Results Framework: Draft 2 of Outcomes Framework for Diabetes: plan still in
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Results Framework: Inner East Community Health Services – Dietetics Program
Population Accountability
The RESULT that Inner East Community Health Services Contributes to:
A Fairer Victoria
How is Victoria Doing in 2010 1?
It is unacceptable for any Victorian to be excluded from the opportunities this state offers – opportunities in economic,
social and civic life that the majority of us take for granted. A Fairer Victoria is our long-term commitment to reduce
disadvantage and ensure more Victorians have the opportunity, capability, and support to lead active, fulfilling lives.
A Fairer Victoria has five long-standing objectives. These continue to guide our approach and investments in 2010.
1. Increasing access to universal services
Access to universal services – maternal and child health, kindergarten, education and health – provides the
basis for reducing disadvantage and improving health and wellbeing.
2. Reducing barriers to opportunity
To take advantage of the opportunities around them, people need a range of personal capabilities (skills, health, social
networks), mobility, and access to facilities and services.
3. Support for disadvantaged groups
We are creating targeted programs and building stronger partnerships with people who need extra help to fulfil their
potential – people with a disability, people experiencing mental illness, Indigenous Victorians, refugees and vulnerable
young people.
4. Supporting high needs places
Some places in Victoria have experienced deep disadvantage over a long period due to the compounding effects of
unemployment, poor services and infrastructure, low education levels and poor health.
5. Making it easier to work with government
The Government continues to work in partnership with Victoria’s community sector, local communities and other levels
of government to reform services, provide clearer pathways through service systems, and work better at a regional and
local level.
A Fairer Victoria
• improves health and wellbeing and reduce inequalities in health status
Victoria sits above the Australian average on most social well-being measures
In priority areas of A Fairer Victoria – early childhood, education, health and wellbeing, and the safety and liveability of
our communities – Victoria outperforms other states on most key measures where comparable data is available.
1 Government of Victoria., A Fairer Victoria: Real Support-Real Gains May 2010
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Highly disadvantaged Victorians tend to have poorer mental health and this has flow on effects for their
physical health. This is one of the reasons why mental health continues to be a major focus of A Fairer Victoria as it has
been over the past five years.
Improving Aboriginal wellbeing continues to be a major challenge for the Government and the Aboriginal community. It
is a challenge we are working hard to overcome and we are seeing improvements. We are keeping up the effort with
major new initiatives in A Fairer Victoria this year.
In looking at the story of specific health indicators in Victoria2
LIFE EXPECTANCY
Life expectancy at birth is an important measure of long-term health and wellbeing. Every step up the social ladder
results in increased life expectancy – this is true in Victoria and around the world. In Victoria, the average life
expectancy is 79.8 years for men and 84.3 years for women. However, the life expectancy gap between Indigenous
Victorians and non-Indigenous Victorians is 19.8 years for men and 19.2 years for women. This gap is larger than
between many other Indigenous and non-indigenous populations across the world.
SELF REPORTED HEALTH
Self-assessed health is reliable indicator of illness, overall well-being and health service use. The proportion of
Indigenous and low socioeconomic Victorians rating their health as poor or fair suggests longterm/ persistent health
problems that inhibit their ability to enjoy life and participate fully in society. Victorians from a non-English speaking
background report better results than the general Victorian population – this suggests the potential for improvement
for all other population groups. Additionally, each step up the social ladder corresponds with improvement in selfreported health.
MENTAL HEALTH
Psychological distress is an important indicator of overall health and wellbeing. The proportion of low socio-economic
status and Indigenous Victorians reporting high or very high levels of psychological distress suggests that these
populations have significant psychological strain in their lives which can influence their ability to fully participate in
society and attain optimum wellbeing. This type of
psychological distress can manifest itself as depression, anxiety and anger and can be transient and short lived or long
term.
DIABETES PREVALENCE INDICATOR 5
Diabetes is one of several key chronic diseases that together account for 80% of the disease burden in Victoria.
Victorians with low socioeconomic status and from non-English speaking backgrounds have
higher than average rates of diabetes. This also puts them at greater risk for other diseases, especially cardiovascular
disease (where there is also observable inequalities). Measuring prevalence is difficult
because half of cases are estimated to be undiagnosed. Data estimates for Indigenous Victorians are unreliable so are
not reported here but research indicates that prevalence within the Indigenous population in Australia is three times
the average.
FOOD INSECURITY
Food, like housing, is a basic necessity. The inability to afford food indicates substantial hardship which also has direct
health consequences. Victorians with low socio-economic status have significant levels of food insecurity with nearly a
quarter reporting that within the last 12 months they ran out of food and couldn’t afford to buy more.
PREVALENCE OF CURRENT SMOKING
2
Dept of Human Services., Fair Health Facts 2009
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Despite having one of the lowest smoking rates in the world, tobacco remains the leading cause of preventable deaths
and hospitalisation in Australia. Victorians of low socio-economic status and Indigenous Victorians smoke at higher rates
than other sub-groups. This puts them puts them at increased risk of negative long-term health effects such as
emphysema, coronary heart disease and cancer.
NUTRITION: FRUIT AND VEGETABLE CONSUMPTION
It is widely recognised that intake of adequate fruit and vegetables is strongly linked to the prevention of numerous
chronic diseases. Most Victorian do not eat the recommended serve of vegetables and a high percentage do not eat the
recommended serves of fruit. Victorians of low socio-economic status have consistently lower intake of fruit and
vegetables than the general population and the other sub-groups which puts them at increased risk for coronary heart
disease, hypertension, stroke, Type 2 diabetes, and some cancers.
FEELING VALUED BY SOCIETY
Issues of distress, violence and feeling valued have substantial short and long term health impacts. This indicator is a
subjective measure of how valued people feel in society. A greater proportion of Victorians of low socio-economic
status report not feeling valued by society. As a result of this, they may lack the resources and knowledge to gain access
to quality health services and may have greater difficulty coping with stress and illness. They may also experience higher
rates of morbidity and mortality than people with social networks.
AVOIDABLE MORTALITY
Avoidable mortality is one of the best overall measures of the health care and preventative health system. It measures
early deaths (pre- 75yrs) from selected conditions for which effective preventative or medical interventions are
available. While rates of avoidable mortality have been declining over time for all groups, Victorians with low socioeconomic status and rural/regional Victorians still experience greater rates of avoidable mortality.
AVOIDABLE HOSPITALISATIONS (AMBULATORY CARE SENSITIVE CONDITIONS)
This indicator describes conditions that with appropriate primary care, delivered, for example, by a general practitioner
or at a community health centre, should not become serious enough to require admission to a hospital. High rates
indicate problems with access to or use of these services. The rate of avoidable hospitalization for Victorians with low
socio-economic status is significantly higher that the average. The rate for Indigenous Victorians is substantially higher.
The Story Behind the Baselines:
The history and forecast for the focus upon the Result of a Fairer Victoria and its major objectives is:
Victoria’s population continues to grow with 117,900 more people in the year to September 2009. Birth rates are still
high and more people are choosing to make Victoria their home. On current trends the Victorian population will grow
from 5.1 million in 2009 to 6.2 million in 2025.
Like most developed countries, Victoria’s population is ageing. By 2036, for the first time in Victoria’s history, there will
be more people over 65 years than under the age of 18 years. This shift will require changes to the way we design
buildings and public spaces, as well as expanded aged care facilities, medical and community services. At the same time
the ratio of working age Victorians to older Victorians will decline putting pressure on our ability to fund these services.
The ageing of the population will be more pronounced in some areas of regional Victoria, with smaller towns and
settlements experiencing a youth gap. In contrast our Indigenous population is young and growing faster than the state
average.3
3
Government of Victoria., A Fairer Victoria: Real Support-Real Gains May 2010
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4
Health status indicators suggest that overall, Victorians enjoy very good health. In 2006, survey estimates from the
Victorian population health survey (VPHS) indicate that a majority (84.5 per cent) of people reported their health as
either excellent, very good or good. Life expectancy, for example, continues to rise in both males and females. A male
born in Victoria in 2005 can expect to live 79.8 years, while a female can expect to live 84.3 years. Life expectancy at
birth increased significantly, by two to four years, for both males and females, regardless of socioeconomic status
between 1996 and 2005. Avoidable mortality rates in both males and females also declined steadily between 1997 and
2003.There is scope for future health gain in Victoria. Hospitalisation rates for ambulatory care sensitive conditions
appear to be rising, as are avoidable mortality rates for specific conditions, such as poisoning in both males and females,
and suicide in females.
Diabetes
Diabetes was responsible for four per cent of the total disease burden (DALYs) in Victoria in 2001. Just over 25 per cent
of the burden was due to premature death. When the attributable burden of cardiovascular disease was included, the
diabetes burden increased to eight per cent, and diabetes became the leading cause of the disease burden. Estimates
from the VPHS 2006 showed that approximately 5.8 per cent of persons aged 18 years and over in Victoria had ever
been diagnosed with diabetes, of which 68.0 per cent had been diagnosed with Type 2 diabetes. Almost half of all adults
reported having had a test for diabetes in the previous two years. Among those with diabetes, almost a quarter
reported having been diagnosed with heart disease and 6.6 per cent reported having suffered a stroke. Survey estimates
also showed that the prevalence of cardiovascular disease risk factors was high among respondents with diabetes. In
2005–06, there were 139,290 admissions for diabetes on any diagnosis (principal and additional diagnoses combined),
accounting for 6.99 per cent of all hospital admissions, with an average of 5.83 bed days. Admission rates were
significantly higher in rural areas compared to metropolitan areas in 2005-06.
Since 2007 Victoria has had a strategic framework5 for diabetes which has aimed to:
•
•
•
prevent the onset of type 2 diabetes through population-based primary prevention initiatives and
intensive lifestyle interventions for people at increased risk
achieve better management and reduced complications of all types of diabetes by effective early
detection and early intervention
increase capacity in diabetes monitoring, surveillance, evaluation and research to inform effective prevention
and management, and policy and practice.
The St Vincent Declaration and the Istanbul Commitment of the WHO (Europe) and the International Diabetes
Federation recognises diabetes as a major and growing public health problem; the need to create conditions
to achieve reductions in the burden of disease caused by diabetes; and the need to work in active partnership
with people with diabetes, their families, friends and workplaces. Similarly, the core functions of the World
Health Organization’s Diabetes Programme are to set norms and standards, promote surveillance, encourage
prevention, raise awareness and strengthen prevention and control. 6
The following principles underpin the Victorian Diabetes Strategic Framework. They share core features with national
and international approaches and strategies.
• A balanced approach to prevention. Prevention should be broadly based from population-focused primary prevention
to preventive services linked with treatment and care. People must be given the opportunity to lead a healthy lifestyle
in all places where they live, learn, work and play – in a sustained effort over the long term to change individual
behaviours, social norms and community and environmental structures.
• Interdisciplinary models of care that recognise patients as active partners. Treatment should be based in life-stage
targeted strategies, promote patient self-management and linked to prevention. Teamwork means respecting
4
Dept of Human Services 2008 Your Health A Report on the health of Victorians 2007
5
Diabetes prevention and Management: A Strategic framework for Victoria 2007-2010
6
Op cit
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the independence and autonomy of all partners while recognising the interdependence and shared commitment
bringing them together.
• Partnerships at all levels. Dialogue and sharing of ideas, perspectives and experiences means recognising the
broad intersectoral context for prevention, consumers as active partners and the interdisciplinary nature of disease
management in different settings of care. The health sector must work with other sectors and services to influence the
social and environmental factors that determine the burden of diabetes and chronic disease.
• Equity-focused approaches that recognise the social gradient of diabetes. A focus on health inequalities should
be maintained to ensure that equity of access to services and of health outcomes is achieved.
• Accessible and culturally appropriate diabetes prevention and management initiatives, addressing individual and
population needs. The approach must reflect that diabetes impacts on different communities in different ways, as do
the appropriate mechanisms for its prevention, management and treatment.
• An evidence-based approach for action promoting research and supporting information for program planning
and evaluation. Actions must build on existing knowledge and expertise and the evidence base must be grown
through research and evaluation. Surveillance, monitoring, evaluation and research are essential components that will
underpin diabetes prevention, management and treatment.
Mental illness was responsible for approximately 15 per cent of the total disease burden in Victoria in 2001. Less than
five per cent of the attributable burden of 46,390 disability-adjusted life years (DALYs) in males and 48,027 DALYs in
females was due to premature mortality. Anxiety and depression ranked second in the top ten leading causes of disease
burden in Victoria in 2001, representing 7.1 per cent of the total disease burden. In 2006, 2.4 per cent of Victorian males
and 3.3 per cent of Victorian females aged 18 years or over had scores of 30 or greater on the Kessler 10 scale, and were
classified as likely to be at high risk of being affected by psychological distress. Estimates from the 2006 VPHS indicate
that approximately seven per cent of males and 12 per cent of females reported having sought professional help for a
mental health-related problem during the previous year. There were 50,885 hospital admissions for males with a mental
health-related principal diagnosis in 2005–06, a rate of 200.5 admissions per 10,000 males, accounting for 471,681
patient days. Among females, there were 80,646 hospital admissions in 2005–06, a rate of 311.3 admissions per 10,000
females, accounting for 574,336 patient days. Between 2000 and 2004 males aged 20–39 years were consistently at
higher risk of suicide death than any other age group, although this difference was statistically significant only in 2000
and 2001.
IECHS Partners :
In making its contribution to a Fairer Victoria IECHS partners with:
City of Boroondara
City of Yarra
Inner East Primary Care Partnership
Department of Health Eastern Region
Department of Health North Western Region
Ashburton Support Services
Politicians at local, state and federal level
Charitable non government organisations providing material aid
Homelessness services : EastCare
Boroondara Stroke Support Group
Other Primary Health Care Services
Divisions of General Practice
Commonwealth Dept of Health
Integrated Child and Family NGO services
Peak Health organisations
Medicare
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Craig Family Centre
Professional Bodies
Universities: LaTrobe, Monash and Deakin in particular
Private practitioners and consultants
Hospital system esp HARP, St Vincents, St Georges, Eastern Health
What would it take to do better?
The Victorian Government has identified a commitment to recurrent initiatives within health, including a number with
direct implications for the prevention and management of diabetes. New commitments include:
• a range of primary prevention initiatives in community and school-based settings such as Free Fruit Friday,
Better Pools Program and Community Sports Grants
• Men’s Sheds to support middle-aged and older men to remain healthy and active
• Go for your life and Life! lifestyle change programs to help Victorians at risk of developing type 2 diabetes and
children to control their weight
• more doctors for country Victoria
• better vision and dental health for seniors.
This enables Victoria to build on the NCDS, and the joint government investments under the COAG Australian Better
Health Initiative (ABHI), which is linked to the NRA. The five priority areas for action under the ABHI are intended to shift
the focus of health care, through prevention and reduction of the burden of chronic disease, to promotion of good
health. Many of the programs that form Victoria’s contribution to these national initiatives build on the existing work
under Go for your life and other state-level activities. The Victorian Diabetes Strategic Framework brings together
national and local initiatives to form a cohesive agenda for diabetes prevention and management in Victoria. It also
provides the structure for building a range of Victorian strategies for integrated action across the spectrum of care for
chronic disease prevention and management, focusing in this instance on diabetes.
The following strategic directions are a focus for comprehensive action on diabetes:
• health development in all policies
• community-wide primary prevention programs
• accessible services for the prevention of diabetes in individuals at increased risk
• accessible services for the optimal early detection and management of diabetes
• integrated care for people living with diabetes
• workforce
• enhanced surveillance system
• research and evaluation and knowledge exchange.
What is IECHS Role?
The role of Inner East Community Health Services is to work with the communities of the City of Boroondara and Yarra
in Melbourne, Victoria and our partners to contribute to the social inclusion and health equity agendas of the state and
Commonwealth government.
Specifically IECHS addresses the Fairer Victoria objectives of




Increasing access to universal services
Reducing barriers to opportunity
Support for disadvantaged groups
Supporting high needs places
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And its targets of:
 giving all children the best start in life and targeting support to vulnerable children to break entrenched cycles of
disadvantage
 improving health and wellbeing and reducing inequalities in health status
and the 4 priority areas of the Commonwealth Health reform as outlined above.
Its role is to prioritise this work within a universal foundation of the provision of primary health care services for the
community. [ refer Universal / Targeted Model of IECHS]
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Performance Accountability
Program or Service Unit: IECHS Diabetes Services
Population Group:
People with or at risk of diabetes
Contribution to Victorian Quality of Life and Health Promotion Overall Performance:
The Inner East Community Health Services’ diabetes services contributes to the
1. the Victorian Growing Victoria Together State Plan in the areas of:

High quality accessible health and community services
2. the Victorian State Plan - A Fairer Victoria7:
On the priority areas of:

Priority Area 3: Improving Health and Wellbeing:
o
o
o
Reducing barriers to opportunity with a sustained focus on identifying and redressing those factors that
prevent people gaining access to opportunities for a better life. The effort this year is to assist more
Victorians to overcome barriers to economic and social participation.
Strengthening assistance to disadvantaged groups including additional support to Indigenous Victorians,
new options for people with a disability and help for senior Victorians to remain independent. We will
continue to focus efforts on at risk groups including Indigenous Victorians, children, young people, and
people at risk of homelessness or experiencing mental illness.
Better management of Chronic conditions: through the implementation of the Active Service Model and
the integrated service provision
3. the Victorian Primary Health8 goals :
•
•
•
The focus on wellness and person-centred care–keeping people well and designing seamless care and
population health action that considers the person’s holistic needs and enables their participation
Address inequalities in primary health care access–people access the health professional they need, when
and where they need it through an appropriate mix of public and privately funded services
Enable people with chronic and complex conditions to have well-planned, integrated care in a community
setting that supports people’s capacity to self-manage and reduces avoidable hospital admissions–people
are supported to better manage their own chronic conditions and have reduced acute exacerbations.
4. The Victorian Strategic Framework for Diabetes Prevention and Management 2007-2010
•
•
7
8
Prevent the onset of Type 2 diabetes
To achieve better management and reduced complications
Government of Victoria., A Fairer Victoria: Real Support-Real Gains May 2010
DHS. Primary Health Care in Victoria: A discussion paper April 2009
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In particular it addresses the principles of:
•
•
•
•
•
A balanced approach to prevention by providing a continuum of service options for people with or at risk of
diabetes
Interdisciplinary models of care through the involvement of medical, allied, health promotion and non
government staff
Partnerships at all levels through partnering with Diabetes Australia, local government, GP Divisions, PCP’s and
other non government agencies in the catchment
Equity-focused approaches which target our interventions to those with the poorest health status through our
SIFA team
Accessible and culturally appropriate diabetes prevention and management initiatives through the provision of
culturally specific services
•
An evidence-based approach through the use of RBA and current clinical evidence in the design of programs and
services.
5. the IECHS Corporate Plan goal9:
Further development of our multi-disciplinary team approach to achieve continuity of care and best outcomes
6. The principles of the HACC Active Service Model10:
•
•
•
•
•
people wish to remain autonomous
people have the potential to improve their capacity
people’s needs should be viewed in an holistic way
HACC services should be organised around the person and his or her carer, that is, the person should not be simply
slotted into existing services, and
a person’s needs are best met where there are strong partnerships and collaborative working relationships between
the person, their carers and family, support workers and between service providers.
From a service delivery perspective core components are:





promoting a ‘wellness’ approach that emphasises optimal physical and mental health of older people and
younger people with disabilities
acknowledging the importance of social connections to maintain wellness
an holistic and person-centred approach to care
actively involving clients in setting goals and making decisions about their care and
providing timely and flexible services that support people to reach their goals.
7. the National Health Reform Primary Health Priority areas11:


Improving access and reducing inequity
Better management of chronic conditions
9
IECHS Strategic plan 2009-2012
Victorian Government Department of Health 2010: Victorian HACC Active Service Model Implementation Plan 2009—2011
11
Commonwealth of Australia Dept health & Ageing, Building a 21st century Primary Health Care System: Australia’s First National Primary health
Care Strategy. 2010
10
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Basic Facts: How much did we do quadrant?
# Clients
# Client hours
# foot assessments
# exercise prescriptions
# consumers provided with dietary advice
# care plans
# Care co-ordination plans
# consumers attending groups
# annual eye, renal and kidney assessments
# with HSB1C tested
Need to develop measurement methodology for
the additional measures which TRAK and
Medical Director will not help with
Performance: How well did we do it and Is anyone better off Quadrants 2 and 4: Turn the Curve exercise
% people exercising to recommend standards
Recommended standard = 30
minutes of moderate exercise a
day.
Need to develop a methodology to
collect this data from all people
with diabetes in the agency.
55
Percentage clients
40
Measure annually
07
11
14
Year
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% people who understand their diabetes
Factors to measure to assess
understanding:
Consumers can list the:
 Complications: feet, heart,
eyes, kidneys
 Impact of exercise and
nutrition on their condition
 Monitoring practices
 What their levels should be
Percentage clients
75
60
Need to develop a tool for
measurement of these factors
annually
07
11
14
Year
% people with high HBA1C above or equal to 7 who are able to reduce their levels
The sub population that this refers
to are those who have High HBA1C
readings.
This will be measured through blood
test
Percentage clients
25
10
07
11
Need to develop the methodology
for the annual collection of this data
for all people who are in this sub
population.
14
Year
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% people eating well
Measured by :
60



50
Percentage clients

Weight within standard range
BMI within standard range
Eating correct portions of food
within 5 food groups
Meet standard for intake of salt,
sugar, alcohol, saturated fats
Need to develop a methodology for
the annual collection of this data for
all people with diabetes in the
agency.
07
11
14
Year
Story Behind the last 3 years of Performance: Story behind the baseline remembering it has a history and forecast
What is the evidence for turning the curves
Why have we not done so well over the past 3 years in achieving improvements?
What do you propose to do to improve performance in the next 2 years? [ Action Plan to get better] Three Best Ideas,
No Cost Low Cost Idea
% people exercising to recommended level










People will have access to gym or home based exercise programs
Use MI to motivate people to exercise and address barrier
Address financial barriers to exercise
All people will have goal setting for exercise
Link people with exiting community opportunities for exercise
Sugar beat
Staff development
IECHS run exercise programs
Phone coaching
Accessible consumer information
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% people who understand their diabetes










Provide series of group programs for people newly diagnosed, for updates
Provide self support groups
All appointments to cover the basic information on diabetes
Use accessible consumer information which is culturally appropriate
Protocols for delivery of information by all clinicians
Investigate IT communication of information
Website to include diabetes specific area
Diabetes week activites
Integrated case management with services internal and external
Investigate the use of volunteers to assist consumers
% people with high HBA1C above or equal to 7 who are able to reduce their levels





Regular blood test and monitoring
Exercise and nutrition
IDEAS clinic and ITJ integration with our ideas
Diabetes clinic for monitoring and EI
Care Co-ordination and care plans for all people
% people eating well
 Individual appointments cover nutrition
 Link to SIFA food access strategies
 Supermarket tours
 Refer RBA Plan dietetics
 Consumer info is accessible\
 Phone coaching
 Label reading information
 CALD food choices information
 Evaluate adequacy of written information
 Facilitate access for consumers to affordable food
Data Development Agenda:
Capacity to identify the # of people with diabetes
Data systems which talk to each other between allied and medical
Specific measurement tools for curves as indicated
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Results Framework: Draft 2 of Outcomes Framework for Diabetes: plan still in development
DRAFT Workplan for Diabetes Outcomes Framework IECHS 2011-2015
Performance Measure
Strategy
Actions
% people exercising
to recommended
level
Ensure people have access to exercise
opportunities in a way which motivates
them to meet the recommended levels.
People will have access to gym or home based exercise
programs
Use MI to motivate people to exercise and address
barrier
Who is Responsible
By when
Address financial barriers to exercise
Link people with existing community opportunities for
exercise
Expand Sugar beat program
IECHS run exercise programs
Ensure consumer information on
exercise is accessible to people
Provide phone coaching services for people
Review consumer information currently provided
throughout IECHS for readability, cultural
appropriateness and usefulness to consumers.
Revise or prepare consumer information on exercise
which complies with what consumers find useful.
Staff Development
% people who
understand their
diabetes
Provide a range of group programs to
inform people about all aspects of their
diabetes and its management
Staff will have a minimum of 1 professional development
session on strategies to motivate people to exercise and
recommended exercise regimes.
Provide series of group programs for people newly
diagnosed, for updates
Facilitate the development of self support groups where
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Performance Measure
Strategy
Actions
Who is Responsible
By when
there is interest
Ensure all clinical interventions provide
core information on diabetes and its
management for all consumers in the
agency with diabetes.
Develop accessible consumer information which is
culturally appropriate for clinicians to use in their
interventions
Develop Protocols for delivery of core information by all
clinicians including definition of core information and
monitoring strategies to ensure compliance
Train clinicians in effective delivery of core information.
Develop IT solutions to provision of
information
Develop diabetes specific page on IECHS website
Investigate use of SMS and other ICT for communication
of information to consumers
Promote Diabetes Week as an opportunity to provide
information.
% people with high
Develop clinical pathways which provide
service and care co-ordination and case
management
Implement terms of reference of Care Co-ordination Pilot
to map clinical pathways for care co-ordination and case
management
Participate in the development of service co-ordination
system which takes account of consumers with diabetes
Provide volunteer mentors to assist
people in the management of their
diabetes
Investigate the possibilities for volunteers to act as
mentors and coaches for people with diabetes
particularly in areas of exercise and nutrition.
Implement volunteer program where evidence suggests
it will work
Identify those consumers with HBA1C
results above or equal to 7
Need to identify how we will do this. ?? through Med Director
but what about those coming in through other means and ot
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Results Framework: Draft 2 of Outcomes Framework for Diabetes: plan still in development
Performance Measure
HBA1C above or
equal to 7 who are
able to reduce their
levels
Strategy
Who is Responsible
By when
seeing our GP’s?
Develop diabetes clinic for management
and monitoring all consumers
Note: Actions on
exercise and nutrition
will also have an
impact on this
performance measure
% people eating
well
Actions
Diabetes clinic with multidisciplinary care team to be held
4 times a year for management and monitoring of all
consumes with diabetes. Priority to be given to those
who have unstable management.
Implement care co-ordination and case management
system as developed by SC and CC Working Group and
the Pilot and integrate with diabetes clinic
Ensure integration of initiatives with
Improving the Journey and IDEAS clinic
Review strengths of both models of diabetes clinical care
and include these in design of Diabetes Clinic.
Provide accessible information on
healthy eating
ALL Clinicians to provide information on healthy eating in
their interventions
Clinicians to link consumers to SIFA food access
strategies for affordable food
There must be more strategies than just
providing information to turn this
curve????
What does the evidence say about
access to healthy food . Perhaps we
should consult Anthony on this also.
Conduct Supermarket tours
Provide Label reading information
Review consumer information currently provided
throughout IECHS for readability, cultural
appropriateness and usefulness to consumers
Revise or prepare consumer information on exercise
which complies with what consumers find useful.
Implement RBA Plan for dietetics for the diabetes curve
Provide opportunities for Phone coaching
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Results Framework: Draft 2 of Outcomes Framework for Diabetes: plan still in development
Evaluation Plan
Project Focus
2011 Baseline Measurement
Plan and Tools
2014 Measurement Plan and
Tools
Target
Who is responsible by when?
Appropriate Exercise
Healthy Eating
High HBA1C
Understanding Diabetes
Basic Facts
Project Plan Proforma
Project Title:
Indicator :
Baseline Measurement 2010:
Action to be Taken
Team Leading the Project:
Focus:
Timeline
Worker Allocated
Report on Progress
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Results Framework: Draft 2 of Outcomes Framework for Diabetes: plan still in development
Note: Project Plans become the staff member work plan and are to be used in supervision
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