). Literature Review of Effective Models
and Interventions for Chronic Disease Management in the Primary Care Sector.
Institute for Public Health and Health Services Research, Monash Medical Centre.
Anderson, RM (1982). The team approach to diabetes: an idea whose time has come
up. Occupational Health Nursing, 30, 13-14.
Bayless, M. (1998). The team approach to intensive diabetes management. Diabetes
Spectrum, 11, 33-37.
Bodeker, G. (2001). Lessons on integration from the developing world’s experience.
British Medical Journal, 322, 164-167.
Bonney, M., Harris, M., Burns, J. & Powell-Davies, G. (2000). Diabetes information
management systems: General practitioner and population reach. Australian
Family Physician, 29, 1100-1103.
Centre for Nursing Research and Development (1998). Models of Best Practice for
Integrating Care across the Community-Hospital Interface in Western Australia.
School of Nursing, Curtin University: Western Australia.
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Commonwealth Department of Health and Aged Care, Australian Institute of Health
and Welfare (1999). National Health Priority Areas Report: Diabetes Mellitus
1998. AIHW Cat No. PHE 10. Health and AIHW: Canberra.
Cummings, T. & Worley, C. (1993). Organisational Development and Change, 5th
ed. New York: West Publishing Co.
Davis, R.M, Wagner, E., Groves, T. (2000). Advances in managing chronic disease.
British Medical Journal, 320, 525-526.
DCCT Research Group (1993). The effect of intensive treatment of diabetes on the
development and progression of long-term complications in insulin dependent
diabetes mellitus. New England Journal of Medicine, 329, 977-986.
D’Cunha, C.O. (1999). Diabetes: Strategies for Prevention. Report of the Chief
Medical Officer of Health. www.gov.on.ca/health/english/pub.
DeCourten, M., Hodge, A., Dowse, G., King, I., Vickery, J., & Zimmet, P. (1998).
Review of the Epidemiology, Aetiology, Pathogenesis and Preventability of
Diabetes in Aboriginal and Torres Strait Islander Populations. Canberra: Office
for Aboriginal and Torres Strait Islander Health Services.
Diabetes Integrated Care Pilot Project Evaluation Committee (1995). Diabetes
Integrated Care Pilot Project Evaluation and Implementation Plan. NSW Health
Department.
Dunning, P., Moscattini, G. & Ward, G. (1993). Diabetes shared care: A model.
Australian Family Physician, 22, 1601-1608.
Fisher, E.B., Heins, J.M., Hiss, R.G., Lorenz, R.A., Marrero, D.G., McNabb, W.L.,
Wylie-Rosett, J. (1993). Metabolic Control Matters: Nation Wide Translation of
the Diabetes Control and Complications Trial: Analysis and Recommendations.
Bethesda, MD: National Institutes of Health.
Gold, L. & Baines, D. (1998). Integrated care in the UK and Australia. Health
Services Management Centre, School of Public Policy, University of Birmingham.
Hardy, B., Mur-Veemanu, I., Steenbergen, M., & Wistow, G. (1999). Inter-agency
services in England and the Netherlands: A comparative study of integrated care
development and delivery. Health Policy, 48, 87-105.
Health Department of Western Australia (1999). Survey of AMS Diabetes Services in
Western Australia. Office of Aboriginal Health, DOH: Perth.
Hertzel, C., Gerstein, M., & Meltzer, S (1999). Preventative medicine in people at
high risk for chronic disease: the value of identifying and treating diabetes.
Canadian Medical Association Journal, 160, 1593-1595.
Hirsch, I. (1998). The status of the diabetes team. Clinical Diabetes, 16,
www.diabetes.org/ClincalDiabetes.
International Diabetes Institute (2000). Media Information 30 May 2000.
Kinmonth, A.,Woodcock, A., Griffin, S., Spiegal, N. & Campbell, M. (1998).
Randomised controlled trial of patient centred care of diabetes in general practice:
impact on current wellbeing and future disease risk. British Medical Journal, 317,
1202-1208.
Lawrence, P. & Dyer, D. (1983). Renewing American Industry. New York: Free
Press.
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Lawrence, P. & Lorsch, J. (1967). Organisation and Environment: Managing
Differentiation and Integration. Cambridge: Harvard Graduate School of
Business, Administration Division of Research.
Lawrence, P. & Lorsch, J. (1969). Developing Organisations: Diagnosis and Action.
Reading, Mass: Addison-Wesley.
Lee, V., Rose, V., Harris, E. & Bonney, M. (2000). Case Study 1: Management of
Diabetes in the Aboriginal Population – Eyre Penninsula Division of General
Practice, www.healthinfonet.ecu.edu.au.
Lee, V., Rose, V., Harris, E. & Bonney, M. (2000). Case Study 6: Macleay Hastings
Valleys Diabetes Pilot – Durri Aboriginal Corporation Medical Service and Port
Macquarie Division of General Practice, www.healthinfonet.ecu.edu.au.
Leichter, S. (2000). The Internet in diabetes care: the wild care for the future.
Clinical Diabetes, 18, 188-189.
Naji, S. (1994). Integrated care for diabetes: clinical, psychosocial and economic
evaluation. British Medical Journal, 308, 1208-1212.
National Public Health Partnership (2001). Newsletter: Meeting the global challenge
of chronic disease, Issue 14 December 2000/ January 2001.
Mazze, R.S. (1980). Diabetes Education Teams. In Professional Education in
Diabetes: Proceedings of the Diabetes Research and Training Centers Conference.
Mazze, R.S (Ed) pp.45-74. Bethesda, MD: National Institutes of Health.
Mazze, R.S (1994). A systems approach to diabetes care. Diabetes Care, 17, 5-11.
Mitchell-Funnell, M. (1996). Integrated approaches to the Management of NIDDM
patients, Spectrum, 9, www.diabetes.org/publications/spectrum .
Mundinger, M.O. (1994). Advanced practice nursing: Good medicine for physicians?
New England Journal of Medicine, 330, 211-214.
Commonwealth Department of Health and Aged Care (1999). National Diabetes
Strategy 2000-2004. Australian Health Ministers’ Conference: Canberra.
Rees, L. & Weil, A. (2001). Integrated Medicine. British Medical Journal, 322, 119120.
Rose, M., Hidebrandt, M., Fliege, H., Seidlitz, B. & Cotta, L. (2000). Relevance of
treatment facility to disease-related knowledge of diabetic patients. Diabetes
Care, 23, 1708.
Sheridan, J. (2000). Final Report: Diabetes Integrated Care Pilot Project in Mid North
Coast, Far West and Western Sydney. NSW Health Department.
Sidorov, J. (1996). The integrated approach to diabetes mellitus: The impact of
clinical information systems, consumerism and managed care. Diabetes
Spectrum, 9, 158-162.
Sturmberg, J & Overend, D. (1999). General practice based diabetes clinics: An
integration approach. Australian Family Physician, 28, 240-245.
Toobert, D., Hampson, S., & Glasgow, R. (2000). The summary of diabetes self-care
activities measure. Diabetes Care, 23, 943-950.
Van den Arend, I, Stolk, R, Rutten, G, & Schrijvers, G. (2000). Education integrated
into structured general practice care for Type 2 patients results in sustained
improvement of disease knowledge and self-care. Diabetic Medicine, 17, 190197.
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Victorian Government Department of Human Services (2001). Primary Care
Partnerships, Integrated Disease Management: Interim policy directions and
guidelines. Melbourne: Victorian Government Publishing Service.
Watkins, P.J., Drury, P.L. & Howell, S.L. (1996). Diabetes and its Management, 5th
ed.
Western Australian Diabetes Services Taskforce (1999). Western Australian Diabetes
Strategy 1999. Health Department of Western Australia: Perth.
White, F. & Nanan, D. (1999). Status of national diabetes programs in the Americas.
Bulletin of the World Health Organisation, 77, 981-987.
Wagner, E. (2000). The role of patient care teams in chronic disease management.
British Medical Journal, 320, 569-572.
Wylie-Rosett, J. & Villeneuve, M. (1989). A team approach: overcoming resistance
to change in a long-term care facility: analysis of the team approach and the
consensus approach. Diabetes Education, 15, 122-123.
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6. APPENDIX C: QUALITATIVE DATA THEMES
6.1.
PILOT REGIONS: BACKGROUND AND PROGRESS TO DATE
Four regions were included in the original pilot undertaken by the DOH:
 Inner City
 Upper Great Southern
 Lower Great Southern
 Midwest.
This section provides background information on the implementation of each pilot, as
well qualitative themes relating to the effectiveness, sustainability and generalisability
of the pilot methods used. Data are divided into themes obtained through individual
interviews with regional service providers and focus groups with co-ordinating
committees and consumers. For interviews with service providers, themes are
presented in descending order of frequency.
6.1.1. Inner City Region
Description of the Pilot
Background
East Perth Public and Community Health Unit (EPPCHU) developed the IDC
Program for the Inner City health locality based on the work of Sheridan and Boyages
(1996) form the NSW IDC Program. A business case for funding a 3 year pilot was
submitted to the DOH in March 1998. The business case described the problem areas
associated with the levels of service within the diabetic population at the time
including:
 Lack of access to a multi-disciplinary community health centre of community
health staff in the Inner City area.
 No access to a regional hospital.
 Options for GP referral were restricted to Royal Perth Hospital (RPH), DAWA or
private practice. Some primary care services had to be provided by RPH due to
the limited resources in primary care settings.
 DAWA was the major service provider providing dietary and diabetes education.
At the time there was a 3 week waiting list. The business case clearly stated that
without enhancement, this service could not meet demand.
 Staff required for primary health care was cited as 2.7 Full Time Equivalent
(FTE) for diabetes educator positions, 1.0 FTE for a dietician and 2.0 FTE for a
podiatrist.
 Limited access to community education and podiatry services.
 The focus of programs and evaluation/ needs assessments had been on the areas
of primary care.
Objectives
The IDC Program in the Inner City has followed the NSW model closely by
establishing a co-ordinated network of primary care services to improve the detection
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and management of diabetes complications. After identifying the major deficits
through mapping of current services, the priorities for the Inner City were:
 Access to diabetes education services for people with NIDDM
 Access to podiatry service for people with high risk foot problems
 Assessment of how current gaps in service provision for Non-English Speaking
Background (NESB) people can be addressed
 Implementation of the identified diabetes prevention strategy.
The business case does address National and State goals and targets for diabetes at
the time. These were:
 Providing a co-ordinated approach for developing diabetes management
guidelines
 Referral networks
 Education and lifestyle support
 Quality review activities.
Program Management
A Local Advisory Committee (LAC) has existed in the Inner City since 1997. The
steering committee formed for the pilot drew on this group and developed the
following Terms of Reference:
 Basic structure is developed for a steering committee
 The Project Officer assumed an administration and co-ordination role
 The EPPCHU managed operational aspects
 No definition of roles of Steering Committee members was defined other than to
advise/ guide the development of primary health services.
The LAC stated its commitment to enhancing services at all levels including health
promotion, primary service provision, community health, ambulatory care, Aboriginal
and NESB health services. The Committee conducted a 2 day workshop to develop a
diabetes prevention strategy for the Inner City with the objective of guiding the
implementation of priority programs and assisting with submissions for funding and
pilot programs.
Financials
The business case submitted for funding over a 3 year period (1998-2001) and
identified 4 key output areas to track costs. These outputs are indicated in table 11
and show the original proposal and actual expenditure for each acquitted financial
year.
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Table 11. Financial output areas with budgeted and actual expenditure for the Inner
City
Output 1
Provide community based
diabetes education activities to
480 people with NIDDM and
their partners per year
Output 2
Conduct a needs assessment and
pilot programs to identify
appropriate services and service
locations for people with diabetes
from NESB
Output 3
Implement at least 4 programs
targeting high risk groups that
will increase early diagnosis and
reduce modifiable risks for
developing diabetes
Output 4
Implement systems for coordinated care, quality standards
of care, health professional
training, and support and systems
for monitoring of health
outcomes
TOTAL
SURPLUS
98/99
Actual
$49,773
98/99
Budget
$56,500
99/00
Actual
$43,724
99/00
Budget
$65,000
$36,423
$13,000
$27,286
$40,000
$1,000
$27,000
$26,307
$10,000
$59,247
$135,000
$102,970
$125,000
$146,443
$231,500
$200,287
$240,000
$85,057
$39,713
Framework
 Has copied the NSW model
 A steering committee of service provider representatives guides the
implementation of programs
 Community education programs were supplied by DAWA and the Perth Division
of GP. Funding was originally used to subsidise these organisations. After the
first year funds were provided directly by IDC Program for ease of management
and reporting.
 The IDC Program Co-ordinator has played an active role in the actual evaluation
of pilot clinics and needs assessments
 The administrative role for implementing programs became increasingly
demanding on the Co-ordinator
 Planning and reporting has been consistently applied. However, performance
measures and indicators abundant in documentation have not been collated or
determined in any measurable way. Resources were not allocated to this task.
Application in practice
In the business case the IDC Program is described as an opportunity for service
providers to come together on projects that will ultimately lead to greater local
knowledge of diabetes clients. As a practical application of this, the Inner City
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conducted a variety of programs throughout its 3 year lifespan. The programs have
gathered information that has allowed for a diabetes population demograph to be built.
It has enabled areas of need to be identified and consequent programs to be
implemented to begin educational and clinical assessments of clients. The evaluations
have been directed towards the high risk groups that were identified in the original
business case. The major programs included:
 Community consultation process to collect information on people with a family
history of diabetes.
 An Inner City Eye Check program designed to improve communication between
providers and establish lines of referral for service providers dealing with
retinopathy.
 Diabetes care with the aged – a training program for people working in aged
care.
 Evaluation of pilot community education program, which was aimed to provide
more accessible essential service for people with diabetes. Five pilot programs
were conducted and offered to people with diabetes in the community.
 Evaluation of the pilot diabetes clinic at Perth Aboriginal Medical Service
(AMS), which aimed to provide culturally appropriate clinical service for
Aboriginal men and women with diabetes attending Perth AMS. A total of 156
assessments were conducted.
 Diabetes in Italian and Vietnamese communities, which assessed service needs
in the Inner City. This was a joint initiative of EPPCHU and Inner City
Diabetes Services.
 The establishment and evaluation of community podiatry services for people
with diabetes in the Inner City area.
 The early detection and risk reduction program for Type 2 diabetes in women
with GDM.
Implementation Actions Undertaken







The evaluation programs and community education programs continued
identifying the existing baseline data of the community, and its subsequent
needs.
The LAC followed the NSW model. It identified its 4 main output areas and
focused on guiding the programs and evaluations that were identified to achieve
these outcomes.
The LAC’s role continued as it had started. The LAC had input into the
different project briefs and used these to reflect their common agency needs.
The Co-ordinator managed the IDC Program by using the business case
prepared as a planning tool and checking mechanism.
The Co-ordinator made regular, in-depth reports to the LAC. The LAC
remained focused on its goals.
Although there has been no reporting against the indicators that were developed
from the business case, there is sufficient evidence in the projects/ programs
achieved that indicate progress of, and improvements in service delivery to
diabetes in the Inner City. One means of identifying integration progress can be
identified through the joint projects that have been undertaken.
Indicators that can be obtained are focused on the results of programs and
services. These measure the outcome of programs.
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Definition of an Integrated Care program (from interviews)



It is about different disciplines who work together
Formal communication between the different caregivers is essential
It is about having no duplication or gaps in service
Effectiveness – Themes from interviews
Progress against program objectives
How the IDC Program in the Inner City region operate




It is a coordinated program
There are some problems
It has improved over the time of its operation
Training is involved
Actual impact of IDC service




Improved services and service integration
The service is appropriate to local community
Patients are behaving differently and demonstrating better understanding
It is too early to say
Consistency with other state/national strategies

There were mixed views as to whether the program was consistent with other
states. However those who believed the program was consistent were also better
informed about integrated care as a model.
Level of service integration achieved
General themes


There have been significant improvements and there are room for more
improvements
There are some problems, particularly with the GPs
Monitoring outcomes/measurement systems


There are sufficient measuring and monitoring systems
There are not sufficient measuring and monitoring systems
Equity of access for different demographic groups

The majority of respondents believed there is not equity of access to services
Access for professionals to training & support:

Mixed responses were received as to whether training and support was accessible
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Level of acceptability
Service providers

Generally high
Patients:

Between medium and high, with a theme of over popularity of the service starting
to emerge
At-risk groups:

A trend towards low level of acceptance, but a spread of opinions were obtained
Strengths
 Improved client outcomes
 The breaking down of previous organisational barriers
 The clarity and strong, clear, direction of the steering committee and coordinators
Weaknesses
 The program is under-funded for the demands placed on it
 The poor competence levels of some care providers
 Problems with provider communications
 The unnecessary bureaucratic procedures are off putting for private providers
 Problems with poor understanding of community groups
 Insufficient data collection and monitoring systems
 The success of the program is very dependent on the role of the coordinator
Unintended consequences
Positive consequences:



Increase of carer awareness, cross-fertilisation of information and education
Increase of community awareness and education
Service improvements
Negative consequences:


Dependence of lower risk patients on the service can drain resources from high
risk areas
Being inundated with the lower risk patients because the care is free
Barriers
 Cultural barriers and practices between different service providers
 Service provider attitudes, knowledge and clinical practices are out of date
 Insufficient funding to do what is needed
 Maintaining the communication between the different service providers
 No single physical focal point of services in the Inner City
 Time demands being placed on service providers
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Gaps and Duplications
Gaps:
 Services for particular demographic groups
 Funding
 The cooperation and commitment of some service providers
 Patients living in poverty
 Data collection and monitoring
 Counselling services for non-compliant people with diabetes
 There are still communication gaps between service providers to be filled
Other issues related to this study:
 Best practice issues and ideas
 There is not enough emphasis on preventative care
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Effectiveness – Themes from focus groups
REGIONAL SERVICE PROVIDERS
FOCUS GROUP HELD WITH COMMITTEE
Strengths
 Appropriate consultation with key
stakeholders
 Adequate financial resourcing to
implement pilot
 Excellent skills and commitment from
IDCP co-ordination unit
 Multi-strategy/ multi-disciplinary approach
 LAC commitment to program
 Sufficient flow of information and
resources between public health area and
public health service providers
 Podiatry program fulfilling its objectives
Weaknesses
 Inadequate integration of AHW and
community health workers
 No commitment to community health
 Constantly asking for funding – short term
pilot projects may not be sustainable
 Multiple complex streams being developed
at the same time
 Setting up expectations of community
services but not following through
 Mindset (that) the private health insured
clients have that there is an appropriate
level of resources
 Many projects developed so fast so no time
to think through
 Absence of prevention strategy for high
risk groups
 Podiatry program limited by RPH,
community and funding
 Community diabetes education for Type 2
 Because of demand and growing consumer
need, programs continue to need to grow
 Support to educators eg. community
meetings and professional support
 Planning cycle
 Response to program needs
 45% of WA population has private health
insurance. Perception that private health
insurance will support everything. Diabetes
care costs more when insured
 No regulation of diabetes educators
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Barriers
 Paternal medical model
 Turf warring/ territorialism
 Has taken 2.5 years for GPs to come on
board
 Funding submission process is too time
restrictive
 Knowledge held by specialists and not
shared with all levels
 Black and white (views) of GPs and
specialists
 Under-resourced core and podiatry
program with no potential for capacity
building
 Lack of support and services for tertiary
care
 Reporting to everyone and every funding
source/ levels of reporting
 Time spent negotiating and building
partners
 Copping the flack
 People not prepared to share information
Gaps
 A physical diabetes site for service
providers and the public – except for
DAWA, RPH and Mercy
 No secondary hospital eg. Swan Districts,
Bentley
 Don’t know if the model we have in place
in IDC is working – no feedback
 No good baseline data
 Quality improvement processes are not
built in
 Support groups and mechanisms for selfcare and continuing education
 Type 2 focus – no attention to Type 1
 Privately insured individuals miss out on
the opportunity to be included in the
collection of health data, receive follow-up
information and education on diabetes
 No appreciation of public and private
health sectors and the integration of
processes to achieve a continuum of care
Duplications
 Resource duplication
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Sustainability– Themes from interviews
Potential impact on health outcomes
 Better access, awareness and prevention
 For health organisations to work together to break down the barriers between
them
 There needs to be enough time to demonstrate that good outcomes are happening
Ways to improve sustainability
 Increases in service
 Increased funding
 Improvements in the attitude, education and competence of service providers
 Increased communication between service providers
 Data collection and monitoring needs to be addressed further
 Patient attitude and long term viability of the service
 Knowledge about the outcome of this and other studies
 A longer-term perspective on the part of the funder
 The potential of the WWW for enhancing service delivery and carer education
Is quality of care ensured through sufficient standards and guidelines?

The majority of respondents believed there are sufficient standards and guidelines
to ensure quality of care
There are not enough policies and plans in place to ensure the future of diabetes services





The future and sustainability of the IDCP needs to be thought about
Attention must be given to non-compliant patients
The diabetes epidemic is exploding, prevention plans are lacking
Some currently excluded services providers could make an important contribution
Standards of care provision should be legislated
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Sustainability– Themes from focus groups
Suggested improvements
 Define the level of capacity so the level of service that can be provided meets the
expectation of service delivery
 Policy level changes for interaction between secondary and tertiary care
 Remove processes that clog rather than invent new ones. Reduce over reporting
 Sharing of information when overloaded
 Development of eye program
 Services for aged care, standard and resourcing
 Specific services for CALD groups eg. educational health and support groups
 Including pharmacists and health promotion services and skills in the loop
 Further development of database
 Resources/ processes to private health system/ from non-government organisations and the
public sector
 Giving recognition to health workers on the ground – provide with adequate support and
training
 Promotion of IDC services for understanding and fit specifically with personnel, GPs and
health providers
 Communication lines between services
 Directory of service contact lists
 Need to plan for longitudinal evaluation of clients self care and diabetes management
 GP training in diabetes care
 Primary prevention and early detection eg. gestational diabetes mellitus, family screening
and reducing risk factors
 Not aware of public and private demographic mix within catchment areas
 Canvas model to private health sector to gauge proposed involvement
Applicability– Themes from interviews





The IDCP has the potential to influence other health service deliveries
For many different diseases where prevention minimises complications
Wherever a lot of health disciplines get together to provide a holistic service
For long term chronic diseases, the personal goal setting component is especially
good for falls programs, mental health etc.
Arthritis, hypertension and heart problems, obesity, renal problems, eye checking
6.1.2. Upper Great Southern Health Locality
Description of the Pilot
The majority of background information on the UGS is merged with that of the LGS
pilot. Where additional information is required please refer to the reporting on the
LGS.
Background
Towards the end of the first 12 months a local diabetes co-ordinator (LDC) position
was established for the UGS, this was separate to the IDC Co-ordinator.
Objectives
These are essentially the same as the LGS pilot.
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Program management
In the last 12 months a LAC was established. This was comprised of local service
providers and GPs and its role is to implement and expand diabetes services in the
immediate local area.
Funds management
As with the LGS pilot, funds for the program were distributed from General Health
Purchasing to the primary health service. The money becomes the responsibility of
the General Manager and is allocated to a general pool of funds. There is no set
budget for diabetes specific services and no acquittal of funds against either program
that are implemented to improve or extend diabetes services.
Some funds have been allocated to additional FTE for dieticians and community
educators. However, not all the work of these additional FTE’s is specific to diabetes.
Therefore it is not possible to provide any actual costs associated with the IDC
Program in UGS or LGS. It is important to note that in addition to the funds allocated
through the IDC Program, funds have been sourced from:
 Great Southern Division of GP
 Primary Health Services
 Public Health Services.
Some of these funds have contributed to projects and programs, and have also assisted
with the establishment of the additional FTEs. The method of distribution of funds
and the cost definitions does not allow for activity based costing. The LDC position
is funded by the UGS Health Service. The role of the LDC is to provide an
organisational link to the IDC Co-ordinator, liaise with local service providers,
administrate, educate and perform clinical tasks.
Funds allocated specifically through the business case for UGS are listed in the table
below. It seems clear that the budget was significantly underestimated in the original
business case.
Table 12. Funds budgeted in the original submission for the UGS pilot
UGS Pilot
Year 1
Year 2
Year 3
TOTAL
Budget
$36,000
$36,000
$35,500
$107,500
Implementation Actions Undertaken
See LGS section.
Definition of an Integrated Care program (from interviews)




It is about a multi-disciplinary team
Patient care is coordinated or case managed
Its about different health services working together
It is about organised systems for multi-disciplinary care
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Effectiveness – Themes from interviews
Progress against program objectives
How the IDC Program in the UGS region operates:






The GPs are supposed to take a central role but do not do so
There is a steering committee representing several health services that meets
It is a coordinated approach to patient care and initiatives
I have little idea of how it works
There is a system of diabetes data collection
There is a multi-disciplinary team
Identifiable improvement outcomes
Actual impact of IDC service:




There is better patient support happening
Care providers are becoming more educated
There are changes to patients behaviour
It is a good program but it still has a long way to go
Consistency with other state/national strategies:

The IDCP is consistent with other states
Level of service integration achieved
General themes







There appears to be partial integration of care within the region
Things are improving and even looking good
The success of the integration depends on a coordinator to keep the enthusiasm
for integration going and to trouble shoot
There are tensions relating to the role and activities of the GPs
Some GPs are making proactive initiatives related to diabetes care
There are tensions relating to the role of Silver Chain
Recruitment and retention problems have hampered partnerships
Monitoring outcomes/measurement systems.

There could be more systems that relate to access to patient records in order to
coordinate properly
Equity of access for different demographic groups:

The majority of respondents believed there is not equity of access to services
Access for professionals to training & support:

There is not enough access for carers to training and support
Level of acceptability
Service providers

Acceptability trended towards high with most difficulties relating to GPs
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Patients:

Generally high acceptability
At-risk groups:

Trend towards low acceptability. Reasons relate to lack of services, noncompliance or non-understanding, poor management, language, cultural or
disability barriers and poverty. Some significant differences in perceptions of
acceptability were highlighted.
Strengths


Improvements in the quality of diabetes services
The quality of the staff working on the program
Weaknesses









The varying interest of the GPs
The success or otherwise of the program rests on the ability of the coordinator
Problems with recruitment and retention in the country
The need for a greater focus on prevention and promotion of diabetes care
Health service political issues
The overload of new information that newly diagnosed people with diabetes have
to take in
Funding concerns(2)
The ad hoc nature of the partnerships
The difficulties in providing care to the Aboriginal population
Unintended consequences
Positive consequences:




Education and involvement of GPs and other carers
The program has catalysed the various diabetes services into work together
Better regional services
Support for integration of services and with other disease programs
Negative consequences:

Some people are still slipping through the gaps and not getting education and care
Barriers






The lack of support and diabetes management understanding from some GPs
Recruitment and retention of staff
Cultural and educational barriers associated with the Noongar patients and carers
Barriers to education of carers
Geographical distances
Lack of communication with other service providers
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Gaps and Duplications
Gaps:
 Some demographic groups are being missed or not addressed sufficiently
 Communication between carers
 Geographically isolated areas
 Patient awareness is lacking
 Health promotion programs
Duplications:



Relating to GP management of patients
Duplication of the diabetes education service already offered by Silver Chain
Relating to Aboriginal people
Effectiveness – Themes from focus groups
REGIONAL SERVICE PROVIDERS
No service provider focus group was held with
this region as the Committee had just changed
membership.
REGIONAL CONSUMERS
Strengths
 Educational elements from Diabetes
Educator
 Good referrals between GPs and Diabetes
Educator
Weaknesses
 Other community services (e.g. police)
have a poor understanding of diabetes
 Nobody to talk to other than GP, who may
not have good knowledge of diabetes
 No local access to diabetes specialist
Barriers
 Cost of diabetes equipment (e.g. test strips,
syringes)
 Have to go to Perth to see specialist but no
transport
 No after hours help except hospital, where
staff have limited training in diabetes
Gaps
 Need for more community education
 Contact for local diabetes advice needed
 No education to school aged children or
gestational mothers
 Optometrist clinic booked out
 More dietary advice needed
 Hospital staff not trained in dietary needs
Sustainability– Themes from interviews
Potential impact on health outcomes


Impact on short-term health service efficiencies
Impact on long-term health expenditure
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
The prevention of complications, and the management of the diabetes diagnoses
Ways to improve sustainability







Communication and involvement of the GPs
Need for formalisation of service provider structures and roles
More health promotion
Educational services for carers
Commitment to funding the program
Expansion of the services
The diabetes coordinator should change the way she works – more strategic focus
needed
Is quality of care ensured through sufficient standards and guidelines?

The majority of respondents believed that there are sufficient systems in place
There are not enough policies and plans in place to ensure the future of diabetes services

There are enough policies and plans in place to ensure the future of diabetes
services
Sustainability– Themes from focus groups
REGIONAL COMMITTEE
No service provider focus group was held with
this region as the Committee had just changed
membership.
REGIONAL CONSUMERS
Suggested improvements
 Education on self-management
 Educators who are up to date with
information, knowledge and equipment
 Handbook or video for education
 More consumer support groups
 Supermarket tours
 Get people with diabetes to talk to the
community
 Health promotion nights and free testing
for blood sugar
 Support systems to help deal with the
change to managing own diabetes
 Flexibility in opening hours of blood bank
Applicability– Themes from interviews
 The program has the potential to influence other health service programs
 Diseases cited include: Chronic diseases where early intervention, self
management and the right treatment mix are key factors. Examples include
asthma, arthritis and heart disease, (especially cardiac rehabilitation), cervical
screening and immunisation. It wouldn’t be suitable for alcohol problems because
the program requires that the patient admit that they do have the disease
 The program has potential to influence other health regions
 There is already health program integration occurring as a result of the scarcity of
the resources which has nothing to do with the IDCP
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6.1.3. Lower Great Southern Region
Description of the Pilot
Background
Following the establishment of the Inner City pilot project, the DOH requested the
Southern Public Health Unit (SPHU) to make a submission for the LGS, UGS and
Midwest. The SPHU presented a submission to create these additional 3 pilot
projects, which included a strategic plan developed in collaboration with local health
services and AMS’. The submissions requested funding for 3 years (1998-2001).
Objectives
Each submission was tailored towards the local area needs at the time. The main goal
of the LGS pilot was “to enhance diabetes services at all levels of service delivery,
including health promotion, primary practice, community health, ambulatory care,
Aboriginal and NESB.”
The business case provided key objectives for each funding year. These objectives
focused on:
 Establishing a regular steering committee forum
 Establishing and enhancing a register recall system (used at the time by the Great
Southern Division of GP)
 Increasing access for people with diabetes to community education, assessment
and treatment services
 Improving systems for hand held patient record keeping – ‘passports’
By the third year of the program additional objective had been added, including:
 Identifying the number of elderly people in the population living with diabetes
 Identifying the number of IDDM patients older than 15 years
 Implementing a diabetes prevention program for first degree relatives
Each of the objectives also defined a strategy, target population, effectiveness
indicator, outputs and expected outcomes. The business case was accepted and
approved for the period requested. The total funds allocated in the contract to the
LGS pilot were $96,000. The contract for the LGS IDC pilot was held between the
SPHU and the General Purchasing Unit of the DOH. The business case also sought
support to:
 Establish a state-wide public health diabetes program network
 Establish formal links between metropolitan tertiary institutes and diabetes
services in the rural sector
 Identify principles of networking for generalist and specialist diabetes services
 Assist with the development of a co-ordinated diabetes program strategic plan
for population based diabetes service delivery in collaboration with other key
stakeholders
 Develop an integrated service delivery model for population based diabetes
services in collaboration with other key stakeholders and a pilot model in 1997/
1998
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 Evaluate all information systems available in WA for the collection of diabetes
data
 Identify the diabetes training requirements of health professionals in the SPHU
area
Program Management
A steering committee for the LGS was established in August 1998. The Great
Southern Diabetes Steering Committee (GSDSC) was formed to represent the great
variety of service providers associated with diabetes as well as showing a best
representation of the region. At the time of commencement, the co-ordinator for the
LGS was also the co-ordinator for the UGS.
The GSDSC therefore included the UGS and aimed to oversee and ensure a coordinated approach to integrated diabetes services in the region. The GSDSC
included representatives from:
 Primary Health Service managers
 Family Futures (Southern Aboriginal Corporation)
 Silver Chain Nursing Association
 Consumers
 Regional hospitals
 Public Health Services
 Diabetes specialists and GPs
The roles proposed by the GSDSC for:
 Primary health services in the LGS and UGS were:
Provision in general practice of a diabetes educator to assist with
registration of patients; assist in implementing systems of data return
and patient recall; provide initial education and coordinate referral; and
ensure regular feedback to GPs.
Provision of community based diabetes education, dietetic and podiatry
services for people with diabetes, at risk of diabetes or other chronic
lifestyle diseases.
Support for Aboriginal diabetes programs.
 The Great Southern Division of GP was responsible for all activities surrounding
the development and maintenance of diabetes register activities.
 The Great Southern Public Health Services were responsible for executive
support to the Committee, planning, training, monitoring and reporting of
diabetes initiatives, writing proposals and liaising with the DOH.
 Roles were also defined for hospital-based diabetes staff, Silver Chain, and
Family Futures.
Funds management
The pilot was allocated funding for 3 years. These funds were provided by General
Health Purchasing and distributed to the LGS Health Service. Funds allocated
specifically through the business case for LGS are listed in the table below. It seems
clear that the budget was significantly underestimated in the original business case.
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Table 13. Funds budgeted in the original submission for the LGS pilot
LGS Pilot
Year 1
Year 2
Year 3
TOTAL
Budget
$27,000
$32,500
$36,500
$96,000
Application in practice
GSDSC projects have included:
 Representation by all key diabetes service providers, health service
representation and stakeholders on the Committee
 Development of the Great Southern Diabetes Strategic Plan
 Development of diabetes policy
 Development of standards for diabetes education programs
 Establishment and continual development of diabetes register through the Great
Southern Division of GP
 Increased access to services to dietetic, podiatry and Aboriginal population needs
 Achievement of sustainable diabetes education services in the Great Southern
Region (however this is contradicted by findings in the evaluation regarding
Silver Chain)
Reporting has included:
 Bi-monthly meetings of the GSDSC
 A progress report on the objectives of the LGS IDC pilot in June 1999
Definition of an Integrated Care program (from interviews)
 A variety of different specialist service providers working together in a
coordinated way to improve patient outcomes
 Communication
 Better meeting client needs
 Shared client care
 Cost effectiveness/ efficiency
Effectiveness – Themes from interviews
Progress against program objectives
How the IDC Program in the LGS region operate:
 The different service providers / health services work as a team to provide an
integrated service
 There is some sort of working together happening with the service providers /
health services to provide services to diabetic patients
 There is a steering committee
 The steering committee has jurisdiction of funds and responsibility for
monitoring diabetes care in the region
 Don’t know much about the program / It is hard to distinguish this diabetes
program from the others
 There is a steering committee that has representatives from the health services
and professions
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 There is a central coordinator who coordinates all the service provision
 There is a database that is related to the steering committee
Actual impact of IDC service

There was some indication that the program achieved integrated care, but
perceptions were mixed
Consistency with other state/national strategies

WA is working in consistency with other states
Level of service integration achieved
General themes


Perceptions were mixed as to whether the program was integrated, with problems
such as duplication of Silver Chain services and GP commitment cited
There are identifiable indicators of the positive impact of the IDCP such as:
“Clients are giving good feedback, more motivated and changing their
behaviour.
Even some of the Aboriginal people are attending the services.
Previously undiagnosed people are being identified, this includes in
parts of the community where services didn’t go prior to this program.
Diabetic people are staying out of hospital more.
There has been an increase in health indicators such as blood glucose
control, foot care, eye complications screening and blood pressure
control.
There are a lot more people being screened and followed up now.
There is increased awareness and understanding being shown by
clients and GPs.
Professionals are supporting each other.
Improvements related to cost efficiency and optimal management are
happening.”
Monitoring outcomes/measurement systems




There is difference of opinion as to the intended use of the database and who
should have access to the information
The systems are in the process of being developed
The systems for monitoring outcomes are inadequate
A satisfactory method of measuring outcomes has not yet been achieved
Equity of access for different demographic groups

The Aboriginal and remote communities do not get equity of access to services
Access for professionals to training & support

There is insufficient access for isolated and country carers, residential aged care
carers, GPs and consumer reps on the steering committee. There are problems
with the structural changes to Curtin University’s new educator program making
it less accessible.
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Integrated Diabetes Care
FINAL REPORT
Level of acceptability
Service providers

The acceptability of the IDCP is mainly high for service providers
Patients

The acceptability of the IDCP is medium to high for the patients
At-risk groups

There is a trend towards a low level of acceptability of the service for at-risk
groups. Some distinct differences in opinions were identified as to the level of
acceptability
Strengths
 Team work and coordination leading to better patient care
 Resource efficiencies
Weaknesses
 The funding and resources are insufficient to run the program properly
 The difficulties with, and lack of cooperation of, the GPs
 There is not enough understanding about the program or what it is about
 Politics, such as the differing objectives of the health service providers
 Communication between the IDCP teams and private providers
 The success of the program depends on having a coordinator who is entirely
focused on it
 Problems related to integrating State and Commonwealth funding of services
 The most needy patients do not use the services
 The service has deteriorated from what it was
Unintended consequences
Negative consequences

There were some minor unintended consequences. The most significant of these
was probably the implementation of the Division of General Practice’s
Commonwealth funded surgery-based diabetes education program.
This
initiative had a significant impact of the existing program run by Silver Chain,
which it duplicated, and the lack of consultation prior to the delivery of this
program led to resistance to the IDCP and bad feeling on the part of the Silver
Chain providers.
Positive unintended consequences

The strong interest in the diabetes talks by the community was unexpected
Barriers
 Lack of initial coordination of services and communication with Silver Chain by
the Division of GP in implementing a (Federally funded) surgery-based service,
leading to duplication of the GPs diabetes education service with the Silver Chain
education service
 Problems related to GPs
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Integrated Diabetes Care
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



Lack of funding and resources
Educational barriers for carers
The initial use of culturally inappropriate diabetes education programs for
Aboriginal people
The problem of coordinating with the private service providers
Gaps and Duplications
Gaps
 Programs and services for Type 1 people with diabetes, particularly post PMH
support for young adults
 Other broad sectors of the community who need services but are missing out
 Programs and services for the immobile and frail elderly
 Other specific sectors of the community who need services but are missing out
 Resource gaps
Duplications:
 There are some service duplications. These mainly centre around the duplication
of the Silver Chain service by the surgeries
 One duplication, multiple foot screening, is considered to be positive
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Integrated Diabetes Care
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Effectiveness – Themes from focus groups
REGIONAL SERVICE PROVIDERS
FOCUS GROUP HELD WITH COMMITTEE
Strengths
 UGS and LGS adequate numbers of
diabetes educators (although the services
are not necessarily adequate)
 Education programs for clients
 Diabetes education network/ education up
to date
 Ophthalmology services
 Podiatry services good access, $ still a
concern
 Steering committee and local advisory
group
 Data systems
 Organisation/ departmental networks i.e.
Family Futures, Silver Chain, Public and
Primary Health - have regular meetings
REGIONAL CONSUMERS
FOCUS GROUP HELD WITH PEOPLE WITH
DIABETES
Weaknesses
 Lack of diabetes expertise and dedicated
time in primary health
 Lack of primary health co-ordinating
 Inadequate attendance of diabetes specialist
on steering committee
 Community education – general, relatives
and follow-up areas
 Use of centralised database
 Podiatry services
 Common goals inadequate for the future
 Reporting and feedback processes
 Training of workforce
 Clinical indicators and outcomes of referral
patterns
 Not enough clinical time in student
placements for students training at tertiary
centres
 Co-ordinator in danger of burnout due to
reliance on their role
Unintended consequences
 Having an educator who is always available
leads to encouragement and greater selfmotivation
Barriers
 Overdependence on Public Health Coordinator
 Diabetes education for service providers
has become elitist and beyond the reach of
many rural providers (cost and distance)
 Commitment to adequate and permanent
diabetes education workforce
 Ad hoc evaluation of diabetes education
program
 Interagency trust and sharing of resources
 Limited monitoring and reporting
prevalence and incidence
 Lack of recurrent resources to sustain/ meet
the increasing demand for services
 Links between EPC items and diabetes
WRAS PTY LTD
Strengths
 5 day training is exceptionally good
 People discuss diabetes more now
 Recall system as creates good continuity
 Consumer knowledge is more up to date
 Encouragement received from community
educator
Weaknesses
 People not on the register have out of date
knowledge
 People with diabetes don’t know how to
deal with stress
Gaps
 People on farms have no support
FOCUS GROUP HELD WITH ABORIGINAL
STAKEHOLDERS
Strengths
 A co-ordinator is crucial
 Enhanced Primary Care items have helped
 Having extra people, and therefore extra
time is critical
 St John Ambulance has noticed that
hospital admissions have dropped
 Partnerships mean you are able to pick up
the phone for advice
 Family Futures has no medical component
 The community can have their own GPs
 Education of GPs – they now rely on
others’ advice too and see AHW as a
resource
 Regional podiatry providers have good
links with tertiary specialist services
Weaknesses
 Have to accept that any approach will stop
short of the ideal
 Meetings with AHW are impossible – can
only manage case conference 1-1
 Reliance on a few AHW leads to problems
if turnover
 Bonds between service providers in
horizontal structures are stronger than those
vertically
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Integrated Diabetes Care
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
service development and DOH commitment
Integration at state and commonwealth
levels
Gaps
 Individuals falling through the gaps not
being identified
 Medical commitment from a GP to the
steering committee impacts on leadership
 Total commitment to joint planning and
service implementation
 DOH leadership
Duplications
 Frequency of meetings ie. The split up of
meetings into LGS, UGS and CGS (for
people who cover all regions)
 Knowledge and expertise clinically and
strategically


No real integration with tertiary services
Time taken for notice of changes to insulin
regimes to flow from specialist to GPs
 No centralised collection of resources
 Cost of Aboriginal promotional resources
(e.g. pamphlets)
 New AHW need generalist training but
little time and money to do this
 Funds going into GPs incentives but not
being redistributed to allied health services
to cater for additional demand/ awareness
 Older Aboriginas have an element of
dependency that this model can feed
 Links between Aboriginal organisations in
regions and the metropolitan area
Barriers
 Talking directly to GPs is easier than
working through the Division of GPs
 Endocrinology is a ‘no go’ area for local
service providers
 Regionalisation and isolation – no links
across profession except through own
efforts
 Model of dividing up services to regions.
Tertiary services would like the money and
they will disperse the way they want.
Better to allocate money to Health Services
to purchase services wanted. Conflict of
models between Family Futures and
Primary Health Care on management and
territory
Unintended consequences
 Contact with Aboriginal (people) in their
homes leads to further contact, demand and
expectation
Sustainability– Themes from interviews
Potential impact on health outcomes
 To give access for many population groups to a range of different diabetes service
providers, who provide a coordinated service that is effective and cost effective.
It covers prevention and management so that diabetes complications, and thus
cost to the community, are minimised.
 To enable effective management through follow-up via the use of a patient
database that carers have access to. Patients would sign a consent form to be
included on this database.
 The potential of the program is huge and progress is being made towards this
potential.
Ways to improve sustainability
 Funding needs to be made more definite, and increased in order to deliver the
appropriate service
 Issues related to communication improvements
 Increasing educational availability
 Greater involvement of GPs
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Integrated Diabetes Care
FINAL REPORT

There should be more equity between the different service providers
Is quality of care ensured through sufficient standards and guidelines?

There are sufficient systems for ensuring quality of care standards
Are there enough policies and plans in place to ensure the future of diabetes services?


There are sufficient policies and plans in place to ensure the future development
of diabetes services
The issue is not about having sufficient policies and plans but to know that the
funding will continue
Sustainability– Themes from focus groups
REGIONAL COMMITTEE
Suggested improvements
 More education programs needed for
Aboriginal (people)
 Aboriginal diabetes education – register
greater emphasis
 Gestational diabetes – aged care
 Early prevention program
 Skills to deal with first degree relatives
REGIONAL CONSUMERS
FOCUS GROUP HELD WITH PEOPLE WITH
DIABETES
Suggested improvements
 Have a buddy to talk to who has diabetes
 Set up a support network especially for the
newly diagnosed
 More community education and
promotional pamphlets at surgeries
 Advertising on TV
 Supermarket tour
 Information on how diabetes is allied with
other diseases
FOCUS GROUP HELD WITH ABORIGINAL
STAKEHOLDERS
 Reports should be fed back to medical
group and result in better care plans
 Want specialists to relate to GPs and to
other service providers
 Best practice service delivery for
Aboriginal is for AHW to attend
appointments with GPs, specialists and
allied health workers
Applicability– Themes from interviews
 Examples of diseases for which this model would be appropriate include: asthma,
drugs and alcohol, rehabilitation, mental health, palliative care, arthritis,
screening (cervical smears and mammograms), immunisation and cardiovascular
disease and other chronic diseases
 This model is already being used for other programs, such as asthma, domestic
violence, and Healthy Bodies. Other service providers already do shared care
programs and work within a multi-disciplinary team too
 There are significant efficiencies to be gained from the application of integrated
models
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Integrated Diabetes Care
FINAL REPORT
6.1.4. Midwest Region
Description of the Pilot
Background
As the business case for the Midwest was included in the submission for the UGS and
LGS, readers are referred to the LGS section for further details on background to the
pilot. Of all the pilots, the Midwest IDC project had the least amount of information
on its population, especially in relation to diabetes. Therefore this pilot was
commenced from very rudimentary foundations.
Objectives
The main objectives of the Midwest IDC pilot were:
 To establish a collaborative forum to implement integrated diabetes service in the
Midwest Health Zone
 To identify an appropriate health service capacity to meet consumer needs in
Geraldton
 To increase access to diabetes training
 To improve access to quality diabetes education programs
 To establish a register and recall system for the Midwest
The second and third year objectives focused on building upon the community
education, training and support for health professionals.
Program management
The Midwest Diabetes Steering Committee (MWDSC) was established in March
1998 and meets every 6 weeks. The Committee was originally comprised of local
service providers including:
 A private practice podiatrist
 The Midwest Division of GP
 The Director of the Midwest PHU
 A private consultant dietician
 The Director of Nursing, Northampton District Hospital
 Silver Chain
At the time of commencement no co-ordinator was appointed to the pilot, but a
Diabetes Project Officer was recruited shortly after the first MWDSC meeting. The
role of the Project officer was to perform administration, and conduct promotional
activities surrounding the program of events cited in the business case. The person
filling this position has changed three times during the course of the pilot. The first
Project Officer was full time, the second part-time, with the current position changing
roles to incorporate diabetes co-ordination and education. From 1998 to early 2000
the Diabetes Project Officer was based at the Midwest PHU. The funding for the
current role is now provided by Geraldton Regional Hospital.
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Integrated Diabetes Care
FINAL REPORT
Funds management
The Midwest IDC pilot was successful in obtaining funds from the DOH for
establishment. The current co-ordinator position was established in October 2000.
Funding for this position has come directly from the Midwest PHU. This has allowed
funds for the pilot to be allocated for project work. The table below highlights
budgeted and actual funding during the pilot.
Table 14. Midwest budgeted funds and actual expenditure.
Total
Surplus
1998/1999
Actual
$33,303
$3,697
1998/1999
Budget
$37,000
1999/2000
Actual
$39,332
$2,168
1999/2000
Budget
$41,000
Application in practice
 A needs assessment was undertaken by MWDSC. It included the areas covered
by Geraldton, the Midwest and Murchison Health Services. The assessment
collected information on:
Population projections for diabetes
Number of health professionals required to service the projected
demand, equipment and educational needs
Community needs for education and promotion.
The needs assessment collected information that could address areas of focus
during the lifespan of the pilot. It gives a clear understanding of the resources
needed in FTEs and equipment as well as the areas of focus for building
awareness in the community
 Aboriginal health worker training in diabetes prevention and control was
conducted by the SPHU in partnership with the Central West College of TAFE
on behalf of the Midwest PHU
 Health Professionals training and education seminars were conducted
 National Diabetes Week was promoted in 1998 and 1999
 The Midwest PHU introduced ‘study days’
 HBF display and risk assessments
 Community Awareness of Diabetes campaign
 Developing a business case for a dietician at the Geraldton Health Service
 Lobbying for a visiting endocrinologist
 Diabetes promotion at the Mingenew Expo
 Diffuse diabetes seminars and risk assessments
 Current development of a web-site for the area that will detail services and
resources available and how to access them
 Carers’ course.
In 1998/1999 an annual report was provided against the business case objectives and
gave a brief update on the 5 first year objectives. Another report in 1999/2000 gave
an outline against each of the 4 second year objectives.
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Integrated Diabetes Care
FINAL REPORT
Definition of an Integrated Care program (from interviews)
 Coordinated services and service providers working together for better patient
care
 Sharing resources
Effectiveness – Themes from interviews
Progress against program objectives
How the IDC Program in the Midwest region operates

The majority of respondents said they had some understanding of how the
Midwest IDCP operates and gave the following descriptions:
There is a steering group that administers the funds
The outcomes of the IDCP in the Mid West have been affected by
politics and competition for the resources. Other closely related
overarching themes include the lack of representation of the remote
health services and the isolation from the GRAMS.
The IDCP is trying to support the achievement of certain initiatives
Very little seems to have actually happened as a result of this program,
or, observable outcomes are just getting started in the Mid West
There was a needs analysis done
There was some promotion and education work done using the IDCP
funds
There is a project officer with a coordination role
Distance is a problem for attendance at meetings
It works in isolation from the GRAMS programs
Actual impact of IDC service

The majority of respondents stated the program did not achieve integrated care
Consistency with other state/national strategies

Few people could comment on this issue
Level of service integration achieved
General themes


The quality of the integration and partnerships as a general theme is poor. This
seems to be about a combination of political maneuvering to secure scarce
resources, remoteness; the cultural differences between the Aboriginal and nonAboriginal
service
providers
(exacerbated
by the
division
of
State/Commonwealth funds); the apparent impossibility of being able to stretch
the funds sufficiently to benefit urban Geraldton, let alone the remote locations;
and the IDCP being the wrong model for this region. This combination of factors
is reflected throughout the whole study of this region.
There is some good integration happening in remote areas but it has nothing to do
with the IDCP
Monitoring outcomes/measurement systems

There is a lack of appropriate systems for monitoring outcomes, particularly a
diabetes database
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Equity of access for different demographic groups

Aboriginal and remote locations feature very strongly on the list of the sectors
that lack access to the diabetes services
Access for professionals to training & support


Remote carers need access to further training. The diabetes educators course is
way above the generalist needs of the remote carers, and not accessible to them.
The courses need to be customised for remote locations because they tend to
assume urban conditions
There are not enough carers available to do the roles
Level of acceptability
Service providers

The level of acceptability amongst service providers is inconsistent
Patients

The acceptability of the service for patients is low to medium. Acceptability is
higher for those Geraldton-based patients who access it and does not include
remote patients
At-risk groups

The acceptability of the service for at-risk groups is poor
Strengths
 Potential strengths, including holistic care, collaboration, communication and
coordination. Use of the strength and resources of the whole group for some visits
to remote locations
 Existing strengths such as better support of carers; coordination; knowledge and
experience of carers being pooled
Weaknesses
 The politics between competing health service providers, including particular
difficulties with the GPs as a whole general group, has diluted the program’s
impact significantly
 That nothing much has happened so far with the program as far as GPs are aware,
and in the remote locations.
 The formal role and support of the diabetes coordinator
 The paucity of carer education and training
 The tenuous partnerships have not been supported by the necessary formal
structures
 The fact that it is an urban-focused program
 The extra pressure on existing roles as a result of participation in the IDCP
 Cultural ignorance in relation to Aboriginal needs
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Unintended consequences
Negative consequences



Service providers have been forced to do their own thing to achieve the outcomes
they need
The lack of maintenance and use of the diabetes data base
Some unexpected carer appointments
Barriers
 Issues related to ownership and control of the IDCP resource:
Conflict regarding the approach to, and control of, treatment and
management of diabetes
The parochialism of the health service organisations
 Specific barriers relating to the steering committee:
The geographical distances
Lack of access to education and support
Staff retention and unreliability
Poor communication out from, and back to, the steering committee
The competing pressure on the steering committee members of their
other roles
 Lack of patient compliance and understanding of their disease
Gaps and Duplications
Gaps
 Specific services for Aboriginal and remote patients
 A lack of general services and service providers
 Specific services for education of carers
 The lack of integration and relationships with the GPs
 Evidence of identifiable outcomes of IDCP
Duplications
 Services for Aboriginal, particularly between the State and Commonwealth
funded programs
 Services offered by the GPs, Silver Chain and the IDCP
 Duplications between the different health services
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Integrated Diabetes Care
FINAL REPORT
Effectiveness – Themes from focus groups
REGIONAL SERVICE PROVIDERS
FOCUS GROUP HELD WITH COMMITTEE
Strengths
 Provision of service for people who are
actively seeking information/ advice/ care
 Clinical care for non-difficult clients
 Exercise programs for identified clients
(referral process and waitlist)
 PMH visits Type 1
 Eye care – 2 ophthalmologists and 3
optometrists (although differs between
locations)
 Podiatry in the Midwest and Murchison
 Group education
 Emergency support-tourism, medications
 Campaign content is well supported
 Standardised information sheets/ education
material
 Direction of MWSC
 Opportunities for liaison between service
providers in region with the exception of
some individual GPs/ visiting specialists
 Continuity and interchange/ back up of
clinical staff (i.e. relief of positions)
Weaknesses
 Not enough diabetes awareness promoted
 Promotion restricted to Geraldton Guardian
 Education of HCP locally
 GP Register- Recall database NDSS, DA
 Referrals
 Community based train the trainer model
 Reliance on HCPs to fix/ treat diabetes
 Program Sustainability
Barriers
 Reliance on Silver Chain community
nutritionist/ dietician
 Diabetes awareness week has lost impact,
not reaching intended targets
 Funding and other focus resting with
clinical treatment services rather than
preventative early diagnosis services
 Reliance of consumers on health system
rather than self management (clinical model
promotes this)
 Lack of communication between doctors
and health professionals
 Limited communication between GRAMS
and GHS, MWAH, GMs, MHS and Health
Services
 GPs won’t support centralised register
without incentive
 GPs too busy so refer immediately to Silver
Chain
WRAS PTY LTD
REGIONAL CONSUMERS
Strengths
 Silver Chain diabetes clinic very good
 Good to have chemist supplying people
with diabetes needs, but could allow for
more than 2 packets of test strips
 Good podiatry service
 GPs well regarded
 GRAMS offer a great support team for
people who have diabetes
 Aboriginal people and non-Aboriginal
people who can’t afford to go to private
doctor who don’t bulk bill and AMS does
Weaknesses
 Access to dietician
 No understanding of diabetic pain and the
tension and stress it brings on life. Answer
is always ‘that’s diabetes’ and consumers
just have to put up with it – makes the
client feel there is no hope
 Not enough self-management
Barriers
 Understanding by community of disease
 Not being able to see your doctor when
needed
 Cost factors, particularly cost of related
services and exercise classes
Gaps
 Unavailability of test strips
 Chemist having to order insulin from Perth
overnight
 Dire need for diabetes specialist
 No support groups re social activity
 Missing follow-up
 Respect for consumer intelligence missing
amongst service providers
Duplications
 Too much contradictory information
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Integrated Diabetes Care
FINAL REPORT



GPs developing own integrated team away
from everyone else
Absence of planning between the steering
committee and Midwest Health Services
Planning Committee
Diabetes as a non-core business is a
problem – no-one to drive it
Gaps
 Meekatharra Diabetes Service
No exercise program
No access to nutritional
information
No endocrinologist
Limited educator visits
Ophthalmologist 2x per year
 Clinical psychologist for chronic
dysfunction/ utilisation/ availability
 Monetary reward for specialist nurse
educators
 Support groups – Type 1 insight, Type 2
exercise group and other
 Multidisciplinary clinic
 Access to visiting adult endocrinologist
 Midwest Health Service
Areas of need
No diabetes educator
Ad hoc service only
 No community dietician in public service
 Input from outlying areas in consultative
processes
 Positive promotion
 Culturally targeted media message for AMS
clients
 After hours availability of diabetes
educational services
 Standard of care/ screening – standard
education tools/ awareness, very important
for quality assurance
 Opportunities for exercise/ activity –
facilities issue and lack of infrastructure
particularly in small towns
 Succession planning/ relief pool for
Diabetes Educators
Duplications
 Lack of knowledge of what services are
available
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Sustainability– Themes from interviews
Potential impact on health outcomes
 There is a huge potential if it is well managed as a program
 To make an impact on prevention
 For better care of patients
 To be useful for treating Aboriginal people
Ways to improve sustainability
 Development of remote services
 Implementation of a rural/remote focused model
 Expansion of Aboriginal programs
 Development of useful technology for remote service delivery
 Changes to the steering committee
 Improved relationships with the GPs and to nurture a more integrated style of
services
 Better funding of services and continuity of funding
 Better coordination of the services
 More focus on diabetes health promotion
Is quality of care ensured through sufficient standards and guidelines?


Systems for ensuring quality of care are being developed
There are sufficient guidelines for ensuring quality of care but we cannot meet
them due to a lack of funding
Are there enough policies and plans in place to ensure the future of diabetes services?

There are insufficient policies and plans in place for the future(9)
Sustainability– Themes from focus groups
REGIONAL COMMITTEE
Suggested improvements
 More education programs needed for
Aboriginal people
 Aboriginal diabetes education – register
greater emphasis
 Gestational diabetes – aged care
 Early prevention program
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REGIONAL CONSUMERS
Suggested improvements
 Need more exercise classes – too long in
between sessions
 Need longer time in weights class
 Need a support group for weight loss/ diet
sessions
 Need at least one more chemist for diabetes
supplies
 Provide more details in relationship to long
term effect, include graphic drawings of
specific results
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FINAL REPORT
Applicability– Themes from interviews



There is potential application for other health service deliveries such as:
Asthma, cardiovascular disease, continence care, mental health,
arthritis, some allied health programs and other chronic long-term
diseases that have preventative components
Coronary care, renal care and diabetes programs should work together.
The first two are complications of diabetes due to the vascular damage
Eye and ear programs
There is little potential for application of this model of health service delivery
There is potential application for other health service regions. The Dongara
diabetic clinic ‘Roadshow’ and ‘One-stop shop’ would be a very useful model
anywhere.
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Table 15. Forces of Integration and Differentiation applied to the four Pilot IDC Projects
Inner
City
LGS







 System solutions that are focused on diabetes as
a whole
 Geographical proximity
 Continuum of care
 Active consumers who self-manage












 Accountability, information technology
(decision support systems, intelligent
information systems)
 Focus across primary, secondary and tertiary
prevention
 Focus across primary, secondary and tertiary
service providers
 Guidelines, protocols and care paths
 Relatively objective, evidence based treatment
(outcomes assessment, economic evaluation)
 Monitoring and evaluation
 Chronic disease focus

Forces for integration
These are elements that require integration in order to
promote good outputs of products, services and ideas:
 Service providers forming a multidisciplinary
team around the individual (ie. Medical and
non-medical, specialists and generalists)
 Health care as core business
Inner
City
LGS
UGS
Mid
West


















 Aboriginal and other cultures working across
core businesses (e.g. health, education, social,
housing, socio-economic structures)
 Solutions focused on sub-populations and
individuals
 Remote locations
 Disease episodes
 Passive consumers who are reliant upon the
system
 Relative autonomy






 Tertiary care














 Competition between generalist and specialist
ideology
 Therapeutic freedom
 Professional judgement














 Focus on delivery
 Diabetes focus


Key
= Pilots have considered issue and are making progress
= Partial progress only
UGS
Mid
West




Forces for differentiation
These are elements that require individual attention
to promote flexible, high quality diabetes care.
 Individual professions
6.2.
THEMES FROM OTHER WESTERN AUSTRALIAN STAKEHOLDERS
6.2.1. Implementation of the IDC model
 Identification and awareness of the need for greater diabetes care. GPs and other
AHPs are slowly exchanging information.
 Increased awareness of need for focus on chronic disease other than diabetes.
 In some areas nothing has changed except increased confusion. Due to health
professionals being unwilling to ‘let go’ of their own territory.
 Has helped establish the needs of the Central Great Southern Region, which has
undertaken its own integration model as a result.
 Some large hospitals are more aware of what happens out in the community.
Rapport with hospitals is increasing.
 Co-ordinated Care program has encouraged integration.
 Integration is occurring in regions apart from pilots (e.g. North West,
metropolitan regions)
6.2.2. Effectiveness of the IDC model
Strengths
 Co-ordinator’s role is crucial to get things done.
 Move to integration of chronic diseases in primary prevention programs. Risk
factors between diabetes and other chronic diseases are similar.
 Co-ordinators who hold the purse strings have the authority to get people
together and implement changes.
 LGS has good project funds that can be specifically allocated to the project as
the co-ordinator’s position is funded by the PHU.
 Midwest – management committee is made up of all the partners that put
forward funding submissions.
 Inner City – holds cost Centre under PHU and holds the purse strings.
 Diabetes registers are seen as a sound practice but also have limitations in
reporting and non-release of data to service providers other than GPs.
 Incentives for GPs through Enhanced Primary Care are of great assistance.
Weaknesses
 New pilot co-ordinators are thrown into the job. Have no direction and no idea
of how to go about integration. Desperately need support and direction – also
has potential for duplication. Is the co-ordinator role about doing the doing or
generating enthusiasm in others?
 Co-ordinator’s communication skills are paramount to success but no training
provided in managing organisational change and negotiation.
 Planning is now at the co-ordinator level only. The concept of integration
requires full uptake and therefore 360 degree planning that considers:
inclusion of state-wide stakeholders
what has happened to date
what works and what doesn’t
available resources
authority aligned with change responsibilities
 Separation of private/ public sector policy and planning.
Integrated Diabetes Care
FINAL REPORT
 Need for marketing of the image of diabetes. There is little understanding of the
impact that diabetes has on health populations. A badged program would be
appropriate with leadership, visibility, ownership and drive.
 Not enough qualified people around – more practice nurses needed. GPs very
well supported in commonwealth funding, and placed in a lead role, but not
always willing to do the work.
 Rural areas are without a critical mass of experts.
 The set up of training at Curtin means that good people are discouraged due to
the quest for professionalism. In rural and remote areas this is a particular
problem.
 Succession planning for diabetes experts not in place – more visibility is needed.
 Load of staff updates and upskilling is on tertiary hospitals.
 Service providers unsure as to what skills diabetes professionals would like them
to have.
 Turnover of staff in DOH means no continuous link with diabetes programs.
Recruitment and retention is a general problem –a lot of poaching occurs from
the public sector.
 No aggregation of data.
 Patients dealing with infighting between professionals – comes from problems
with diagnosis and differences in perspectives of how to manage diabetes.
Definitions of standards of diabetes care needed.
 Professional group conflict – need to identify what is required, tasks, skills and
who is responsible.
Unintended Consequences
 People who are knowledgeable about diabetes are likely to also have good
knowledge of other chronic diseases.
Barriers
 In service seminar to promote chronic disease has to compete with the market for
people to listen and attend. Doesn’t have the attention of workforce to generate
interest.
 There is an attitude that the Division of GP get a huge amount of money. Most
of this funding is allocated to administration.
 Personality conflicts.
 Difference in emphasis on where health funding is allocated and how the tertiary
sector is involved is a problem.
 Directed from higher level management with little liaison from ‘doers’.
 Contradictory perspectives of different government organisations.
 Resource limitations prevent expansion. Focus of incentives is on acute rather
than secondary care. The funding model for chronic care needs to be changed.
 Fears that if the state government takes over funding, the commonwealth will
reduce funding levels.
 Difficulties in obtaining funding. Little visible funding to support integration.
 Conflict over what should be taught. Conflict within diabetes education courses.
The Curtin University program versus shorter, cheaper and more practical
generalised courses.
 No support systems for consumers.
 Remote locations.
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Integrated Diabetes Care
FINAL REPORT
 Targeting Aboriginal people with diabetes.
 Pilot programs have been a barrier. All they have done is delay a co-ordinated
effort.
 DOH’s annual treasury cycle is a problem. The focus goes onto competition
rather than collaboration.
 GPs very busy people – need to know variety of things but also need to be
updated on diabetes.
 Flexibility is important in the way people are managed when dealing with rural
and remote areas (e.g. education of AHWs), where populations are low and
generalist skills are needed.
 DOH needs to take a stance with regard to diabetes because costs will eventually
come back to tertiary care anyway.
Gaps
 Public Health and Community Health don’t work together.
 The disease doesn’t have the health industry’s attention.
 Focus on the transition from kids to adult diabetes. Kids are losing their identity
in the transition and need education on this change.
 Awareness that other health services have of AMS.
 Empowering Aboriginal people and getting them to take things up for
themselves rather than being dependent on an intensive service.
 Distribution of funds between the city and the country.
 Knowing how to get a pilot program started.
 Two levels of training are required – supervisor training for specialist diabetes
educators; and generalist training for others.
 Need for IDC services to work in geographical nearness to GPs so patients get a
self-contained unit.
 Absence of indicators to measure performance.
 No resources for Ethiopians, Arabians and other ethnic cultures.
Duplications
 Integration can lead to fragmentation as areas of expertise can suffer i.e. absence
of consideration for the importance of each differentiated area.
 Resource development is a difficult process. Need to be centralised to ensure
resources are not lost when projects finish. Centralisation would also help with
language, colour, and literacy as each person has to duplicate the research into
these things when developing a new resource.
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Integrated Diabetes Care
FINAL REPORT
6.2.3. Sustainability of the IDC model
Ways to improve sustainability
 A dedicated state-wide strategic plan is required – people are very enthusiastic
but they need direction and long term goals, as well as some assessment of how
things are progressing.
 DOH should take responsibility for the co-ordination of a strategic planning
forum.
 A clear understanding of what integration is about with a focus on integrating
everyone including consumers.
 Resources and funding. At the moment the attitude is ‘stop’ because extra
funding is not available.
 Need support for people in programs so they are not battling alone.
 Need to meet and know people who are service providers. Informal networks
are crucial, especially where emergency contact is needed.
 Common vision on early detection at a management level.
 Developing partnerships with long term locals e.g. hospital boards.
 Learning how to deal with organisational change.
 Have a definition of integration including all the layers of integration.
 Recall systems helpful as reminds of all areas, is a methodical process giving
protocols, and gives feedback to GPs. Also highlights shortfalls in local services
through prompts for referrals.
 Mini-clinic focus is better than just using nurse co-ordinators for administration
– gives extra time to GPs.
 Intranet/ Internet access in GP practices so linked directly to hospitals.
 Enhanced Primary Care is an untapped resource.
 Aboriginal liaison is necessary for improvement in Aboriginal health. More
links for Derbarl Yerrigan Health Service and the AMS to work with other
health services. This is starting to happen in the Inner City through a coordinated referral system.
 The use of teleconferencing between Public Health Unit and Community Health
Unit.
 Meetings are arranged around GP availability, but they are the only ones to get
paid for attendance.
 More training of staff, including AHW.
 Reduction of waiting lists of clients for diabetes educators.
 More consumer input needed as to how integration should occur.
 More health promotion and community awareness of diabetes.
 Promote chronic disease rather than diabetes.
 Fund ways to improve quality systems for collecting and maintaining records.
 Greater involvement from Division of GP.
 Facilities and access for remote people. Funding focusing specifically on remote
areas. Health services are fundamental to sustainability in remote areas. There
is a 40-60% staff turnover, which undermines continuity. The strategy needs to
be developed on the basis that people change.
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Integrated Diabetes Care
FINAL REPORT
 Spread more knowledge around. Open up IDC to everyone in the state. Work
with GPs to get them more involved.
 DOH should recognise diabetes is a core business.
 Research and study into the costs and benefits of early detection/ prevention.
 Register of diabetic Aboriginal people needs to be built and maintained.
 A resource directory. Also needs a consumer guide to rights and services.
 Extend phase 2 of the Co-ordinated Care Program. Phase 2 focuses on lifestyle
modification. The first 3 years have been spent on establishing networks,
creating awareness and getting health workers to visit Aboriginal in their homes
to identify those at risk and get them to visit doctors.
 A passport system for consumers to give continuity between service providers as
to treatment performed.
 Need for stated based integration of tertiary centres.
 Focus on upskilling people in communities more.
 Curtin course is important in maintaining professional standards.
 Set up a tertiary body for rural areas and tertiary centres to meet and discuss
issues relating to diabetes could include PHU, tertiary centres and the Division
of GP.
 Applicability to other regions
What would increase acceptance of IDC?
 Localised planning with clear direction.
 Continuity of people/ co-ordinators – developing ways to increase attraction and
retention.
 Improved communication and effort to getting everyone together at once to
discuss issues.
 Continued funding. Currently spending too much time on short blocks of
funding without the capacity to see change in this time.
 Good relationships with other providers, knowing who to contact.
 Models of good practice. Clarifying what it is that the models are trying to
achieve and being clear about what has been achieved.
 Self-management – patients need to drive this through themselves. IDC needs a
health system to follow.
 A strategy of what needs to be done, why and how.
 Training of staff – health services, primary health care, hospital staff and
dieticians.
 Managers and health service staff at management level need to know that
engaging people early and working from a preventative point is far more
beneficial for the community and reduces long term costs of health care.
 Aboriginal people need to have something of their own.
 Create a diabetes unit within the hospitals to educate GPs and have a common
shared access to patient records.
 Hospitals can provide the link between low income earners who can’t access
other provider services.
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Integrated Diabetes Care
FINAL REPORT
6.3.
SUMMARY OF INTERSTATE TRENDS
The major themes emerging from state and commonwealth health agencies are:
 A solid trend towards application of integrated care models in every state of
Australia
 A trend towards integration of chronic disease services, rather than diabetes
specific integration
 A trend towards integration models which incorporate primary prevention, early
intervention, and quality management of diabetes
 Establishment of registers and recall systems as a part of integration processes
6.3.1. The Commonwealth Department of Health and Aged Care
The focus of the Commonwealth Department of Health and Aged Care has developed
a strategy for Chronic Disease Management, which incorporates diabetes care. This
strategy is based on an integrated approach with emphasis on organisational systems
drawn from clinical streaming models. Integration is viewed as applicable across
regions. The Department has developed an evaluation template with performance
indicators including:











Population demographics
Health service utilisation
Community Care Service utilisation
Program continuity and co-ordination
Participation of service providers
Use of information management &
technology
Safety
Effectiveness
Appropriateness
Consumer participation
Efficiency









Change in work practices
Demand for community health and care
services
Impact on clinical outcomes for target
populations
Improvement in quality of life
Access
Communication links
Participation in administration and clinical
decision
Chronic care governance model
Training and educational materials
The Department has dedicated funds to incentives for integration, such as Enhanced Primary
Care Package for older Australians and those with chronic and complex conditions. Funds for
information technology system development are considered a priority.
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Integrated Diabetes Care
FINAL REPORT
6.3.2. The New South Wales Experience
As previously noted in the literature review, NSW implemented an integrated diabetes
care pilot project in 1997. Discussions with the evaluators of the NSW model
highlighted support for the concept of integrated care models. This state is now
experiencing greater acceptance of the model, with improvements in funding, and a
move towards chronic disease management and prevention. Themes arising from the
pilot project included:
 Barriers to integrated care
Differences in commonwealth and state funding priorities have a direct
impact on the sustainability of structures.
Conflict between professional groups is common with regard to issues
such as what is required, the tasks and skills needed, and who should
perform tasks.
Interpersonal conflict is one of the most difficult elements to address as
it consumes a significant amount of time and is out of the control of
program coordinators.
The Division of GPs agreed to allocate funds to integration within
Aboriginal Health Services but the Aboriginal Medical Service had no
additional funds to support the time and people needed.
The model of integrated care is viewed as a means of attaining cost
savings. However, there is significant risk to the sustainability of the
model when savings are shifted from the project to alternate services.
 Integration of care has ethical considerations
The pilot programs raised expectations of people with diabetes and
service providers. It was not considered to be ethical to run the pilots,
return the data and then discontinue the process.
 Development of terminology, standards, and measurement tools
Integrated care terminology is not clearly understood and there is
inconsistency in definition.
The definition of standards for diabetes care is crucial to establishing a
‘common language’ of indicators for service providers.
The establishment and measurement of outcomes requires considerable
effort in the future.
More funding needs to be dedicated to the development of information
systems to support integration.
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Integrated Diabetes Care
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6.3.3. The Tasmanian Experience
At present Tasmania appears to be behind the other states in developing a diabetes
strategy. At present the state government health department is focusing on
maximising communication between stakeholders to develop understanding of
existing services and roles. This approach has focused on the Department of Health
and Aged Care, Divisions of GP, Diabetes Australia, and service delivery
organisations communicating through a Ministerial Advisory Committee, and a
monthly newsletter on diabetes issues. A shared care model was recently established
in Launceston to establish standard referral and response procedures. The Tasmanian
Department of Health and Human Services is facing challenges including:




The level of state government services to diabetes, which provide for one person
fulfilling a number of roles.
A population with very high prevalence of diabetes.
Absence of economies of scale for dedicated funding to diabetes programs.
Workload of GPs, who have limited time for attention to diabetes services.
Tasmania is also developing some innovative programs to deal with geographical
isolation, such as the use of telehealth services, promotion of optometrist services to
GPs, and development of a Diabetes Resource Manual for GPs. Anecdotal evidence
suggests stakeholders are communicating more frequently and have a higher level of
awareness of diabetes services.
6.3.4. The Australian Capital Territory Experience
The ACT has made significant steps towards integration of chronic disease care in the
last three years. The state had a history of professional conflict between service
providers working within the area of chronic disease care and started the change
process through significant consultation and integrated planning. The model of
integration is based on a matrix structure and relies upon key players contributing
funds to a central community care organisation. This organisation is responsible for
administration processes such as the employment of staff, conduct of training and coordination of integration process. Sustainability has been enhanced through:
 Business planning with links between health problems within settings and
population groups.
 Establishment of the ACT Diabetes Council (with a Ministerially appointed
Chair), which has the role of oversight of implementation of integration
processes. The council provide advice to the Health Department on new and
emerging issues, purchasing, infrastructure, and planning.
 A focus on information systems underpinning integrated structures.
 The critical role played by GPs, and relative efficiency for investment
The ACT has also faced challenges including:
 The definition of integrated care, which has no formal definition in the National
Health Data Dictionary. A distinction in the definition of diabetes and chronic
disease also appears necessary.
 Absence of baseline data.
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Integrated Diabetes Care
FINAL REPORT
 Low levels of support from endocrinologists.
 Specialist medical practitioners from overseas who apply different models of
care
 Obtaining the budget for diabetes services critical to systemic change. The ACT
specifically examined long term cost savings to be gained from initial
investment.
6.3.5. The Victorian Experience
The Victorian Department of Health Services has recently launched four pilots
focused on Integrated Disease Management. These projects will trial various models
of care for people with, or at risk of chronic conditions to determine which strategies
are effective in improving health and well being and reducing hospital admissions.
Integrated models of care, including diabetes prevention and management, were
investigated by the Department. The definition of Integration applied by Victoria is
broader than that used by the Commonwealth Department of Health and Aged Care
and incorporates a social level focus. The strategy includes the targeting of primary
prevention and early intervention.
6.3.6. The Northern Territory Experience
The Northern Territory Preventable Chronic Diseases Strategy emphasises an
integrated, intersectoral and whole of life approach to prevention, and develops
individual care plans for people with chronic diseases. The Strategy includes
prevention, early detection and tertiary management of chronic diseases, including
diabetes. The Northern Territory Co-ordinated Care Trials developed protocols for
the screening and management of identified chronic diseases. The protocols include
computerised and paper-based recall systems and are due for review in 2001.
6.3.7. The Queensland Experience
Queensland is working towards a long-term sustainable strategy in the area of chronic
diseases. In North Queensland, which has a high Aboriginal population, an
integration strategy focusing on primary prevention, early detection, and management,
is underway. Management of chronic diseases, such as diabetes, includes
implementation of:



Standard treatment protocols.
Registers and recall systems.
Links directly into communities to develop a shared understanding of causes and
management of chronic diseases.
6.3.8. The South Australian Experience
The South Australian Department of Human Services is currently focusing on primary
prevention, and self-management of chronic disease. The general focus of strategy
appears to be on developing sustainable partnerships between consumers, their
families, health professionals, with future emphasis on integration between health and
community services.
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Integrated Diabetes Care
FINAL REPORT
7. APPENDIX D: MONITORING INDICATORS
The indicators in this section are drawn directly from the draft document titled “NSW
Priority Health Care Programs in Cardiovascular Disease, Respiratory Disease and
Cancer: Monitoring and Evaluation Strategy – Background discussion document,
NSW Health Department, November 2000.”
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Appendix 2
Area Program level
Performance indicators and targets
Objectives
Patients
What are the characteristics of
the target population and have
these changed over time?
Indicators



What is the level of health service
utilisation
by
the
target
population?






What is the level of community
care service use by the target
population?

Size of the target population (ie. no. of people satisfying
criteria for inclusion in the Program);
Demographic characteristics of the target population;
and
Disease-related characteristics of the target population,
including disease stage and/or severity and
complications status.
No. of hospital separations by specific ICD codes;
Hospital length of stay (LOS) for specific ICD codes;
No. of re-admissions for specific ICD codes;
Frequency of presentation to emergency departments
(ED);
Frequency of presentation to general practitioners; and
Use of community health services.
For example, use of Home and Community Care
services.
Targets
Data Sources


 separations by __ %

LOS


 re-admissions by __ %

ED
presentations

Appropriate


Appropriate access
Appropriate access
access
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Service provision and processes
Has the program improved coordination and continuity of care
for the target population?
Indicators






To what extent are relevant
service providers participating in
the Program?


WRAS PTY LTD
Sample targets
Extent of use of MBS items for case conferencing and
care planning by General Practitioners;
Strategies to support GPs’ role in case conferencing
and care planning in place;
Extent of use of care plans/clinical pathways by service
providers;
Proportion of target population who have attended an
emergency department of who have had a hospital
admission that have a comprehensive discharge
summary sent to their GP within one week of discharge;
Strategies to ensure appropriate referral of patients to
community care services in place; and
Strategies to ensure rapid access to specialist services
in place.

 uptake of MBS items


Strategy in place by June
2001
Increase
use

 proportion by __ %

Extent of participation in the Program by relevant
stakeholder groups; including Divisions of General
Practice, hospitals, clinicians, community health and
community
care
organisations,
community
organisations, Aboriginal health and medical services,
consumers and carers.
Extent of involvement of key stakeholders in Program
management and governance.

Strategy in place by June
2001
Strategy in place by June
2001
Signed statements of
commitment
and
involvement received by
November
2000

PAGE 95
Data Sources
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Resources
How has the Program impacted
on
use
of
information
management and technology?
To what extent has the Program
changed work practices?
Indicators

Health outcomes
What impact has the Program
had on clinical outcomes for the
target population?
WRAS PTY LTD
Data Sources
Implementation of appropriate clinical decision support
systems, clinical pathways and best-practice
protocols/guidelines for use by service providers.
Evidence of personnel suitably qualified to deliver
specialised components of patients’ care plans.
Workforce re-engineering processes to support
implementation and sustainability of the Program are in
place, eg. GP training, assertive follow-up.
Availability
of
appropriate
community-based
alternatives to hospital care for the target population;
and
Average waiting times for access to appropriate
community health and community care services.




Condition-specific


Complications status; and
No. of re-admissions within the last 28 days for people
with specific ICD codes.



Improve clinical outcomes
 severity/prevention
 re-admissions by __ %


What impact has the Program
had on the demand for
community
health
and
community care services?
Targets


indicators;

PAGE 96
IM
&
T
strategy
implemented by ____
2001
GP training strategy in
place by _____ 2001
waiting
services
time
for
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Health outcomes
Has implementation of the
Program improved the quality of
life of the target population?
Indicators

Targets
Extent of use of self-rated health-related quality of life
measures (including functional status, mobility, role
functioning); and
 Average self-rated health-related quality of life (eg. SF36 and/or condition-specific measure of quality of life).
Has the Program affected the  Extent of use of self-rated assessments of carer wellbeing; and
Quality of life of carers and
 Average self-rated carer well-being (eg. Carer Strain
families?
Index).
Quality: Has the quality of health care improved as a consequence of the Area Program?
 No. of re-admissions for specific ICD codes within 28
Safety
days; and
 Extent of implementation of strategies to reduce crisis
presentations to emergency departments, including
early intervention and secondary prevention.
 Condition-specific indicators (eg., percentage of
Effectiveness
patients admitted to hospital who are discharged home
on aspirin or other anti-platelet therapy); and
 Implementation of a strategy to monitor key program
outcomes and deliverables.
WRAS PTY LTD

 use of QOL measures

Improve participant QOL

Measure of carer wellbeing in use by ___ 2001

 re-admissions by __ %

Strategy in place by ____
2001

 use of best-practice
guidelines

PAGE 97
Evaluation
strategy
developed by Jan 2001
Data Sources
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Indicators
Quality: Has the quality of health care improved as a consequence of the Area Program?
 Percentage of hospital admissions for Program
Appropriateness
participants that adhere to best practice admission
criteria.
 Availability of educational material for Program
Consumer participation
participants, carers and families;
 Involvement of consumers in the planning, operation
and governance of the Area Program;
 Implementation of an effective patient satisfaction
measure;
 Evidence of effective strategies for consulting and
involving people from Aboriginal and Torres Strait
Islander backgrounds and linguistically and culturally
diverse backgrounds in the Program.
 Average length of stay (ALOS) for people with specified
Efficiency
ICD codes;
 Cost per casemix adjusted separation in acute health
services;
 Cost per emergency occasion of service; and
 Cost per primary and community-based occasion of
service.
WRAS PTY LTD
Targets
Data Sources

 appropriate admissions

Educational
material
developed by ____ 2001

Strategy in place by ___
2001


PAGE 98
LOS
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Indicators
Quality: Has the quality of health care improved as a consequence of the Area Program?
 Indicators of distance travelled to access hospital and
Access
community-based services;
 Indicators of length of time spent waiting to access
hospital and community-based services; and
 Access to services by people of culturally and
linguistically diverse backgrounds.
System change
Has the Program improved the  A process in place to ensure effective communication
between service providers involved in providing care to
communication links between
people with the target condition; and
service providers in hospital,
general practice and community
based settings?
Has the Program improved  A strategy is in place to facilitate receiving advice and
providing feedback to community members, consumers,
participation in administrative
industry groups, health and community care service
and clinical decision-making by
providers and other stakeholders about the Program.
consumers,
community
organisations
and
other
stakeholder groups?
Is a chronic care governance  A structure is in place to support clinical leadership of
the Program and to ensure that all key stakeholders are
model in place to ensure the
active participants in Program management and
sustainability of the Program?
governance.
WRAS PTY LTD
Targets
Data Sources



Improved
services

Strategy in place by ___
2001

Strategy in place by ____
2001

Structure in place by Dec
2000
PAGE 99
waiting
access
time
to
Integrated Diabetes Care
FINAL REPORT
Area Program level (continued)
Performance indicators and targets
Objectives
Has dissemination of training
and educational material to
primary and secondary care
providers
improved
as
a
consequence of the Program?
Has there been a shift in
resources from the hospital to the
community
setting
as
a
consequence of the Program?5
5



Indicators
Evidence to ensure that all service providers are
informed of the Program, relevant State and
Commonwealth initiatives (eg., Commonwealth’s
Enhanced Primary Care initiative) and have access to
best-practice guidelines, clinical pathways and
protocols.
Evidence of savings incurred in the hospital sector as a
consequence of implementation of the Program; and
A re-investment strategy has been developed to guide
the transfer of savings made in the hospital sector to
community-based services.


Targets
Information dissemination
strategy developed by
____ 2001
Re-investment
strategy
developed by June 2001
Advice on this matter will be sought from the Health Services in the Community Implementation Co-ordination Group.
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PAGE 100
Data Sources