Smart systems to simplify diabetes care

AS Australia’s fastest growing chronic disease, diabetes is a time-consuming and complex challenge for general practice.

With the Australian Bureau of Statistics predicting the disease incidence will grow by 1% each year, the need has never been greater for practices to put in place efficient systems to manage this patient group.

Dr Chrys Michaelides is a Queensland GP and member of Diabetes Australia who runs regular workshops designed to help GPs optimise prevention and give management strategies to practices.

“Diabetes is such a massive and expanding disease,” he says. 

“If we could organise ourselves in primary care so we can optimise outcomes in a time-efficient manner, in the long term everyone will win.”

He says the best way to achieve that is by the mini-clinic model of care – in other words, a dedicated session or sessions each week just for patients with diabetes.

Dr Michaelides points to the results of a self-conducted audit of his practice (published by the American Diabetes Association) that showed GPs can ensure a higher percentage of type 2 diabetes patients achieve ABC (A1c, BP, Cholesterol) targets if they adopt the mini-clinic model, compared to standard management.

His approach, used since 1995, involves an electronic diabetes register – using practice software to code patients, structured diabetes-specific consultations, recalls and pathology every three to four months, along with diabetes ‘mini clinics’.

Dr Michaelides says creating a diabetes register then allows his practice nurse to independently “interrogate” patient records, checking that each patient has their Cycle of Care plan done, albumin test, ECG and so on.

CLINICS CATCHING ON

And other GPs have recognised the benefits of diabetes clinics. 

RACGP Queensland faculty member and GP at Condamine Medical Centre Dr Evan Ackermann says his practice runs chronic disease management clinics three days a week.

Practice nurses play an essential role in ensuring much of the groundwork, such as necessary pathology and investigations, is done before the patient reaches the GP, he adds.

Dr Ackermann believes Medicare does reward good quality care but there is no point in approaching diabetes care by “plonking in” the item numbers (see below) and hoping for the best – forward planning is essential.

“You have got to work out what is good quality care, what the patients like and what is a good business plan,” he says.

That means organising your systems; creating active recalls, regular reviews and testing; and ensuring care plans are in place.

AGPN chair Dr Emil Djakic is another advocate of diabetes clinics and strongly supports the Federal Government’s proposed diabetes scheme, which will shift the emphasis from fee for service to practice payments of about $1200 a year for each diabetes patient enrolled.

He argues that fee-for-service medicine has “tied the funding to the doctor action”, rather that recognising the key contribution that staff such as practice nurses can make to diabetes management.

With a register of 500 patients with diabetes at Dr Djakic’s practice, a streamlined system is essential to proactively manage all patients.

Dr Djakic recommends Doctors Control Panel, a free mini program that is compatible with Medical Director, Best Practice or PracSoft software.

Developed by Melbourne GP Dr Anton Knieriemen, the program has a pop-up at the bottom of the clinical screen that alerts the GP to preventive care items that need to be addressed and colour-coded ‘tablets’ that advise when information should be updated. This information includes medication, measurements and tests.

“It allows nursing staff to identify needs of patients and independently take action with that patient without the involvement of the GP,” Dr Djakic says.

A different approach has worked well for Dr Bronwyn Edwards at her semi-rural practice in Galston, NSW. It runs diabetes clinics three times a year using practice nurses and a diabetes educator from the local hospital.

Dr Edwards says the practice used to send mail-outs to all patients with diabetes reminding them of clinic dates, but now finds it easier to “pick up” eligible patients each week during regular consultations and refer them to the clinic list.

She says using practice software such as Medical Director or PracSoft to compile a diabetes register is useful, but it is vital to ensure everyone in the practice using the system enters the data correctly.

Brett McPherson, national president of the Australian Association of Practice Managers, agrees that the quality of data input to clinical notes is very important, along with developing a clear practice strategy for managing patients. 

“It can be useful, while having all nurses involved, that a particular nurse is identified as the coordinator for diabetic patient management,” Mr McPherson says. This creates a direct communication line for the practice manager and gives the nurse responsibility and accountability (perhaps even a pay bonus based on achieving compliance targets could help).Mr McPherson also recommends practice nurses use diabetes clinics as an opportunity to educate patients on why their compliance is essential for the best outcome. 

If patients understand why they need to follow a particular course of treatment, and the nurse and GP stick to agreed appointment timeframes, the chances of success are higher.

LITTLE BY LITTLE

There are other GP-driven initiatives looking at the big picture of diabetes. 

Dr Michaelides is particularly passionate about his project, It Takes 3. The idea is simple: if every GP in the next five years in Australia can help three patients each year with diabetes record an HbA1c of less than 7%, it would result in a 10% increase in the number of patients with a lower risk of complications. 

“Unfortunately, more than 40% of the Australian diabetes population do not meet this (less than 7%) target, placing them at significant risk of developing complications,” Dr Michaelides says. He believes his project could reap “enormous savings” in complication prevention.

However, the impact of the Government’s diabetes scheme on general practice is less certain, according to Mr McPherson.

Because the proposed funding system will be provided to manage patient care regardless of the numbers of consultations during the funded time frame, this has raised concerns from RACGP president Dr Chris Mitchell that it will create “perverse” incentives for doctors (MO, 9 April).

He says doctors may not seek to enrol patients with diabetes who have the most complex problems because of the potentially high cost of funding their care.

Mr McPherson agrees the potential is there for practices to avoid the complex patients to make the scheme financially viable. But he says that shifting to a practice team focus means GPs may only need to see a patient with diabetes once a year “if they work smart”.

The Government needs to set clear practical guidelines for the scheme, or risk creating more red tape and compliance issues for practices and patients, he adds.

In the meantime, GPs can be encouraged by the fact that management of diabetes can be made more efficient by using a combination of team care, technology, planning and business savvy.

DIABETES ONLINE RESOURCES

www.diabetesaustralia.com.au

www.bakeridi.edu.au

www.diabetessociety.com.au

www.adea.com.au

www.idf.org

www.racgp.org.au (access Diabetes Management in General Practice: Guidelines for Type 2 Diabetes 2009/10).

www.racgp.org.au/guidelines/redbook (guidelines for preventative activities in general practice (The Red Book)

MBS ITEM NUMBERS FOR DIABETES CARE

• Chronic disease management: 721-723,729,731 and 732
• Practice nurse (once care plan is in place): 10997
• Home medication review: 900
• Annual Cycle of Care: 2517,2518,2521,2522,2525,2526,2620,2622,2624,2631,2633,2635
• ECG (every 18 months to two years): 11700
• Measurement of ankle: brachial indices and arterial waveform analysis (if practice has a Doppler): 11610.