DiabetesStrategic Plan

2019–2024

Sydney Local Health DistrictHead Office information

Street address:Level 11, KGV BuildingMissenden RoadCamperdown NSW 2050

Postal address:Post Office Box M30Missenden Road NSW 2050

Phone: (02) 9515 9600Fax: (02) 9515 9610

Sydney Local Health District contact email:SLHD-ESU@health.nsw.gov.au

Sydney Local Health District Board contact email: SLHD-Board@health.nsw.gov.au

www.slhd.nsw.gov.au

Acknowledgement of Country 3

Foreword 4

1/ Introduction 6

2/ Policy context 9

3/ Diabetes picture of health 11

4/ Sydney Local Health District diabetes services 18

5/ Diabetes models of care 26

6/ Diabetes strategic directions 30

7/ Next steps 33

8/ Diabetes Action Plan 34

Appendix A/ Other diabetes services in Sydney Local Health District 37

References 41

ContentsDiabetesStrategic Plan

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Acknowledgement of CountrySydney Local Health District acknowledges that we are living and working on Aboriginal land. We recognise the strength, resilience and capacity of Aboriginal people on this land. We would like to acknowledge all of the traditional owners of the land and pay respect to Aboriginal Elders past and present.

Our District acknowledges Gadigal, Wangal and Bediagal as the three clans within the boundaries of the Sydney Local Health District. There are about 29 clan groups within the Sydney metropolitan area, referred to collectively as the great Eora Nation. Always was and always will be Aboriginal Land.

We want to build strong systems to have the healthiest Aboriginal community in Australia.

Together under the Sydney Metropolitan Partnership Agreement, including the Aboriginal Medical Service Redfern and in collaboration with the Metropolitan Local Aboriginal Lands Council, Sydney Local Health District is committed to achieving equality to improve self-determination and lifestyle choices for our Aboriginal community.

Ngurang Dali Mana Burudi – A Place to Get Better

Ngurang Dali Mana Burudi — a place to get better, is a view of our whole community including health services, Aboriginal communities, families, individuals, and organisations working in partnership.

Our story

Sydney Local Health District’s Aboriginal Health story was created by the District’s Aboriginal Health staff.

The map in the centre represents the boundaries of Sydney Local Health District. The blue lines on the map are the Parramatta River to the north and the Cooks River to the south which are two of the traditional boundaries.

The Gadigal, Wangal and Bediagal are the three clans within the boundaries of Sydney Local Health District. They are three of the twenty-nine clans of the great Eora Nation. The centre circle represents a pathway from the meeting place for Aboriginal people to gain better access to healthcare.

The Goanna or Wirriga One of Australia’s largest lizards, the goanna is found in the bush surrounding Sydney.

The Whale or Gawura From June to October pods of humpback whales migrate along the eastern coastline of Australia to warmer northern waters, stopping off at Watsons Bay the traditional home of the Gadigal people.

The Eel or Burra Short-finned freshwater eels and grey Moray eels were once plentiful in the Parramatta River inland fresh water lagoons.

Source: Sydney Language Dictionary

ArtworkNgurang Dali Mana Burudi — a place to get better

The map was created by our Aboriginal Health staff telling the story of a cultural pathway for our community to gain better access to healthcare.

Artwork by Aboriginal artist Lee Hampton utilising our story.

NG

URANG DALI MANA BURUDI

A PLACE TO GET BETTER

Canterbury Hospital Strategic Plan 5Diabetes Strategic Plan4

Foreword

Diabetes is one of the most significant health challenges facing Sydney Local Health District (the District) and the health system in general. Diabetes is the collective name for a group of different conditions in which the body cannot maintain healthy levels of glucose in the blood. To address this challenge, over the next five years, the District will support our people to ensure that we deliver and facilitate whole-of-system delivery of evidence-based diabetes prevention, earliest intervention and care.

The Australian Institute of Health and Welfare (AIHW) advises that diabetes now constitutes the leading current and prospective burden of disability in our nation. The ageing population and increasing numbers of risk factors for chronic diseases means the management of diabetes is becoming increasingly complex, with new therapeutic agents becoming available and more refined treatment approaches being developed. It is estimated that about 350,000 residents of Sydney Local Health District are at risk of diabetes, about 70,000 people have pre-diabetes and about 45,000 have diabetes.

This plan introduces an integrated and coordinated model of care to prevent, manage and reduce the social, human and economic impact of diabetes. Partnerships between patients and clinicians and between primary and secondary care providers are critical in addressing this issue.

The Agency for Clinical Innovation’s (ACI’s) Leading Better Value Care Program (LBVC) provides an important focus for the District to improve patient and provider experience, population health outcomes, and system efficiency and effectiveness for patients with diabetes. In this context, health outcomes are importantly defined as the outcomes that matter to the patients and address our shared priorities. This strategy builds from the LBVC program.

It addresses issues associated with data and information and the need of priority populations, it improves prevention and our service models and it supports research. We are committed to ensuring our services target priority populations that are most at risk of developing diabetes and also suffer the comorbidities and complications of diabetes. This strategy has four goals:

• Prevention and Health Promotion

• Primary Care, Earliest Intervention and Self-Management

• Service Development

• System Capacity Building, Education and Research

We are proud of this important strategy. We wish to acknowledge and thank the many clinicians, service providers and community members who contributed to it. The strategy will be used as our framework to lead, collaborate and contribute to better care and improved health and wellbeing across our District.

Dr Teresa Anderson am The Hon. Ron Philips aoChief Executive Chair of the BoardSydney Local Health District Sydney Local Health District

Abbreviations

ACI Agency for Clinical Innovation

AIHW Australian Institute of Health and Welfare

AMS Aboriginal Medical Service

ANDS Australian National Diabetes Strategy 2016–2020

AUSDRISK Australian Type 2 Diabetes Risk Assessment Tool

BGLs Blood glucose levels

CALD Culturally and Linguistically Diverse

ccCHIP Collaborative Centre for Cardiometabolic Health in Psychosis

CDE Credentialed Diabetes Educator

CESPHN Central Eastern Sydney Primary Health Network

CGM Continuous glucose monitoring

CNC Clinical Nurse Consultant

CPC Charles Perkin Centre

CRGH Concord Repatriation General Hospital

DM Diabetes Mellitus

DSP Diabetes Strategic Plan

ED Emergency Department

GDM Gestational diabetes mellitus

GP General Practitioner

HiTH Hospital in The Home

HRFS High Risk Foot Service

LBVC Leading Better Value Care

LGA Local Government Area

LHD Local Health District

MoC Model of Care

MoH Ministry of Health

MODY Maturity onset diabetes of the young

NAFLD Non-alcoholic fatty liver disease

NDPF NSW Diabetes Prevention Framework 2016

NDSS National Diabetes Services Scheme

PHN Primary Health Network

RPA Royal Prince Alfred Hospital

The Plan SLHD Diabetes Strategic Plan

The District Sydney Local Health District

T1DM Type 1 diabetes mellitus

T2DM Type 2 diabetes mellitus

VMO Visiting Medical Officer

Diabetes Strategic Plan 7Canterbury Hospital Strategic Plan6

Diabetes is a chronic condition marked by high levels

of glucose in the blood. It may result in a range of health

complications, including heart disease, kidney disease,

blindness and lower limb amputation. Appropriate early and

ongoing management of diabetes can reduce comorbidities,

improve health outcomes and contribute to a reduced

economic and disease burden in our community.

1/ Introduction

It is estimated 1.2 million Australians have diabetes and data indicates over one million hospitalisations (10% of all hospitalisations) were associated with diabetes in 2015–161. However, local data sources and a point prevalence survey conducted in Melbourne suggest that the real rate of hospitalisations associated with diabetes is three-fold of that reported2. The prevalence of diabetes mellitus (DM), especially type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM), is continuing to increase across Australia.

1.1/ Our Vision

Sydney Local Health District’s vision

To achieve excellence in health and healthcare for all

In the context of diabetes, our vision is

To prevent diabetes and improve the health of people living with diabetes

1.2/ Our Goals

Sydney Local Health District’s vision for diabetes is drawn from the goals of the Australian National Diabetes Strategy 2016–20204 (ANDS) and the NSW Diabetes Prevention Framework 20165 (NDPF).

We aim to reduce the impact of diabetes by:

Prevention and early diagnosis of type 2 diabetes mellitus (T2DM), gestational diabetes mellitus (GDM) in pregnancy and the recurrence of GDM in subsequent pregnancies through evidence-based strategies

Enhance and build partnerships to work collaboratively with our community and primary care providers to increase capacity for primary care, earliest intervention and self-management

Improve the quality of life of people with diabetes, including reducing the occurrence of diabetes-related complications

Reduce the impact of diabetes in women in pregnancy and in the post-partum period, including consideration of the long term impacts of diabetes on their babies and children

Targeting Aboriginal people* for prevention, early intervention and diabetes treatment services to contribute to ‘Closing the Gap’ for Aboriginal health

Ensure diabetes services are accessible, equitably distributed, with clear pathways, based on the agreed evidence based models of care

Support expanded research in diabetes to ensure evidence-based care and active translation of research into clinical practice

The goals of the Plan are:

Prevention and Health Promotion

To address prevention and outline the incidence and prevalence of diabetes in the District

Primary Care, Earliest Intervention and Self-Management

To promote and support earliest intervention and self-management of diabetes across the District

Service Development

To identify and prioritise strategies to meet the diabetes health need of the District in an effective, efficient, integrated and evidence-based manner based on the ACI’s Diabetes Model of Care (MoC) and consistent with the principles of the LBCV program

System Capacity Building, Education and Research

To enhance the role of education, training and research in diabetes across the District

 

* Note that within NSW Health, the term ‘Aboriginal’ is used in preference to ‘Aboriginal and Torres Strait Islander’, in recognition that Aboriginal people are the original inhabitants of NSW.

It is estimated that about 350,000 residents of Sydney Local Health District are at risk of diabetes. Approximately 70,000 people have pre-diabetes with an estimated prevalence of 7.0–8.6% and there are approximately 45,000–55,000 residents living with diabetes in the District3. The ageing of the community means that this prevalence rate is likely to increase significantly in the forthcoming decades.

This inaugural Sydney Local Health District Diabetes Strategic Plan 2019–2023 (the Plan) sets the vision for diabetes prevention and the development of the District’s diabetes services. It guides integrated service development, research and collaborative partnerships for diabetes services within the District over the next five years. It has been developed to align with the Australian National Diabetes Strategy 2016–2020 and the Agency for Clinical Innovation’s (ACI) Leading Better Value Care program (LBVC).

The diabetes services across Sydney Local Health District are predominantly provided by primary health providers including General Practitioners (GPs) and private and public allied health professionals, endocrinology specialists, District public health services and Diabetes NSW & ACT. The District’s public diabetes services are provided in ambulatory care settings with services and consultations for inpatients also available in our hospitals. Royal Prince Alfred (RPA) and Concord Repatriation General Hospitals (CRGH) have Diabetes Centres as a core part of their delivery model.

Diabetes Strategic Plan 9Canterbury Hospital Strategic Plan8

1.3/ The planning process

The planning process for the Diabetes Strategic Plan has included a review of the progress to date of the District’s Clinical Stream position paper for Endocrinology, Metabolism and Andrology 2013–20186 and Aged Health, Chronic Care Rehabilitation and General Medicine (ACC&R)7. It also involved analysis of the current policy and planning context, consultations with consumers, staff and relevant

1/ Introduction

2.1/ National

The Australian National Diabetes Strategy 2016–20208 (ANDS) aims to inform and prioritise the nationwide response to diabetes across all government levels and reduce the impact of diabetes in the community. It evaluates current approaches to diabetes services and care, aims to maximise the efficient use of existing, limited health care resources, improve the better coordination of health care resources across all levels of government, and focus resources where they are needed most’9. The goals of the ANDS are to:

• Prevent people developing T2DM

• Promote awareness and earlier detection of T1DM and T2DM

• Reduce the occurrence of diabetes-related complications and improve quality of life among people with diabetes

• Reduce the impact of pre-existing diabetes in pregnancy and GDM

• Reduce the impact of diabetes among Aboriginal and Torres Strait Islander peoples

• Reduce the impact of diabetes among other priority groups

• Strengthen prevention and care through research, evidence and data.

Diabetes in Australia: Focus on the Future 10 is the Implementation Plan for the ANDS that aims to operationalise each of the ANDS goals and prioritise diabetes-related actions that include addressing gaps in current diabetes direction and investment, minimising duplication of effort across all sectors and ensuring the current focus of activity across sectors remains strong and relevant and sustainable.

2/ Policy context

2.2/ NSW

The NSW State Health Plan: Towards 2021 11, aims to keep people healthier and out of hospital, recognises that preventive health keeps people well now and prevents future illness developing, and also helps people with chronic conditions such as T2DM from developing further complications. Key groups for prevention initiatives (Aboriginal people, socio-economically disadvantaged people) are identified as they experience much poorer health than the rest of the NSW population. Key state-wide initiatives supporting the prevention of T2DM include reducing smoking, tackling overweight and obesity and increasing physical activity.

stakeholders and the incorporation of available best practice in diabetes care delivery and prevention. The planning process was coordinated by and governed through the Diabetes Action Plan Steering Committee with the assistance of Sydney Local Health District’s Planning Unit.

The Plan has been developed in close consultation with the Diabetes/Endocrinology executive, staff and clinicians from hospital and community settings, the Central Eastern Sydney Primary Health Network (CESPHN), Clinical Directors, General Managers, Sydney Local Health District’s Aboriginal Health Unit and other organisations and consumers.

A District-wide forum on diabetes was held in late 2017 to discuss issues impacting on diabetes services in the District and identify priorities to improve patient outcomes.

Several policies are relevant to addressing diabetes, including the NSW Healthy Eating and Active Living Strategy 12; the NSW Integrated Care Strategy; the NSW Aboriginal Health Plan 2013–2023 13; and the NSW Tobacco Strategy 2012–2017 14.

The NSW Diabetes Prevention Framework (NDPF)15 (Figure 1) identifies existing interventions for T2DM and enhancements to evidence-based practice. Primary prevention is the prevention or delay of the onset of diabetes in high-risk populations. Secondary prevention is the prevention of the immediate and longer term health complications for people with diabetes. The NDPF aims to support Local Health Districts (LHDs) in decreasing the incidence and risk factors of T2DM and improve health outcomes for people already diagnosed with T2DM.

Figure 1 The NSW Diabetes Prevention Framework16

A standard questionnaire was sent out to clinical streams, Community Health, Diabetes NSW & ACT, Aboriginal Medical Service (AMS) and CESPHN. Consultations were held directly with staff from two diabetes centres at RPA and Concord Hospitals and a service mapping exercise was undertaken.

Community and consumer feedback was sought as part of Sydney Local Health District’s Strategic Plan community and consumer consultations. Consultations with culturally and linguistically diverse (CALD) groups and a local diabetes network group were held. An Aboriginal Health Impact Statement has been completed for this plan in line with NSW Health Policy Directive PD2017_034, Aboriginal Health Impact Statement.

Diabetes Strategic Plan10 Diabetes Strategic Plan 11

The NDPF identifies a range of approaches delivered at both the state level (for example, the Get Healthy Information and Coaching Service) and at the LHD level. This includes screening and risk stratification, referral to the Get Healthy Service and appropriate clinical management of people already diagnosed with T2DM.

The NSW Ministry of Health (MoH) through the ACI is responsible for ‘reviewing clinical variation and supporting clinical networks in clinical guideline/pathway development with encouragement toward standardised clinical approaches based on best evidence’17. The ACI has developed a variety of resources and guidelines aimed at improving healthcare for people with DM including standards for High-Risk Foot Services (HRFS) in NSW, adult subcutaneous insulin prescribing chart and diet specifications for inpatients with diabetes18, 19 including inpatients with diabetes in pregnancy20.

In 2016, the NSW MoH introduced the LBVC initiative to improve the health status of people in NSW and to ‘implement opportunities for delivering value based care’21. Inpatient management of diabetes mellitus and HRFSs are two of the eight clinical initiatives that have been included in the LBVC program for 2017–2018.

The ACI is considering a model of care (MoC) for the management of people with diabetes, which will provide an evidence-based framework for comprehensive, accessible, efficient and coordinated services. In addition to reducing the frequency of diabetes-related presentations to hospital Emergency Departments (ED), lowering rates of hospital admission, shortening lengths of stay and improving patient outcomes, the key objective is to ensure that diabetes services are optimally configured to:

• Prevent or delay the onset of diabetes (raise awareness, early diagnosis)

• Improve quality of life for people who have diabetes (optimal initial and long-term management)

• Prevent and slow the progression of diabetic complications, especially heart disease, renal failure, impaired vision and lower limb amputations (early detection and optimal management)

• Reduce inequities in diabetes service provision, particularly for Aboriginal people and other disadvantaged groups22.

2.3/ The District

Across Sydney Local Health District there are a number of policy directives, protocols, procedures, guidelines and referral pathways that relate to diabetes including:

• Women and Babies; Neonatal hypoglycaemia23, 24, Diabetes in pregnancy protocol25, Diabetes management guidelines for intrapartum and postpartum care in pregnancy26, 27

• Management of hypoglycaemia in the inpatient28, 29, 30 and community setting31

• Diabetic ketoacidosis (DKA) guidelines32, 33

• Blood glucose monitoring and insulin for inpatients34

• Triple B (Basal-Bolus-Booster) Protocol for In-Hospital Subcutaneous Insulin Treatment35

• HealthPathways Sydney36

• Referrals to High Risk Foot Services

• Sydney Local Health District Aboriginal Health Strategic Plan 2018–2022.

3.1/ Diabetes as a priority health area

An estimated two million Australians are at high risk of developing type 2 diabetes and there are large numbers of people with silent, undiagnosed T2DM38. The Australian Health Survey data indicates that for every four adults with diagnosed diabetes, there is one who was undiagnosed. That is, around one in five adults with diabetes do not know they have the condition39. There is strong international evidence that shows diabetes prevention programs can help prevent T2DM in up to 58% of cases by maintaining a healthy weight, being physically active and following a healthy eating plan, managing blood pressure and cholesterol levels and not smoking.

Excess weight, especially in the obesity range, is a major risk factor for developing chronic diseases, including T2DM40. In 2014–15, an estimated 63% (11.2 million) of Australian adults were overweight or obese and one in four children (27%, aged 5–17 years old) was overweight or obese41. Obesity is a major contributor to T2DM with estimates showing that eliminating obesity from the population can potentially reduce the incidence of T2DM by over 40%42. Weight management, healthy diet and regular physical activity can assist in preventing chronic diseases including T2DM43.

3/ Diabetes picture of health

A cluster-randomised trial conducted in the United Kingdom demonstrated that intensive weight management over a 12 month period showed that almost half (46%) of participants achieved remission of T2DM44.

Chronic diseases are becoming increasingly common in Australia due to population growth and ageing. These diseases constitute the leading causes of illness, disability and death in Australia for some decades. An estimated 1.2 million Australians (5.1%) had DM in 2014–1545. If diabetes continues to rise at current rates, up to 3 million Australians will have diabetes by 202546.

The estimated prevalence of diabetes in Sydney Local Health District for 2015–16 was 7.0–8.6% and this has increased from 4.4% in 200247. The rate of potentially preventable hospitalisations for diabetes complications in the District also increased from 88.1 per 100,000 population in 2010–11 to 100.8 per 100,000 population in 2015–16. NSW remained steady between 124.5–127.9 per 100,000 population for the same timeframe48. In 2015–16, there were 722 hospitalisations in the District with diabetes as the primary/principal diagnosis49, a rate of 114.3 per 100,000 population, which was lower than the state rate of 148.5 per 100,000 population50.

In 2015–16, 10% of all hospitalisations in Australia (over one million hospitalisations) were associated with DM (principal and/or additional diagnosis) with the majority (95%) of the hospitalisations listing diabetes as an additional diagnosis51. This would appear to be a gross underestimate of the true picture of diabetes. Local data sources and the point prevalence survey conducted in Melbourne suggest that the actual rate of hospitalisations associated with diabetes is three-fold of that reported52. In 2015, Sydney Local Health District, had the second highest rate (4.6%) of DM in pregnancy as a maternal medical condition in NSW (1.5%)53, with the rate for GDM being above the state average at 9% (NSW 8.3%). Those who reside in the lowest socioeconomic areas are reported to have diabetes hospitalisations and death rates double that of higher socioeconomic groups.

‘Diabetes is a chronic condition marked by high levels of glucose

in the blood. It is caused either by the inability to produce insulin

(a hormone made by the pancreas to control blood glucose levels),

or by the body not being able to use insulin effectively, or both.

Diabetes may result in a range of health complications, including

heart disease, kidney disease, blindness and lower limb amputation.

It is frequently associated with other chronic health conditions such

as cardiovascular disease and chronic kidney disease’37.

2/ Policy context

Diabetes Strategic Plan12 Diabetes Strategic Plan 13

3/ Diabetes picture of health

The Atlas of Diabetes Prevalence (by LGA), in December 2017, indicated 30,825 Sydney Local Health District residents were registered under the National Diabetes Service Scheme (NDSS)54, 55. Figure 2 illustrates the diverse values of DM prevalence within the District56. Of note, the percentage of GDM NDSS registrants was high to very high in all of the District’s

3.2/ Priority populations

Priority populations are negatively impacted by DM more than the general population, with both a higher prevalence of DM and a greater burden of disease in these groups. Priority populations for DM in the District include: Aboriginal people59; CALD groups; people with chronic diseases and related risk factors; pregnant women; elderly and frail people; people with mental health conditions; and populations using selected tertiary and quaternary services related to rare conditions and diseases.

3.2.1/ Aboriginal people60

Diabetes is a major contributor to the disparity in health between Aboriginal and non-Aboriginal people. Aboriginal Australians have higher rates of diabetes than the general population. Prevalence, hospitalisation and death rates of DM are around four times higher than that of non-Indigenous Australians61. In 2015–16, there were around 2,400 and 54,000 hospitalisations for T1DM and T2DM respectively (as the principal and/or additional diagnosis) among Aboriginal people in NSW62. The rate among Aboriginal Australians was 1.7 and four times as high as for non-Indigenous Australians for T1DM and T2DM hospitalisations respectively63.

Aboriginal people are also more likely to experience comorbidities that contribute to an increased risk of diabetes. Aboriginal people are 2.6 times more like to smoke daily, 1.2 times as likely to be overweight or obese and 1.2 times as likely to have

Table 1National Diabetes Services Scheme (NDSS) Aboriginal and Torres Strait Islander registrants, by LGA of residence, number and proportion of LGA population, January 201958

Local Government Area (2011 LGA boundaries)

Aboriginal registrants/ estimated Aboriginal

population in LGA

Percentage of LGA population

% LGA registrants

Ashfield 10/328 3.0% 4.7%

Burwood 8/174 4.5% 5.1%

Canada Bay 10/397 2.5% 4.3%

Canterbury 45/1060 4.2% 6.7%

Leichhardt 27/730 3.7% 2.9%

Marrickville 60/1596 3.8% 4.2%

Strathfield 10/130 7.7% 5.0%

Sydney 120/3059 3.9% 2.7%

Source: National Diabetes Services Scheme Australian Diabetes Map.

Figure 2National Diabetes Services Scheme (NDSS) registrants, by LGA of residence, number and proportion of LGA population, December 2017

LGAs, with Burwood and Marrickville LGAs being in the high category and the remaining LGAs in the very high category. The percentage of registrants in Canterbury57 was in the very high category, with the highest number and percentage of registrants within the District, reflecting the growing population, low socioeconomic area and the cultural diversity of its community.

Strathfield

Burwood2,006/40,246

5.0%

87/2,006

4.3%

Canterbury

Canada Bay

Ashfield

Leichhardt

Marrickville

Sydney

10/130

7.7%

162/3,738

4.3%10/397

2.5%

3,738/86,292

4.3%

1,889/36,870

5.1%

65/1,889

3.4%8/176

4.5%

96/2,219

4.3%

10/328

3.0%

2,219/46,752

4.7%

10,417/156,547

6.7%

459/10,417

4.4%

45/1,060

4.2%

3,629/87,033

4.2%

120/3,629

3.3%

60/1,596

3.8%

1,696/59,390

2.9%

90/1,696

5.3%

27/730

3.7%

5,231/193,215

2.7%

278/5,231

5.3%

120/3,059

3.8%

Total NDSS registrants/LGA populationProportion

Gestational NDSS registrants/LGA gestational populationProportion

ATSI NDSS registrants/LGA ATSI populationProportion

high blood pressure64. It is estimated that 38% of Aboriginal people have two or more chronic diseases, such as cancer, respiratory diseases, diabetes, cardiovascular and chronic kidney disease. All of these factors contribute to an increased risk of T2DM and diabetes related complications65

The data available on Aboriginal diabetes does not truly represent the impact of diabetes amongst the District’s Aboriginal population. The table below illustrates the number of Aboriginal or Torres Strait Islanders who are registered in the National Diabetes Services Scheme which indicates an overrepresentation

Diabetes Strategic Plan14 Diabetes Strategic Plan 15

compared to the overall percentage of the LGA.

3.2.2/ Culturally and linguistically diverse (CALD) groups

Certain CALD groups in Australia have a high prevalence of diabetes compared with the Australian-born population. The regions of birth with the highest diabetes prevalence, incidence of insulin treated diabetes and diabetes related hospitalisations and/or mortality rates are the South Pacific Islands, Southern Europe, Eastern Europe and Central Asia, the Middle East, North Africa and Southern Asia66, 67.

Around 44% of residents of Sydney Local Health District were born overseas, compared to the 27% for NSW as a whole. The most frequent ancestries reported in the District are Chinese,

Lebanese, Italian, Greek, Vietnamese or Korean ancestry68.

The 2016 Australian Bureau of Statistics Census showed that Canterbury is one of the most culturally and linguistically diverse (CALD) areas in Greater Sydney. 48% of residents were born overseas. Within Canterbury, Chinese, Lebanese and Greek ancestries were most common accounting for around 47% of the population69. About 5% of the population reported Bangladeshi ancestry, which was a markedly higher proportion than in Greater Sydney as a whole. As previously noted, CALD groups in Australia have a high prevalence of diabetes.

3.2.3/ Socioeconomic disadvantage

Socioeconomic status has been shown to be a risk factor for diabetes and is related to complex lifestyle factors such as low income, smoking rates, being overweight or obese, lower levels of physical activity and higher intake of unhealthy foods.

Diabetes rates are generally higher in those in low socioeconomic areas. AIHW has reported that people in the lowest socioeconomic groups have diabetes hospitalisation and death rates that are two times higher than the highest socioeconomic groups70. These differences can be seen in Figure 3 using NSW data.

The District is characterised by socioeconomic diversity, with pockets of both extreme advantage and extreme disadvantage. As an example, the Canterbury area (previously an LGA, now part of Canterbury Bankstown LGA) and Inner West LGA (formed in 2016, consists of Ashfield, Leichhardt, and Marrickville Councils) has the

Figure 3Diabetes hospitalisations by socioeconomic status and type of diabetes, all ages, NSW 2017–18

Source: Centre for Epidemiology and Evidence. Available: http://www.health.nsw.gov.au/epidemiology/Pages/default.aspx

Type 1

Type 2 1st Quintile

Least disadvantaged

2nd Quintile

3rd Quintile

4th Quintile

5th Quintile Most disadvantaged

Total

0 30 60 90 120 150

Number

450

964

668

1,240

681

1,616

945

2,107

908

2,408

3,670

8,352

Rate per 100,000 population

highest proportion of people on welfare assistance. There are also significant pockets of disadvantage in the suburbs of Redfern-Waterloo, Glebe and Strathfield.

The Canterbury area is recognised as being socially vulnerable, highly culturally diverse and with greater comparative health need related to a complex combination of lifestyle factors, social and physical environments, disadvantage and low socio-economic status. People living in the Canterbury area have higher rates of smoking, obesity, Type 2 Diabetes, infectious diseases and asthma compared with District averages.

3.2.4/ Women and pregnancy

The reported rate of GDM in NSW rose from 6.4% in 2011 to 8.3% in 2015, while the rate of DM in pregnancy also increased from 0.6% to 1.5%71, 72. Across the District diabetes (pre-existing or GDM) in pregnancy increased from 7.2% in 2015 to 14.8% in 201673.

Contributing factors to this is an increase in the maternal age of presenting pregnant women, an increase in the Asian and Middle Eastern populations and an increasing prevalence of obesity and overweight in women of child bearing age. From 2015 all pregnant women began to be tested with a glucose tolerance test, rather than first undergoing initial screening with a ‘glucose challenge test’ which was recognised to have a high false negative rate, failing to diagnose an estimated 20% of women. Asian-born women were found to be up to three times more likely than their English speaking country-born peers to have GDM74.

According to the National Diabetes Register, 7,405 women aged between 15–49 years began using insulin to treat GDM, representing almost one in four women diagnosed with GDM in 201575. The incidence rate was highest among women aged 30–34 (307 cases per 100,000 women aged 30–34), followed by those aged 35–39 and 25–29 years (238 and 194 cases per 100,000 women respectively)76.

Aboriginal women are also at a higher risk of developing gestational diabetes than non-Aboriginal women, particularly those who have a family history of GDM. Compared to other Australian women, Aboriginal women are more than 10 times as likely to have T2DM in pregnancy, and 1.5 times as likely to have gestational diabetes77.

Around 48,300 hospitalisations with GDM were recorded in Australia as the principal and/or additional diagnosis in 2015–16 (the majority recorded as an additional diagnosis, 46,000 or 95% of GDM hospitalisations)78. Clinicians advise that this data is an underestimation of the true extent of GDM in the community.

Figure 4Diabetes in NSW, by age and sex, 2017

3/ Diabetes picture of health

Source: Centre for Epidemiology and Evidence. Available at: http://www.health.nsw.gov.au/epidemiology/Pages/default.aspx

0510152025

16–24

25–34

35–44

45–54

55–64

65–4

75+

All ages

Males Females

2520151050

Percent of population

2.1

1.4

7

12.1

15.9

22.9

25.1

10.7

2.7

6

4.2

9.9

12.4

17.4

19

9.4

Canterbury Hospital Strategic Plan 17Diabetes Strategic Plan16

Figure 5Type 2 diabetes hospitalisations (principal and/or additional diagnosis), by age and sex, 2016–17

3.2.5/ People who are frail and elderly

In NSW, the overall diabetes prevalence is higher in men (10.1%) than women (7.8%) and increases for each decade of age, with rates among 75 years and over (21.5%) more than 2.7 times as high as for 45–54 year-olds (7.8%) and 1.3 times high as for 55–64 year olds79 (see Figure 5). The population of people aged 65 and over in the District has grown at a faster rate than the rest of the population, increasing 29% between 2006 and 201680.

In 2015–16, hospitalisation rates (as the principal and/or additional diagnosis) for T2DM increased with age, with the majority (87%) of hospitalisations occurring in those aged 55 years and over81. Hospitalisation rates were highest among males aged 85 and over (30,055 per 100,000) and females aged 75–8482 .

For elderly patients, diabetes is frequently one of a range of comorbidities contributing to an acute presentation with, for example, confusion, falls, gait disorders and vascular disease. Diabetes is a risk factor for dementia, which in turn can lead to poor diabetes management. Diabetes needs to be managed as part of a broader spectrum of disorder/illness. Self-management can be very challenging for elderly people, even with supportive carers.

Residential aged care facilities may not have the capacity required to deal with diabetes in frail residents, especially those with T1DM. The implementation of outreach teams to aged care facilities and utilisation of telehealth would improve the capacity to provide better care.

3.2.6/ People with mental health conditions

Mental health conditions are one of the most commonly reported chronic diseases in Australia (18%)83. One in four younger persons will experience a mental disorder and, for the population as a whole, life-time prevalence is almost one in two84. People with a mental illness are said to receive a ‘double whammy’. In addition to their psychiatric/psychological problems they are between two and five times more likely to demonstrate significant cardiometabolic risks such as diabetes, cardiovascular disease and obesity. If those with enduring psychotic and related disorders are considered, premature mortality stands at between 20–30 years of life lost for illnesses such as schizophrenia and about 10 years for persons with bipolar illness. It has been estimated that this group, sometimes referred to as serious mental illness (SMI) represents between 2.5 to 5% of the population.

The high prevalence of mental and physical health comorbidities is driven by clear biological and societal factors. With respect to diabetes, for example, a two-way causal connection has been hypothesised but remains controversial85. The risk of developing diabetes is disproportionately weighted against the younger mentally ill cohort with relative risk in the 20s being up to 10 times the population risk and only approaches unity in the late 60s. Overall, in the District’s population, the overall T2DM risk is three times the gender and age matched population risk.

The Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHIP) identified that 24.9% and 19.2% of people with severe mental illness were diagnosed with diabetes and pre-diabetes respectively. Further, many new diagnoses were made after many years of undetected diabetes, leading to the concern that this high-risk population is more likely to present with more advanced presentations of micro- and macrovascular related pathology.

3.2.3/ People with chronic diseases, complex conditions and related risk factors

Diabetes is associated with a range of health complications and chronic health conditions including cardiovascular disease, kidney disease, blindness and lower limb amputation86. Self-reported data indicates that approximately 68% of people who have diabetes also have cardiovascular disease and/or chronic kidney disease87. Diabetes contributed to 10% of all deaths in Australia (16,400 people), with the majority of these (72%) recording diabetes as an associated cause of death for cancer, coronary heart disease and stroke in 201588. In NSW, Aboriginal people experience higher prevalence of most chronic disease risk factors compared with non-Aboriginal people, and at younger ages.

Patients attending the tertiary and quaternary services of RPA and Concord Hospitals often have a significantly higher than average rate of diabetes and require specialised interventions. These complex patients not only require access to diabetes services but also access to other specialised, multidisciplinary services.

These chronic and complex patients include:

• Transplant patients • Cancer patients requiring

corticosteroids • Cystic fibrosis patients• Diabetes in young adults

(T1DM and T2DM)• Patients with severe mental illness

(SMI)• Patients with severe obesity • Patients with high-risk foot disorders

related to diabetes.

Source: AIHW analysis of the National Hospital Morbidity Database.

0

<25

25–34

35–44

45–54

55–64

65–74

75–84

85+

Males Females

0

Diabetes hospitalisations per 100,000 population

17

206

908

3,011

7,931

18,338

30,075

31,425

46

416

1,180

2,659

5,665

11,708

19,712

19,592

5,00010,00015,00020,00025,00030,000 5,000 10,000 15,000 20,000 25,000 30,000

3/ Diabetes picture of health

Diabetes Strategic Plan18 Diabetes Strategic Plan 19

4.1.4/ Chronic care

The Aged Care, Rehabilitation, General Medicine, Chronic and Ambulatory Care and General Practice (ACCR) service provides care coordination, care navigation and health coaching to patents with complex care needs and multiple comorbidities including diabetes. However, diabetes data is not collected separately. The Chronic Care service:

• Reviews patients to assess the impact of their social and psychological status on their ability to self-manage their health conditions

• Negotiates with patients and carers to establish agreed goals to optimise their health by implementing a sustainable management plan in consultation with treating medical teams and service providers

• Frequently identifies issues, such as medication mismanagement, multiple medical providers with limited communication, access to supportive services, complex treatment regimens requiring simplification to improve patient compliance which may lead to suboptimal glycaemic control, especially in those with T1DM.

4.2/ Sydney Local Health District diabetes services

4.2.1/ Royal Prince Alfred Hospital

RPA receives referrals of patients with complex diabetes and those with multiple diabetic complications from across NSW (as well as from other facilities in the District). In particular in the areas of diabetic foot disease, diabetes in pregnancy, oncology and post-transplant.

Inpatient endocrine beds are available for admissions as required.

4.2.2/ RPA Diabetes Centre

The RPA Diabetes Centre is an ambulatory care unit that operates on weekdays. All services are multidisciplinary. The key elements of the Chronic Care Model are: multidisciplinary team management, self-management, education and organisation of healthcare that facilitates the collection, documentation and evaluation of clinical outcomes.

The Diabetes Centre provides and coordinates a package of specialised services designed to replace traditional inpatient diabetes care. Services include: Initiation of insulin therapy and stabilisation of glycaemic control; Insulin pump therapy, CGM and ongoing management; T1DMs Service; Young Adult Diabetes Service; pre-pregnancy counselling and assessment for women with pre-pregnancy diabetes, T1DM, T2DM, Cystic Fibrosis–related diabetes, and impaired glucose tolerance (including women referred from fertility services for assessment) and management of diabetes in pregnancy; Postnatal GDM Service; HRFS; Assessment and management of complications for all types of diabetes; Diabetes and Liver/Transplant Service; and a limited inpatient service.

Outreach diabetes and endocrine services are provided to Far West NSW and Dubbo.

RPA provides the services of a specialist Endocrinologist for four hours per fortnight to be part of the Aboriginal Medical Service’s Endocrinology/Diabetes clinic in Redfern.

4.2.3/ Charles Perkins Centre

The Charles Perkins Centre has a Healthy Lifestyle and Diabetes Prevention service, an at-risk pregnancy clinic and two post-GDM clinics.

The RPA Diabetes Centre runs clinics for Diabetes/Pre-diabetes Liver and Youth Onset T2DM

• The Diabetes/Pre-diabetes Liver Clinic is for people with blood glucose abnormalities of pre- diabetes and T2DM. These people have a particularly increased risk of having more severe non-alcoholic fatty liver disease (NAFLD). This multidisciplinary clinic across RPA’s Endocrinology and Gastroenterology Departments facilitates targeted assessment of NAFLD in people with blood glucose abnormalities. This ambulatory clinic undertakes a comprehensive assessment with recommendations in follow-up treatment. It is not an ongoing treatment clinic but an assessment and treatment recommendation service, as well as a focal point for subsequent clinical research, and for health care professional education

• Young Adults Diabetes Service is a specialised multidisciplinary clinic for this high-risk population (including high-risk ethnic groups). This service runs fortnightly and establishes collaborations with youth services and genetic services.

4.1/ Prevention, Primary Care and Community Health

4.1.1./ Prevention and pre-diabetes

Pre-diabetes and Type 2 diabetes can be prevented or delayed in people by maintaining a healthy weight, regular physical activity, making healthy food choices, managing blood pressure, managing cholesterol levels and by not smoking. It is estimated that about 350,000 residents of Sydney Local Health District are at risk of diabetes and about 70,000 people are pre-diabetic. Pre-diabetes is a condition in which people have elevated blood glucose levels which are not yet high enough to be diagnosed as T2DM. Commonly people with pre-diabetes have no signs or symptoms.

Sydney Local Health District provides and supports a number of programs and services for the prevention of diabetes, such as:

• Get Healthy Service (Get Healthy Telephone Coaching Service, Get Healthy @ Work, Get Healthy in Pregnancy)

• General Practitioner (GP) Exercise Referral Scheme

• Heart Foundation Walking groups

• The Healthy Children’s Initiatives (Munch and Move, Live Well @ School, Go4Fun, Aboriginal targeted programs)

• Make Healthy Normal Campaign (social marketing and risk awareness)

• Health Food Environments (NSW Healthy Food and Drinks in Health Facilities Framework, Healthy School Canteens)

• Healthy Built Environment and Urban Development (Building Better Health, Healthy Urban Development Checklist).

4.1.2/ Primary care

Primary care is generally the first point of contact with the health service. It includes General Practice (GP), allied health services, community health and community pharmacy services. With rising demand for services and a shift towards providing care closer to home, primary care is increasingly at the forefront of delivering diabetes care.

Sydney Local Health District works closely with GPs along with other primary and allied health professionals. Typical primary care interventions may involve regular monitoring of a patient’s weight levels, blood levels, general health status, and more focused examinations of a patient’s eyes and feet. Where diabetes complications arise, patients are referred to endocrinologists, cardiologists, nephrologists, obstetricians and/or ophthalmologists. Some examples of primary care services provided within the District are:

• The District and CESPHN provide support and advice to assist practices in setting up diabetes related programs and resources (Diabetes toolkit for General Practice and Health Assessment for Diabetes Risk) to help prevent people from developing type 2 diabetes

• The District’s specialist diabetes services and CESPHN also provide educational to support to GPs and private allied health practitioners to ensure quality interventions

4/ Sydney Local Health District diabetes services

• Health Pathways is an online information portal to support GPs and health professionals at the point of consultation. It provides clinical decision support frameworks on how to assess and manage diabetes

• My Health Record is a secure online summary of an individual’s health information, providing a shared source of patient information that can improve care planning and decision making.

4.1.3/ Community health

Sydney District Nursing provides care for people either in their homes or at community-based clinics. A proportion of these patients have diabetes. These services also provide wound care, insulin administration and short form education and support. Aboriginal health workers provide a community support program.

Podiatry services are offered at Croydon and Marrickville Community Health Centres under the auspices of Sydney Local Health District‘s Podiatry services. A key aim of the service is to provide preventive care for people with diabetes with high-risk foot characteristics. Between 40–70% of the activity in these services is for people with diabetes and high-risk foot characteristics, including foot ulceration not requiring immediate referral to the High Risk Foot Service (HRFS). The podiatry services provided in the community work in close collaboration with the HRFS.

Diabetes Strategic Plan20 Diabetes Strategic Plan 21

4.3/ Sydney Local Health District diabetes activity

4.3.1 Diabetes Emergency Department (ED) activity

In 2015–16 there were 253 ED presentations with diabetes as the primary diagnosis across the District, compared with 147 in 2011–12 (see Figure 7). This equates to an increase of more than 70% in 5 years. In 2015–16, the majority of people (72%) presenting for diabetes at a Sydney Local Health District ED resided in Canterbury (n=59, 23.32%) followed by Marrickville (n=34, 13.44%) and Canada Bay (n=26, 10.28%)89.

4.3.2/ Inpatient activity and diabetes

In 2015–16 there were 722 hospitalisations with the primary diagnosis of DM in Sydney Local Health District90. This represents only 2.9% of all hospitalisations with a diabetes code. 97.1% of diabetes coded hospitalisations were as an additional diagnosis. The District had 25,284 hospitalisations coded with diabetes as an additional diagnosis in 2015–1691. Each year since 2012–13 the District has seen an increase in hospitalisations with diabetes coded as an additional diagnosis year on year, with a more than 30% increase in hospitalisations in 2016–17 compared to 2012–1392.

A recent one month snapshot of diabetes diet orders in the District found that there were 21,280 diabetic diets (out of a total 102,842) ordered across the District, equal to 20.7% of all diets93. Of these the majority (41.2%) were

ordered at RPA, followed by Concord (36.3%), Canterbury (12.3%) and Balmain (10.1%). Balmain ordered the greatest percentage of diabetic diets out of the total number of any diets ordered at 30.5%, followed by Canterbury (at 21.9%), Concord (21.6%) and RPA (18.2%).

Figure 6Presentations to SLHD Emergency Departments for diabetes (primary diagnosis), 2011–12 to 2015–16

Figure 7SLHD hospitalisations for diabetes (all diagnoses), 2011–12 to 2015–16

4/ Sydney Local Health District diabetes services

The Charles Perkins Centre also provides Endocrine support to the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) service. The ccCHiP service currently runs on two days of the week with one clinic at the CPC and one clinic at Concord Hospital to ensure that the ccCHiP service is accessible to patients throughout the District.

4.2.4/ Concord General Repatriation Hospital

Most patients are admitted through the ED with diabetic emergencies, hypoglycaemia or skin/bone infections (cellulitis, osteomyelitis). The majority of these patients are consultations where DM may not be the primary diagnosis.

Specialist Diabetes Dietitian services are available for adult patients with T1DM and T2DM under the care of Concord Hospital endocrinologists only. Three half day clinics are available weekly. Depending on priority, waiting times vary from one week to three months for appointments. Criteria to be seen by Specialist Diabetes Dietitians include T1DM and complex T2DM on insulin or sulfonylureas.

Long standing T2DM (no insulin or sulfonylureas) and newly diagnosed T2DM (no insulin or sulfonylureas) are recommended to liaise with GP for dietetic services though a chronic care plan. A very limited service is available in the half day general Dietitian outpatient clinic, which occurs monthly however the waiting list is extensive (currently a five month wait).

Outpatient services are provided by the medical team and consultants daily along with Diabetes Educators. The services encompass care of patients with T1DM (insulin pumps and continuous blood glucose monitoring) and complicated and complex T2DM, and twice weekly endocrinology support for ccCHiP. These services also provide medical support for the Gestational

Diabetes Clinic at Canterbury Hospital. The Rapid Response Service operates daily.

Diabetes and general endocrinology clinics operate daily. A Rapid Response Service weekly, run by the Diabetes Educators and Advanced Trainees occurs as required, ensuring that ‘urgent’ referrals are seen promptly.

4.2.5/ Canterbury Hospital

Canterbury has Endocrinology Staff Specialists (2 x 0.5 FTE).

The inpatient service is a consultative service. Patients are admitted under the General Medical physician on call and a referral is made to the Endocrine Staff Specialist as required.

Medical staff ensure patients are referred to the Diabetes Educator prior to discharge. The majority of patients seen are women with GDM and those with T2DM. The majority of patients

come from CALD backgrounds requiring regular utilisation of the interpreter service. The Diabetes Educator links, and has ties, with multicultural health workers to promote diabetes education.

Diabetes services include a General Endocrinology Outpatient service run by medical staff weekly, which sees patients with T1DM and T2DM, including pre-pregnancy counselling and planning in women with T2DM and other endocrinology issues. A significant number are follow-ups of previous hospital inpatients or ED presentations.

4.2.6/ Balmain Hospital

A Diabetes service is provided by the Geriatrician who is also an Endocrinologist and a Clinical Nurse Specialist in Diabetes. One weekly outpatient clinic is provided with additional support from an Advanced Trainee in Geriatric Medicine and Clinical Nurse Consultant/Diabetes Educator.

0

20

40

60

80

100

120

Canterbury Concord Royal Prince Alfred

2011/12

2012/13

2013/14

2014/15

2015/16

Emer

genc

y D

epar

tmen

t pr

esen

tatio

ns

Source: NSW MOH Clinical Services Planning Analytics (CaSPA). ED Activity Analysis Tool (EDAA) v16.0. ICD-10-AM codes included: E10–E14 and O24.

Source: HIE. ICD-10-AM codes included E10–E14 and O24. All records and all ages for patients attending a SLHD facility.

0

20

40

60

80

100

120

Canterbury Concord Royal Prince Alfred

2011/12

2012/13

2013/14

2014/15

2015/16

Emer

genc

y D

epar

tmen

t pr

esen

tatio

ns

Canterbury Concord Royal Prince Alfred

Hos

pita

lisat

ions

0

3,000

6,000

9,000

12,000

15,000

Balmain

Diabetes Strategic Plan22 Diabetes Strategic Plan 23

There are a number of issues related to capturing accurate NAP data for GDM and DM in pregnancy. This includes a different reporting approach changes to reporting across the District and underreporting of telephone consultations97. From July 2014 up to and including February 2015, a total of 4116 individual services were reported, averaging 515 per month98. RPA’s Women’s and Babies Ambulatory Service has seen an increase in diabetes activity overall, with the number of women attending the multidisciplinary Diabetes Antenatal Clinic increasing by 28% between 2012 and 201799. From 2012 to 2017 RPA’s GDM service patient number has increased by 155%100.

A number of issues have been identified, which impact the data quality and reporting of diabetes activity including:

• Limitations of the data collection in distinguishing diabetes services. For example, Diabetes patients may be seen as part of the Endocrinology Clinic but the activity may not be identified as Diabetes

4/ Sydney Local Health District diabetes services

Figure 8SLHD non-admitted occasions of service for diabetes, 2014–15 to 2016–17

Figure 9RPA Diabetes Centre activity for diabetes services, 2015 to 2017

Figure 10RPA Diabetes Centre service provision to women attending RPA Women’s and Babies Services, 2013–2017

Figure 11RPA Diabetes Centre, gestational diabetes activity, 2013–2017

4.3.3/ Diabetes non-admitted patient activity

The majority of diabetes-related non-admitted patient (NAP) activity in Sydney Local Health District occurred at specialist diabetes or endocrinology ambulatory services, with a much smaller proportion occurring at generalist outpatient clinics. Figure 9 significantly underrepresents the true diabetes activity by approximately 50% if a diabetes clinic provides patients with both specialist and nursing and or allied health care on the same day.

There are significant data collection and local facility reporting limitations negatively affecting data comparability, accuracy and completeness. Data from the RPA Diabetes Centre Annual Report 2017 suggests that NAP diabetes services have been increasing by 4% annually equating to approximately 700–850 additional services provided per year (Figure 10).

Canterbury Concord Royal Prince Alfred

Oca

ssio

ns o

f ser

vice

2013/14

2014/15

2015/16

Balmain0

3,000

6,000

9,000

12,000

15,000

Source: STARS94, 95, 96 data provided by facility data managers. Note that STARS data includes ‘in scope’ services only. *excludes diabetes in antenatal-related services

Source: RPA Diabetes Centre Annual Report 2017

Serv

ices

pro

vide

d2015

0

5,000

10,000

15,000

20,000

2016 2017

Source: RPA Diabetes Centre Annual Report 2017. Source: RPA Diabetes Centre CRS 2017. Data provided by RPAH Diabetes Centre Data

0

1,000

2,000

3,000

4,000

5,000

Serv

ices

pro

vide

d

2015 2016 20172013 2014

Women and BabiesPregnancy Diabetes Clinic

Diabetes GDM Education 5

Diabetes GDM Education Post Natal Group

Diabetes GDM Education Groupwith individual consultation

Diabetes GDM Education Start Insulin Group with individual consultation

Diabetes Pregnancy drop in

• Inconsistencies between facilities and services in capturing and reporting similar activity. For example, all facilities provide Diabetes Clinic services but the data reported may not be listed as a Diabetes Clinic, inconsistency in reporting of allied health data

• Changes to MoH reporting requirements, definitions and classification principles which impact on data collection, classification, reporting, trends and comparability across years

• Historic data reporting across facilities not meeting current MoH reporting requirements, such as the capture of 100% patient level data across all facilities and limited resources to implement this

• Use of multiple data sources (scheduling, service contact forms, CHOC forms, and aggregate data) to inform activity

• Need for a single interface such as STARS application to collate and summarise all non-admitted activity including out-of-scope activity (services and financial classes) to inform the breadth of activity provided and to enable consistent detailed reports.

In 2017 the MoH published a number of non-admitted data collection guidelines and information bulletins relating to establishment type definitions101, classification principles102 and reporting rules103 to enable health services to collect, classify and report non-admitted data in a consistent and comparable manner across the state.

2013

Unique patient numbers

Service events

Occasions of service

Number commencing insulin0

1,000

2,000

3,000

4,000

5,000

2014 2015 2016 2017

Diabetes Strategic Plan 25Canterbury Hospital Strategic Plan24

4.4/ Other Sydney Local Health District diabetes services

4.4.1/ Mental health

Sydney Local Health District provides the award-winning104 Living Well, Living Longer program and associated initiatives to improve the overall health of people living with mental illness. This service was built from the cardiometabolic clinic initiative termed ccCHiP (Collaborative Centre for Cardiometabolic Health in Psychosis).

The ccCHiP service provides a multidisciplinary clinic focusing on metabolic and cardiovascular risk factors in people living with mental illness. Each patient is seen by up to seven clinicians in an afternoon and the collaborative team formulate practical evidence-based action plans. The clinics are offered principally for people living in the community. A small liaison service also reviews inpatients.

Where necessary medical staff will follow-up complex patients in their own specialised clinics such as cardiology and diabetology to complete practical management plans for these patients. The core clinical team comprises psychiatrists, endocrinologists, cardiologist, clinical nurse consultant, dietitian and exercise physiologist who review family history, blood test results, and clinical indicators. The ccCHiP clinic also provides services for oral health and sleep medicine. Allied health members provide interventional clinics in the community that are linked to ccCHiP and the community teams.

This service is unique to Australia, in respect to the interdisciplinary service provided and the translational informatics systems used to support it.

All people with a mental illness are offered metabolic monitoring as metabolic syndrome is a precursor to diabetes and cardiovascular disease.

4/ Sydney Local Health District diabetes services

Figure 12Structure of ccCHiP services105

Community MHC

ccCH

IP

Heal

th li

tera

cy g

roup

-bas

ed

Chip lifestyle

Integrated EP/dietary group-based

GP/specialist interventional services

General physical exam,

EP screening

risk history

External and anamnestic

Slee

p, s

piro

met

ry,

body

com

posi

tion

TTE, PP doppler

Cardiology EEG,

Dietitian

Dentist

ccCHIP Consultant pool

Endocrinologist x 2Cardiologist

PsychogeriatricianPsycopharmacologist

Psychiatrist

EP = Exercise Psychologist

TTE = TransThoracic Echocardiogram

PP = Peripheral Pulse

This is provided every three months as part of the Mental Health Services Community Team. These activities include:

• Screening and monitoring using the NSW Health metabolic monitoring form and checking pathology blood results

• Detection by reviewing comorbid physical diagnoses identified on discharge summaries

• Initiation of treatment with medical team, GP, visit to ccCHIP inpatient or outpatient (ambulatory) clinic

• Ongoing management with psycho-education about diet and exercise

• Ensuring that all clients have a physical health check, see a dentist and have an ECG every 12 months

• Consumers who meet an escalation criteria are referred to ED or their nominated GP for follow-up

• Consumers who have had metabolic screening are offered referral to ccCHiP clinics for multidisciplinary screening and treatment planning.

Other associated initiatives for people with mental illness:

• Mental Health Shared Care In-reach Model. Consumer with a nominated GP has a shared care plan established and formally registered in the eMR.

• Specialist care referral. Improving access to specialist care such as endocrinology by maintaining working relationships between mental health services and other health experts and fast-track referral systems.

• GP co-location clinics. People with mental illness who do not have a nominated GP can find it difficult to access primary care services. These clinics are in place at Marrickville, Croydon and Redfern Community Health Centres.

4.4.2/ Aboriginal health

‘Closing the Gap’ in health outcomes and access to health services for Aboriginal people is a high priority for the District. In collaboration with the Aboriginal Medical Service (AMS) Redfern and CESPHN, Sydney Local Health District aims to provide a culturally safe and accessible Diabetes service to reduce health inequity towards Aboriginal people.

• Aboriginal Chronic Care services are provided in the community. Clinicians work with the AMS Redfern and GPs to follow-up patients at home and support their attendance at appointments

• Aboriginal Outreach Workers work with individuals and the community to promote good health and GP engagement

• Sydney District Nursing has expanded the 48 Hour Follow Up program to provide community support programs targeting Aboriginal patients with chronic disease (including diabetes).

• A Endocrinology/ Diabetes clinic has been established at the AMS in Redfern, RPA provides the services of a specialist Endocrinologist for this clinic

• An additional specialist Endocrinologist is available for consultation and advice to the AMS

• Cultural audit undertaken for all chronic disease outpatient units to improve the setting for Aboriginal patients

• Outreach clinics and telehealth services are provided to rural and remote communities, including Broken Hill in far west NSW.

Diabetes Strategic Plan26 Diabetes Strategic Plan 27

5.2/ Prevention and early diagnosis in high-risk groups

Early diagnosis is critical to reducing or preventing the long term impact of diabetes such as eye, kidney and circulatory diseases. Evidence-based education packages ensure people at risk of T2DM have the correct information to encourage screening, early diagnosis and self-management. Consideration and understanding of the impact of the social determinants of health such as health literacy, education level and socio-economic status can be used to improve compliance and health outcomes by simplification of medication regimes, referral to services for support and broadening the focus to include impacts of comorbidities on diabetes management.

Population and community-based health services and NGOs need to work in coordination with diabetes providers to identify vulnerable and high-risk individuals and communities. GP practices may need support in implementing risk assessment tools, strategies and measuring outcomes.

Blacktown Hospital’s Emergency Department conducted a pilot study to assess the efficacy of HbA1c testing to detect diabetes and pre-diabetes in an area of high diabetes prevalence. 27% and 38% of individuals screened as part of the study (n=1,267) were diagnosed with pre-diabetes and diabetes respectively and 32% of these individuals were unaware of their diagnosis107. This study demonstrates the number of people who are invisible to service.

5.3/ Care for people who already have diagnosed diabetes

People diagnosed with diabetes ideally should have a customised management plan outlining a coordinated approach to care. Education should include information about diabetes including its management, potential chronic complications as well as the associated acute medical problems. Screening, detection and optimal management of complications and medical and psychological problems associated with diabetes minimise the risk and impact of life-limiting outcomes.

The ACI Diabetes MoC (draft) recommends:

• Diabetes care is mostly managed in the primary health care setting via the patient’s GP with a GP coordinated multidisciplinary team, which includes dietitians, podiatrists and practice nurses who are responsible for setting patients’ targets

– Care plans developed by the GP facilitate subsidised visits to these services

– Escalation of patients who are not stabilised within the primary care context is facilitated

• Referral to specialist diabetes services from the primary care sector is required for people with T1DM, complex diabetes, diabetes in pregnancy (pre-existing diabetes and GDM), and young people with any type of diabetes

• Ongoing management of patients referred to tertiary/secondary diabetes care occurs with the aim of returning the patient, where possible, to the primary care sector with appropriate follow-up as soon as is practicable108.

The MoC recognises that most people can manage their diabetes themselves with support, dependent on the type and severity of their disease and the impact of lifestyle factors.

Specialist diabetes centres at RPA and Concord Hospitals provide co-ordinated, multidisciplinary ambulatory care for complex and high-risk patients. Research and education are integral parts of the care model, with a strong translational approach and outreach support.

Note: Women with pre-existing diabetes should be referred for pre-pregnancy assessment and counselling by a multidisciplinary specialist team. Referral should not be delayed until they are pregnant. This includes women who are being referred for IVF services.

The system aims of the ACI MoC (draft) can be summarised as:

• Increasing the capacity of GP coordinated multidisciplinary services to prevent and manage T2DM and its complications

• Developing an efficient interface between GP and community-based diabetes prevention and management services at the local level

• Enhancing service quality by increasing the use of guidelines, local protocols, service directories, registers, recall systems, electronic medical records (eMR) and patient-held management plans to ensure that all people with diabetes receive comprehensive, ongoing care

• Improving access to, and effectiveness of, specialist services in ambulatory and hospital settings to address specific problems, and for long-term management of non-complex T2DM to refer back to general practice.

5/ Diabetes models of care

Figure 13Community awareness and prevention of diabetes

5.1/ Community awareness and prevention in the general population

Population health strategies support healthy environments and lifestyle, increasing the community awareness of diabetes risk factors, and reducing the risk of developing diabetes.

The key principles of current diabetes models of care (MoC)as suggested by the ACI relate to diabetes prevention and management for T1DM, T2DM and GDM

1 Community awareness and prevention in the general population

2 Prevention and early diagnosis in high-risk groups (those at risk of diabetes and those who have diabetes but are undiagnosed)

3 Care for people who already have diagnosed diabetes:

Optimal and long term management

Early detection and optimal management of complications

Prevention and management of acute episodes

General population

Community awareness and prevention programs

GP coordinated services

Population-based

Government sponsored programs

NGO sponsored programs

Targeted high-risk groups

Post-GDM

Aboriginal people

CALD groups

Chronic diseases

Mental health

Women in pregnancy

Elderly and frail

Tertiary and quaternary populations

Identification of high-risk people by assessment

Opportunistic

Targeted

Adapted from ACI Endocrine Network: NSW MoC for people with DM106

Lifestyle modification

Delay and prevent the onset of diabetes

Regular diabetes assessment by GP

Early diagnosis T2DM

GP coordinated multidisciplinary care

These strategies focus on the value of a healthy lifestyle, an awareness of diabetes risk factors in the general population and target high-risk groups to ensure effective prevention and delay of T2DM. State-wide population health programs include the Get Healthy Telephone Coaching Service, Munch and Move in early childhood centres, Live Well @ School program,

Go4Fun targeting children aged 7–13 above a healthy weight, the Get Healthy @ Work programs, and Make Healthy Normal. Promoting a healthy urban environment is concerned with facilitating environments which promote healthy choices for consumers.

Diabetes Strategic Plan28 Diabetes Strategic Plan 29

5/ Diabetes models of care

Figure 15Initial and long term management of a proposed Diabetes Model of Care110

Person with diabetes

Adapted from ACI Endocrine Network: NSW model of care for people with Diabetes Mellitus111

Type 1 Diabetes Melitus Type 1 Diabetes Melitus(adult, paediatric, adolescent)

Type 1 and 2 in Pregnancy Gestational Diabetes

Type 2 in paediatrics, adolescent

Complicated Type 2

Type 2 Diabetes Melitus

GP Coordinated Multidisciplinary Team Management

GP Multidisciplinary Team

General Practitioner Credentialed Diabetes Educators

• RN Diabetes Educator• Dietician• Podiatrist• Exercise Physiologist• PharmacistOther Care providers:• Social worker• Psychologist• Dentist• Sleep specialist

GP review

Insufficiant behaviour change Treatment target not achieved

Insufficient management by the GP Coordinated Multidisciplinary Team

Persistent inadequate control Consider referal to Specialist Coordinated Multidisciplinary Team

Managed Care Plan

• Lifestyle target from annual cycle of care

• Behaviour and risk factors (smoking, physical activity, blood glucose, BP, lipids) coordinated by GP

• Blood glucose control identified by GP• Reduction in CVD risk

Treatment target achieved

Prevention, delay or slowing of complications

Specialist Coordinated Multidisciplinary Team Management (public or private)

Specialist Multidisciplinary Team

Endocrinologist Credentialed Diabetes Educators

• RN Diabetes Educator• Dietician• Podiatrist• Exercise Physiologist• PharmacistOther Care providers:• Social worker• Psychologist• Dentist• Sleep specialist

Feedback provided to GP

All care adapted for:

• Location• Cultural factors• Language• Aboriginality• High-risk groups• Vulnerable groups

Figure 14Movement of diabetes patients accessing services

Adapted from ACI Endocrine Network: NSW model of care for people with Diabetes Mellitus109

Ongoing care by a specialist

Ongoing care by Specialist Coordinated Team

Consider specialist referral

GP Coordinated Multidisciplinary Management

Prevention

• People with T1DM• Children or adolescents with diabetes of any type

• Youth onset T2DM• Diabetes in pregnancy including pre-existing or GDM

• Exacerbation of symptoms/complications listed below

• Failure to achieve glycaemic targets• Failure to respond to therapy

• Recurrent hypoglycaemia• Multiple drug intolerances/contradictions

• Development of complications• Hyperglycaemia during hospitalisation

• Suspicion of unusual variants such as LADA, MODY or secondary diabetes• Heavy proteinuria with short disease duration in the absence of other microvascular complications

• A new onset foot complication in diabetes such as a foot ulcer or bacterially infected foot• Diabetics with major psychological disorder

• Pre-diabetes

• Uncomplicated T2DM with uncomplicated risk factors• Patients meeting targets identified by GPs e.g. glycaemic control

• Newly diagnosed T2DM

5.4/ Optimal management of diabetes

Nationally and internationally there is increasing recognition of the need to provide integrated, person-centred health care across the continuum for people with chronic disease, including diabetes. This means that health care professionals and providers across primary, secondary and tertiary care need to collaborate as a team to provide care in accordance with the patient’s

needs, preferences and personal situation. A multidisciplinary approach involving partnerships between patients and clinicians and between primary, secondary and tertiary care is critical to supporting people with diabetes.

Optimal management of diabetes includes:

• Timely access and engagement of services for priority populations

• Enhanced coordination between all health care providers from primary

to tertiary level to optimise use of existing services and programs

• Communication between service providers to prevent inefficiency, duplication of services, errors and reduced quality of care

• Electronic communication between general practice and public hospitals, outpatient clinics, private specialists or allied health112.

6/ Diabetes strategic directions

Diabetes Strategic Plan30 Diabetes Strategic Plan 31

The key strategic directions for the prevention of diabetes include:

Embedding referral to state-wide Get Healthy programs into clinical services (eMR, surgical waitlists/preparation lists/rehabilitation, GHiP in ante-natal settings)

Further implementing Get Healthy@Work including through face-to-face brief health checks

Developing targeted prevention and screening opportunities, especially focused on high need groups such as Aboriginal communities, CALD communities, frail elderly and people with disability

Enhancing and building partnerships for prevention with:

CESPHN (GPs and other allied health workers)

Diabetes NSW & ACT (supporting diabetes literacy and management)

AMS Redfern

Across the District (clinical services, health promotion, multicultural health service, bilingual community educators)

Working in collaboration with other NGO and private providers to maximise opportunities for greater service investment and resource sharing

Influencing urban development and promoting a healthy built environment

The key strategic directions to improve diabetes care in General Practice, Primary Care and Private Allied Health include:

Expanding and developing awareness of HealthPathways

Improving information and transfer of care between LHD services and GPs/allied health

Supporting the implementation of electronic communication (My Health Record)

Focusing on system navigation for those less able

Further developing GP and private allied health continuing professional development (CPD)/education

Establishing a new system of GP affiliates to specialist Diabetes Centres with Continuing Professional Development, mentoring and referral protocols

Promoting referral to Get Healthy service as required

The key strategic directions to improve diabetic care in Sydney Local Health District community-based services include:

Establishing more specialist Registered Nurse positions to complement and expand generalist community nursing capability

Further educating staff on evidence-based wound care

Expanding the earliest detection capability through AUSDRISK screening and early referral

Ensuring there is a shared eMR

Promoting improved services targeting residential aged care facilities

Further developing the concept of community-based chronic care workers to cover diabetes

The key strategic directions to support improvements in Specialist Diabetes Centres include:

Ensuring quality staff and appropriate skill base

Ensuring data quality to allow for monitoring and planning

Resourcing services to minimise unnecessary hospitalisations and to streamline care

Providing Rapid Access Clinics to further reduce unplanned admissions

Providing post-discharge clinics for preventing unnecessary re-admission and for ensuring safe community transfer of care

Cultural safety programs for health professionals to ensure the cultural, religious and linguistic appropriateness of services and education

Implementing new ambulatory technologies such as remote monitoring of complex patients

The key strategic directions to improve care of diabetes in pregnancy include:

Ensuring data quality to allow for monitoring and planning

Undertaking improved risk stratification, ensuring high-risk patients receive adequate services

Implementing new technology where appropriate e.g. smart meters, apps, continuous glucose monitoring

Pre-pregnancy planning and post-natal lifestyle change and support

Implementing group support programs

Providing web-based GDM information

The key strategic directions to improve inpatient care include:

The development of standardised identification and screening processes for new diabetes admissions (both unplanned and planned) through HbA1c screening

The ascertainment of glycaemic control status of all patients with known diabetes, again through HbA1c screening

The establishment of Inpatient Diabetes Teams comprising of senior medical, registrar and Clinical Nurse Consultant staff to manage the newly diagnosed and poorly controlled patients with diabetes identified through the HbA1c screening

The implementation of networked glucose meters into inpatient care to provide automated identification of patients with unstable diabetes, high blood glucose levels or hypoglycaemia

The implementation of standardised practical insulin prescription and administration guidelines in non-critical care settings

The development of improved diabetes assessment, management and prescribing capability in general medical and surgical staff, including improving the use of the eMeds management module for diabetes

The improvement of data quality including better capture of diabetes codes

Better co-ordination and transfer of care between wards and ambulatory care to facilitate discharge and reduce patient length of hospital stay

The establishment of Rapid Access Diabetes Services (RADS) utilising the inpatient teams to improve continuity of care, avoid unnecessary admissions and reduce readmission rates

In the longer term, the adoption of technology to optimise glycaemic control and decrease patient length of hospital stay

Strategies and clear goals for special needs groups such as frail elderly, CALD, Aboriginal patients, people with disability, chronic and complex patients and people with mental health issues

Establish strategies for inpatients not under the care of an Endocrinologist, including consultation, education and training

Diabetes Strategic Plan 33Canterbury Hospital Strategic Plan32

The success of this plan rests with the development of implementation groups:

• Data Governance

• Outpatients, Community, Primary Care and Prevention

• Diabetes in Pregnancy

• LBVC Inpatient Management of DM.

These groups will report to the Diabetes Action Plan Steering Committee, LBVC Committee, and the Chief Executive. An annual report on overall implementation of the Plan will be provided to the District’s Clinical Quality Council.

7/ Next steps

7.1/ Monitoring and evaluation

The Plan will be monitored and evaluated regularly against the strategic action plan. The Diabetes Action Plan Steering Committee will oversee the four Implementation Groups and the ACI’s LBVC Monitoring and Evaluation plans including inpatient management of diabetes mellitus113 and Diabetes High Risk Foot Services114. A Self-Assessment Tool115 developed by the ACI will enable the District to measure performance against key metrics of the ACI Diabetes MoC.

Figure 16Leadership and governance structures for Diabetes

Chief Executive

LBVC Committee SLHD Diabetes Action Plan Steering Committee

LBVC Inpatient Management of DM

Data Governance Outpatients, community, Primary Care and Prevention

GDM and DM in Pregnancy

MoC

Identification and screening processes

Standardised policies and documents

Referal criteria and formatted pathways

Education, training and research

Partnerships and community pathways

Ensure data integrity

Standardise data reporting

Optimise data quality, comparability and completeness

MoC

Referal criteria and formatted pathways

Education, training and research

Partnerships and communication pathways

Prevention programs

MoC

Standardised policies and documents

Referal criteria and formatted pathways

Education, training and research

Evaluation resources

Partnerships and communication pathways

Implementation Groups

The key strategic directions to improve High Risk Foot Services (HRFS) include:

Supporting the further development of the podiatry workforce

Developing formal agreements with specialist departments to provide equitable access to consultation and integrated care for people with diabetic foot complications

Collaborating with CESPHN to support programs to improve timely and equitable access to HRFS via referrals from primary care

The key strategic directions to improve diabetic care for people with severe mental illness include:

Enhancing Sydney District Nursing to support complex medication and lifestyle management

Developing the expectation that staff in mental health will be trained to provide integrated physical and mental health care

Instigating screening for diabetes at all point of care contacts – GP, community health, ambulatory and inpatient care

Working towards transfer of care, being to the patient themselves

The key strategic directions to improve diabetes care for patients with diabetes in selected tertiary and quaternary services include:

Ensuring adequate diabetes specialist team support (endocrine staff, diabetes educator staff) for ambulatory care and during times requiring inpatient care

Ensuring interdisciplinary team management to enable early detection of diabetes through timely screening and then prompt treatment of new onset diabetes

Ensuring systems to detect and promptly treat diabetes induced by transplantation in an interdisciplinary team-based setting

The key strategic directions to improve consumer involvement include:

Continuing to support diabetes-related NGOs and community groups

Continuing to support community-based self-management programs for people living with diabetes

Ensuring the involvement of consumers and community members in service planning, delivery and evaluation

6/ Diabetes strategic directions

Diabetes Strategic Plan34 Diabetes Strategic Plan 35

Goals Strategies Responsible officer(s)

Primary care, earliest intervention and self-management

continued

Provide ongoing professional education and training (GPs, medical and other health professionals) on contemporary diabetes management

SLHD

CESPHN

Implement appropriate referral pathways between general practice, community based, inpatient and/or ambulatory services and specialist Diabetes Centres for diabetes prevention, management and its complications (e.g. diabetic foot, diabetes in pregnancy)

SLHD

CESPHN

Develop strong networks between general practice, community-based diabetes prevention (including chronic care) and diabetes specialty services to improve communication and provide specialist support

All

Develop web-based information/interactive portals targeting women diagnosed with GDM, people with T1DM and people with T2DM

SLHD

Service development

Implement the SLHD Diabetes MoC. Core components of such a model include: Clinical Director Endocrinology

Inpatient Diabetes Teams

Triaging and Rapid Access Diabetes services

Diabetes discharge clinics

High Risk Foot Services

Chronic Care Services

Diabetes on admission

Diabetes in pregnancy services

Special provisions for at risk tertiary and quaternary service populations (e.g. transplant patients with DM, cancer patients on steroids who develop DM, cystic fibrosis patients with DM, Type 1 DM and young adults with Type 2 DM)

Standardise the identification, screening (HbA1c) and risk stratification processes for admissions (planned and unplanned) and community encounters (e.g. inclusion of HbA1c on the Recommendation for Admission (RFA) form as part of routine pre-op blood tests taken at Pre-Admission Clinic with action plan based on the result)

Clinical Director Endocrinology

SLHD Community Health

Sydney District Nursing

Review, standardise and implement District-wide policies, guidelines, procedures, protocols in the management of diabetes including insulin prescription and administration, people with diabetic foot disease and diabetes in pregnancy

Clinical Director Endocrinology

The following action plan was developed in alignment with the goals of the Australian National Diabetes Strategy 2016–2020116 (ANDS) and the NDPF 2016117, ACI’s LBVC118 and Diabetes MoC119 and clinical consultation:

Goals Strategies Responsible officer(s)

Prevention and health promotion

Continue to implement local population-based state-wide prevention programs: SLHD Population Health

Healthy Children Initiative (Munch and Move, Live Life Well @ School, Go4Fun, Aboriginal-targeted programs

Get Healthy services (Get Healthy Telephone Coaching Service, Get Healthy @ Work, Get Healthy in Pregnancy)

Social marking and risk awareness (e.g. Make Healthy Normal campaign)

Healthy environments:

• Food environments (NSW Heathy Food and Drinks in Health Facilities Framework, Healthy School Canteens)

• Built environment and urban development (Building Better Health, Healthy Urban Development Checklist)

Promote and further develop the reach of culturally appropriate prevention programs for SLHD priority populations

SLHD Population Health

Primary care, earliest intervention and self-management

Increase the capacity of General Practice to prevent and manage type 2 diabetes and its complications and promote patient self-efficacy/management through:

SLHD Diabetes Services

CESPHN

Establishing a program of GP-affiliates in collaboration with CESPHN

Supporting a strong CPD program with CESPHN

Developing, implementing and evaluating diabetes-related Health Pathways

Identifying and referring high risk patients (with comorbidities or difficulty managing their health) to the Chronic Care services

Improving IT and communication between general practice and public hospitals, outpatient clinics, Diabetes Centres, private specialists and allied health (e.g. HealtheNet)

Further develop targeted Aboriginal diabetes and related health programs including: SLHD in partnership with Redfern AMS and Sydney Metropolitan Local Aboriginal Health Partnership

Diabetes and related clinics provided through Redfern AMS

Aboriginal staff in community based chronic care and diabetes services

Aboriginal maternity service workers

Aboriginal health workers

Health promotion programs targeting Aboriginal communities

8/ Diabetes Action Plan

Diabetes Strategic Plan36 Diabetes Strategic Plan 37

Population Health

• The Health Promotion Unit (HPU) addresses factors that contribute to diabetes, through the early years intervention ‘Healthy Beginnings’ in partnership with Child and Family Nurses. The aim is to prevent obesity through promoting breastfeeding, appropriate introduction of solids, tummy time, and screen time for 0–2 year olds (SLHD and TRG covers 4 LHDs).

• HPU delivers programs from the Healthy Children’s Initiative (HCI) in Early Childcare Education settings (Munch and Move) and Primary Schools (Live Life Well @ School), which promote healthy eating and active living. In High Schools two programs promoting healthy lifestyle have been trialled. Students as Lifestyle Activists (SALSA) in partnership with Western Sydney Local Health District and University of Sydney and Football United (FUn) in partnership with UNSW. HCI are LHD-wide, while SALSA and FUn target high schools in disadvantaged areas, including Catholic schools.

• The HPU recruits and coordinates the Go4Fun program which is aimed at children aged 7–13 who are above a healthy weight. HPU runs three programs per term, targeting areas of disadvantage (e.g. low socio-economic status/high CALD).

• The HPU runs an Aboriginal specific Go4Fun program run in collaboration with Aboriginal Community organisation targeting healthy eating, healthy lifestyle and exercise.

• The HPU promotes the state-wide Get Healthy Service, which focuses on goal setting with a telephone coach. The HPU has also been working on a partnership project with South Eastern Sydney Local Health District HPU funded by the Office of Preventative Health in promoting the Get Healthy Service for Chinese speaking communities.

• The HPU actively promotes active transport to workplace through the Get Healthy at Work initiative. In addition, HPU provides funding support to an NGO (SHARE) to provide physical activity programs to older people. While this might not prevent diabetes, remaining active in later years is important for many reasons.

• The Multicultural Health service, within Population Health, offers physical activity programs for CALD people at Marrickville, some of whom have diabetes. A Healthy Eating program (designed by Health Promotion) is also conducted. The Arabic Weight Project is provided in collaboration with South Western Sydney Local Health District and targets Arabic speakers who have diabetes.

Appendix A/ Other diabetes services in Sydney Local Health District

• The Multicultural Health Service organises programs for GDM and Diabetes in collaboration with Diabetes NSW and Diabetes Educators, mainly at Canterbury. These target Chinese, Bangladeshi and Rohingyan mothers with GDM in collaboration with Canterbury Hospital. Ongoing education groups include Arabic Mothers Group, older Greek (over 50) groups, Turkish Women’s Group, Multicultural Gentle Exercise classes, and Vietnamese exercise and physical activity groups.

Community-based services

Chronic Care

• The ACCR Chronic Care Team utilises an integrated, patient centred model of care that addresses the person’s health issues, psychosocial issues and the impact of the social determinants of health on their ability to manage their health. Patients seen often have very complex psycho-social issues and are at risk of poor health outcomes and hospitalisation.

• The service provides care coordination, care navigation, health coaching and education for people with chronic disease (primarily with a complicated medical history that could include diabetes, COPD, health failure, and coronary heart disease). Patients are referred to the service or identified by the team as they are often frequent presenters to ED and hospital.

• The clinicians work with the patient, carers, health services and primary care to achieve long term sustainable solutions to address the issues impacting the patient’s capacity to manage their health. This integration of care improves patient outcomes and ultimately can reduce demands on acute services.

• The service is based at RPA but provides services across Sydney Local Health District and is primarily a home visiting service.

• Specific Aboriginal Chronic Care services are provided in the community and clinicians work with the Redfern Aboriginal Medical Service (AMS) and GPs to follow up patients at home and support their attendance at appointments. Aboriginal Outreach Workers work with individuals and the community to promote good health and GP engagement.

Goals Strategies Responsible officer(s)

Service development

continued

Improve Diabetes data collections, in collaboration with the SLHD Performance Unit, through ensuring:

SLHD Performance Unit

SLHD Diabetes Services

Electronic capture of all diabetes data

Standardised data reporting to reflect service utilisation

Optimised data quality, accuracy, comparability and completeness

Data is readily available in the electronic medical record (and able to be analysed)

Assess resources for diabetes (including in pregnancy) services to ensure high quality healthcare provision across the continuum of care, including:

Sydney District Nursing

SLHD Clinical Stream Director (Chronic Care)

Workforce (clinical and non-clinical) (e.g. acute care staff, administration, Nurse Practitioners in SDN)

Infrastructure (e.g. tele-health, telemedicine)

System capacity building

Enhance and build partnerships with general practice, community, SLHD and relevant parties to ensure seamless communication/transfer of care (e.g. Collaborate with Diabetes NSW to maximise NDSS program for patients living with DM).

All

Utilise technology for: SLHD

Optimal and timely service provision

Patient care (including decision support tools, embedding referral to state-wide programs into eMR)

Communication (e.g. use eMR to support communication and continuity of patient care)

Research

New technologies (e.g. smart glucose meters, mobile apps, continuous glucose monitoring (CGM) sensors), including the impact on staff of implementing such technology

Develop linguistically and culturally relevant and accessible diabetes programs and services in consultation with CALD communities

Population Health

Research Support expanded research in Diabetes to ensure evidence-based care and the active translation of research into clinical practice

SLHD

Sydney Research

University of Sydney

Sydney Health Partners

Note: High Risk Foot Service action items will be overseen by the High Risk Foot Service Committee.

8/ Diabetes Action Plan

Canterbury Hospital Strategic Plan 39Diabetes Strategic Plan38

Women’s and Babies RPA

• All inpatient women with DM or endocrine issues and pregnancy (of any kind including antenatal, peripartum and postpartum) are actively seen and managed by the Endocrinology team on a daily basis or more often as required. This includes inpatients who are being induced and those who are inpatients for other reasons such as placenta praevia. All women with diabetes in pregnancy (including GDM) are admitted if they require antenatal corticosteroids.

• Ambulatory care provide initial GDM education via an endocrinologist, diabetes educator and dietitian, mainly in a group setting.

• The multidisciplinary co-located Antenatal Diabetes Clinic is provided once a week for women with pre-GDM and those with GDM. This clinic is serviced by obstetricians, midwives, endocrinologists, diabetes educators and dietitians. Antenatal beds are utilised as required.

• The Diabetes in Pregnancy clinic runs as a single booking for the multidisciplinary clinic. Women with GDM are seen in groups for initial education carried out by the diabetes educator and dietitian.

• Weekly group sessions provide instruction on insulin commencement for women with GDM.

• Stabilisation of diabetes with insulin dose adjustment is also undertaken outside scheduled clinics via phone or email contact between the women with diabetes and the diabetes centre staff.

• A small ‘low-risk’ clinic predominantly midwife-run (specific staff have been upskilled) with an Obstetric Resident/Registrar is run weekly.

• Breastfeeding classes are run weekly for women with GDM/pre-diabetes.

• Postnatal GDM services are mainly in a group setting and now held in CPC once a week.

• Women with pre-gestational T1DM return post-partum to their usual specialist diabetes care provider (public or private) which may include the RPA Diabetes Centre.

• Women with pre-gestational T2DM return post-partum to their usual specialist diabetes care provider (public or private) which may include the RPA Diabetes Centre or the Young Adult Diabetes Service or to their primary care provider with the level of complexity of the diabetes determining the appropriate pathway.

• Aboriginal specific midwife – early prevention program.

Dietitians

• Dietitians provide both individual and group nutritional care services for adult patients with T1DM, T2DM and GDM at RPA through several clinical streams.

• Newly diagnosed youth-onset T2DM are a growing patient group that are prioritised for urgent appointments.

• Newly diagnosed T1DM patients and women who are newly pregnant with pre-existing DM are seen urgently.

Occupational Therapy

• Patients with a diagnosis of DM or associated complications are referred to Day Hospital Occupational Therapy by the Geriatrician or Rehabilitation consultant/team. Occupational Therapy services with the Day Hospital clinic are part of a multidisciplinary team focus/model of care. Clients are seen for a variety of aged and rehabilitation related diagnosis.

Physiotherapy

• RPA physiotherapy does not provide diabetes-only services.

• Exercise plays an important role in DM. Physiotherapists (as well as exercise physiologists) provide exercise prescription and programs for people with chronic diseases, promote self-management practices and assist with the management of diabetes complications.

Appendix A/ Other diabetes services in Sydney Local Health District

Community Health

• Community Health through Sydney District Nursing currently provides health services for people with diabetes relating to case management of wound care, short term education on insulin administration (up to two weeks), and diabetes screening using the AUSDRISK tool on patients registered with the service.

• Aboriginal Health Workers under the 48 Hour Follow-up program also provide community support programs targeting Aboriginal patients with chronic disease, including diabetes.

• Aboriginal specific walking group in the Redfern area.

Allied Health Services

Nutrition and Dietetics

• Dietitians and Dietitian Assistants provide this service. Between 18% (RPA) and up to 31% (Balmain) of patient diet orders include a ‘diabetic diet’. The Dietitian Assistants form the bulk of these services and see patients daily to assist with appropriate menu selection. Dietitians may provide dietary advice to manage DM.

Occupational Therapy

• Admitted patients with a diagnosis of DM or associated complications are seen by the inpatient Occupational Therapists in the acute/sub-acute wards when an online referral is received from the treating geriatric teams.

• The patients referred are provided a general Occupational Therapy service to assess their current function and provided with discharge education and planning.

Physiotherapy

• The Sydney Local Health District Physiotherapy Service does not provide diabetes-only services.

• Exercise plays an important role in DM. Physiotherapists (as well as exercise physiologists) provide exercise prescription and programs for people with chronic diseases, promote self-management practices and assist with the management of diabetes complications.

Podiatry and High Risk Foot Services

• General outpatient podiatry services are available for patients at increased risk of developing diabetes-related foot disease with facilities to manage significant foot deformity and the aged and frail. Services are located at Concord, RPA, Canterbury and Balmain Hospitals as well as Marrickville and Croydon Community Health Centres.

• There are two HRFS managing foot ulcers below the ankle where patients are ambulant and wounds non-palliative:

– RPA podiatrists work within the Diabetes Centre as part of a multidisciplinary team that includes an orthopaedic surgeon. The intake criteria are: infection, Charcot neuroarthropathy and foot ulcers below the ankle. Patients must have DM and live within the District. Rural patients without a local HRFS are also accepted

– At Concord, the HRFS is managed by the podiatry department as part of a multidisciplinary team in consultation with both Endocrinology and Vascular departments.

• Balmain Hospital: An enhancement of 0.5 FTE Podiatrist will be required to provide non-admitted and admitted services.

• Canterbury Hospital has no specific podiatry service for diabetes, however, people with diabetes are a main target group and people with diabetes and foot complications are given priority for ongoing care. There is no HRFS.

• Concord Hospital has a non-admitted podiatry service and HRFS in operation.

Royal Prince Alfred Hospital (RPA)

• Current practice is for inpatient diabetes care to be managed by the treating team. The treating team can refer via the Endocrinology Registrar for advice and consultation on patients as required. Indications for referral are listed on the ACI Thinksulin app and include pregnancy, T1DM, insulin pump patients, transplant patients, Cystic Fibrosis-related diabetes and complex T2DM.

• Current inpatients under the Endocrinology team will be very complex and/or have diabetic emergencies.

Diabetes Strategic Plan40 Diabetes Strategic Plan 41

1 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

2 Bach, LA, Ekinci, EI, Engler, D, Gilfillan, C, Hamblin, PS, MacIsaac, RJ, Soldatos, G, Steele, C, Ward, GM & Wyatt, S 2014. The high burden of inpatient diabetes mellitus: The Melbourne Public Hospitals Diabetes Inpatient Audit. Medical Journal of Australia, vol. 201, no. 6, pp. 334–338.

3 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Diabetes prevalence in adults. Sydney: NSW Ministry of Health. Available at: http://www.healthstats.nsw.gov.au/Indicator/dia_prev_age/dia_prev_lhn?&topic=Diabetes&topic1=topic_dia&code=dia%5b_.

4 Commonwealth of Australia 2015. Australian National Diabetes Strategy 2016–2020. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/Australian%20National%20Diabetes%20Strategy%202016-2020.pdf.

5 NSW Ministry of Health 2016. NSW Diabetes Prevention Framework. Available: http://www.health.nsw.gov.au/heal/Publications/Diabetes-Prevention-Framework-Paper.PDF.

6 Sydney Local Health District. Clinical Stream Position Paper: Endocrinology, Metabolism and Andrology. Available: https://www.slhd.nsw.gov.au/planning/pdf/Position_Paper_Endocrinology.pdf.

7 Sydney Local Health District. Aged Health Care, Rehabilitation, General Medicine, Chronic and Ambulatory Care and General Practice Clinical Stream: Aged Health, Chronic Care Rehabilitation and General Medicine (ACC&R). Available: https://www.slhd.nsw.gov.au/planning/pdf/ACCR_Clinical_Stream_Position_Paper.pdf.

8 Commonwealth of Australia 2015. Australian National Diabetes Strategy 2016–2020. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/Australian%20National%20Diabetes%20Strategy%202016-2020.pdf

9 Commonwealth of Australia 2015. Australian National Diabetes Strategy 2016–2020. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/Australian%20National%20Diabetes%20Strategy%202016-2020.pdf

10 Australian Health Minister’s Advisory Council 2017. Diabetes in Australia: Focus on the future – The Australian National Diabetes Strategy 2016–2020 Implementation Plan, developed in partnership with the Australian Government and all state and territory governments. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/FINAL%20-%20Jan%202018-%20PDF%20%20-%20Implementation%20Plan%20-%20Diabetes%20Australia%20Focus.pdf

11 NSW Ministry of Health 2014. NSW State Health Plan: Towards 2021. Available: http://www.health.nsw.gov.au/statehealthplan/Publications/NSW-state-health-plan-towards-2021.pdf

12 NSW Ministry of Health 2013. NSW Healthy Eating and Active Living Strategy: Preventing overweight and obesity in New South Wales 2013-2018. Available: http://www.health.nsw.gov.au/heal/Publications/nsw-healthy-eating-strategy.pdf

13 NSW Ministry of Health 2012. NSW Aboriginal Health Plan 2013-2023. Available: http://www.health.nsw.gov.au/aboriginal/Publications/aboriginal-health-plan-2013-2023.pdf

14 NSW Ministry of Health 2012. NSW Tobacco Strategy 2012–2017. Available: http://www.health.nsw.gov.au/tobacco/Publications/nsw-tobacco-strategy-2012.pdf

15 NSW Ministry of Health 2016. NSW Diabetes Prevention Framework. Available: http://www.health.nsw.gov.au/heal/Publications/Diabetes-Prevention-Framework-Paper.PDF

16 NSW Ministry of Health 2016. NSW Diabetes Prevention Framework. Available: http://www.health.nsw.gov.au/heal/Publications/Diabetes-Prevention-Framework-Paper.PDF

17 NSW Ministry of Health 2015. NSW Ministry of Health: Our Structure. Available: http://www.health.nsw.gov.au/about/nswhealth/Pages/structure.aspx.

18 Agency for Clinical Innovation 2016. ACI Nutrition Network – Diet specifications for adult inpatients – Diabetes – standard. Available: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/342742/ACI_DIET_SPECIFICATION_Diabetes_FINAL_2-12-16.PDF.

19 Agency for Clinical Innovation 2016. ACI Nutrition Network – Diet specifications for adult inpatients – Diabetes – Higher energy. Available: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/342743/ACI_DIET_SPECIFICATION_Diabetes_Higher_Energy_FINAL_22-11-16.PDF.

20 Agency for Clinical Innovation 2016. ACI Nutrition Network – Diet specifications for adult inpatients – Diabetes in pregnancy. Available: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/342744/ACI_DIET_SPECIFICATION_Diabetes_in_Pregnancy_FINAL_22-11-16.PDF.

21 Agency for Clinical Innovation 2018. Leading Better Value Care Program. Available: http://www.eih.health.nsw.gov.au/lbvc/about/leading-better-value-care-program.

22 Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

23 Royal Prince Alfred Hospital, Sydney Local Health District 2016. Guideline: Women and Babies: Neonatal Hypoglycaemia- Prevention and Management, RPAHHH_GL2016_032. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/RPAHH/RPAHHH_GL2016_032.pdf.

24 Canterbury Hospital, Sydney Local Health District 2014. Guideline: Hypoglycaemia in the Newborn, CANT_PD2014_MP370. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Canterbury/CANT_PD2014_MP370.pdf.

25 Royal Prince Alfred Hospital, Sydney Local Health District 2011. Policy Directive: Women and Babies: Diabetes in Pregnancy Protocol, RPAHHH_PD2011_046. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/RPAHH/RPAHHH_PD2011_046.pdf.

26 Royal Prince Alfred Hospital, Sydney Local Health District 2015. Guideline: Women and Babies: Diabetes Management Guidelines for Intrapartum and Postpartum Care in Pregnancy Complicated by Gestational Diabetes and Pre-Gestational Diabetes, RPAHHH_GL2015_015. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/RPAHH/RPAHHH_GL2015_015.pdf

27 Canterbury Hospital, Sydney Local Health District 2014. Policy Directive: Diabetes: Intrapartum and early postnatal care of pregnant women with, CANT_PD2014_MP120. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Canterbury/CANT_PD2014_MP120.pdf.

28 Balmain Hospital, Sydney Local Health District 2015. Policy Directive: Management of Hypoglycaemia, BH_PD2015_N.015. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Balmain/BH_PD2015_N.015.pdf.

29 Canterbury Hospital, Sydney Local Health District 2013. Procedural Guideline: Guidelines for Inpatient Management of Hypoglycaemia, CANT_PD2013_CLIN049. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Canterbury/CANT_PD2013_CLIN049.pdf.

30 Concord Repatriation General Hospital, Sydney Local Health District 2017. Guideline: Guideline for Inpatient Management of Hypoglycaemia, CRG_GL2017_9052. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Concord/CRG_GL2017_9052.pdf.

31 Community Health, Sydney Local Health District 2017. Procedure: Blood Glucose Monitoring and Management of Hypoglycaemia in Sydney District Nursing (SDN), CH_SLHD_PD2017_N009. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Community%20Health%20SLHD/CH_SLHD_PD2017_N009.pdf.

32 Concord Repatriation General Hospital, Sydney Local Health District 2015. Procedural Guideline: Diabetic Ketoacidosis (DKA): Procedural Guideline (Adults), CRG_PG2015_9102. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Concord/CRG_PG2015_9102.pdf.

33 Royal Prince Alfred Hospital, Sydney Local Health District 2016. Guideline: Intensive Care Services: Diabetic Ketoacidosis Guideline, RPAHHH_GL2016_028. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/RPAHH/RPAHHH_GL2016_028.pdf.

34 Balmain Hospital, Sydney Local Health District 2016. Procedure: Blood Glucose Monitoring and Insulin for Inpatients, BH_PCP2016_N.006. Available: http://slhd-intranet.sswahs.nsw.gov.au/SSWpolicies/pdf/Balmain/BH_PCP2016_N.006.pdf.

35 Department of Endocrinology, RPAHHH 2014. Triple B (Basal-Bolus-Booster) Protocol for In-Hospital Subcutaneous Insulin Treatment. Available: http://slhd-intranet.sswahs.nsw.gov.au/RPAHH/drugcomm/pdf/Clin.Guidelines/CG14a.pdf.

References

Concord Repatriation General Hospital

• Inpatient endocrinology/diabetes beds are co-located with renal medicine.

• There are direct admissions from consultants, usually with complications related to DM such as cellulitis. Most admitted patients are frail and elderly.

• Consultant on-call and advanced trainees assist with the management of diabetes patients admitted under other specialist teams with around 5–10 consultations per day.

• Provision of rapid access for high-risk patients five days a week, such as diabetes patients presenting to ED (referred by GPs, self-referred or other service providers). Patients are seen within 24 hours.

• The HRFS is staffed by an endocrinologist twice a week, ensuring medical support for imaging, antibiotics and the general care of these complicated patients.

• The ccCHiP service operates two days a week, with one clinic at Concord Hospital and the other at Charles Perkins Centre.

• There are also insulin titration clinics, continuous glucose monitoring (CGM) and insulin pump clinics during the week.

• The ccCHiP and diabetes clinics provide a unique model of cross disciplinary (psychiatrist, cardiologist, endocrinologist, dentist and allied health) and multidisciplinary care respectively (endocrinologist, diabetes educator, dietitian and exercise physiologist).

• Metabolic rehabilitation clinic for morbidly obese patients with diabetes is run weekly by a dedicated multidisciplinary team (endocrinologist, bariatric surgeon, advanced trainee, nurse practitioner, dietitian, exercise physiologist and psychologist).

Canterbury Hospital

• There are two sessions of combined Endocrinology/Antenatal clinics one day per week delivered by one Endocrinologist, one endocrinology advanced trainee (from Concord for one session only), one certified diabetes educator, one diabetes educator (credentialing) and one dietitian. One is a group education session and clinic for insulin.

• Allied health services associated with clinics include:

– Diabetes educator provides one session per week in the Diabetes Clinic for diabetes patient education, insulin and other injectable medication use, stabilisation of insulin dose, and review of hospital discharge and other urgent patients

– Podiatry provides service for active ulcers referred to by Concord/RPA via central podiatry intake. There is no High Risk Foot Service

– Dietetics provide one general diabetes group education sessions per month and six to seven group education sessions for GDM per month.

Balmain Hospital

• Balmain General Practice Casualty (GPC) also supports Hospital in The Home (HiTH) ambulatory care for older people with DM.

• General dietetics clinics for patients with diabetes and pre-diabetes run monthly.

Appendix A/ Other diabetes services in Sydney Local Health District

Diabetes Strategic Plan42 Diabetes Strategic Plan 43

69 The cultural, social and economic characteristics of the Canterbury Region of Sydney Local Health District. https://www.slhd.nsw.gov.au/populationhealth/pdf/Canterbury_Socioeconmics.pdf

70 Australian Institute of Health and Welfare. Available: https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/diabetes/overview

71 Centre for Epidemiology and Evidence 2016. HealthStats NSW: Maternal medical conditions. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/mab_mmedi_cat/mab_mmedi_cat_comparison.

72 Centre for Epidemiology and Evidence. New South Wales Mothers and Babies 2015. Sydney: NSW Ministry of Health, 2016. Available: http://www.health.nsw.gov.au/hsnsw/Publications/mothers-and-babies-2015.pdf.

73 Centre for Epidemiology and Evidence 2016. HealthStats NSW: Maternal medical conditions. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/mab_mmedi_cat/mab_mmedi_cat_lhd_trend?filter1ValueId=18387&LocationType=Local%20Health%20District&name=Mothers%20and%20babies&code=mum%20mab

74 Centre for Epidemiology and Evidence 2016. HealthStats NSW: Maternal medical conditions. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/mab_mmedi_cat/mab_mmedi_cat_comparison.

75 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

76 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

77 Diabetes Australia 2013. Aboriginal and Torres Strait Islanders and Diabetes Action Plan. Available: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.636.7708&rep=rep1&type=pdf

78 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

79 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Diabetes prevalence in adults. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/dia_prev_age/dia_prev_age_snap?&topic=Diabetes&topic1=topic_dia&code=dia%5b_.

80 Public Health Observatory: A demographic and social profile of Sydney Local Health District. May 2018. Available: https://www.slhd.nsw.gov.au/PopulationHealth/pdf/slhd_demography_2016.pdf.

81 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

82 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

83 2007 National Survey of Mental Health and Wellbeing. Available: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4326.0Main+Features32007?OpenDocument

84 2007 National Survey of Mental Health and Wellbeing. Available: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4326.0Main+Features32007?OpenDocument

85 Tabák, Adam G et al. Depression and type 2 diabetes: a causal association? The Lancet Diabetes and Endocrinology, Volume 2, Issue 3, 236 – 245.

86 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

87 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

88 Diabetes is far more likely to be listed as an associated cause of death because it is often not diabetes itself that leads directly to death but one of its complications that will be listed as the underlying cause of death. Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

89 NSW MOH Clinical Services Planning Analytics (CASPA) 2018. Emergency Department Activity Analysis Tool (EDAA) v16.0.

90 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Diabetes as principal diagnosis: hospitalisations. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/dia_pcohos/dia_hos_lhn_snap.

91 HIE. ICD-10-AM diabetes codes (E10–E14 and O24). All records and all ages for patients attending a SLHD facility i.e. RPAHHH, CRGH, Canterbury and Balmain Hospital.

92 HIE. ICD-10-AM diabetes codes (E10–E14 and O24). All records and all ages for patients attending a SLHD facility i.e. RPAHHH, CRGH, Canterbury and Balmain Hospital.

93 HealthShare data provided by Director of Nutrition and Dietetics for SLHD, 2017.

94 The SLHD Targeting Reporting System (STARS) provides a snapshot of the diabetes activity in the non-admitted setting for in scope activity and excludes certain financial classifications such as Medicare Benefits Scheme, self-funded and other funding source. (Figure 9). The exclusion of these financial classifications from STARS prevents the complete description of all NAP diabetes activity.

95 In scope activity is defined as ‘Under the NSW funding model, all NAP care activity is in-scope for ABF: Specialist Outpatient Clinic Services (series 10 and 20 Tier 2 classes); Stand-alone diagnostic clinics (series 30 Tier 2 classes) and Nursing and Allied Health clinics (series 40 Tier 2 classes).’ Activity Based Management 2017. NSW Activity Based Management Compendium 2017/18. Available: http://internal.health.nsw.gov.au/abf_taskforce/resources/Files/0_ABMCompendium17-18_web_07.pdf.

96 In scope activity is defined as ‘Under the NSW funding model, all NAP care activity is in-scope for ABF: Specialist Outpatient Clinic Services (series 10 and 20 Tier 2 classes); Stand-alone diagnostic clinics (series 30 Tier 2 classes) and Nursing and Allied Health clinics (series 40 Tier 2 classes).’ Activity Based Management 2017. NSW Activity Based Management Compendium 2017/18. Available: http://internal.health.nsw.gov.au/abf_taskforce/resources/Files/0_ABMCompendium17-18_web_07.pdf.

97 From March 2015 onwards, data was collected as part of the Antenatal Clinic which does not distinguish between GDM or antenatal services.

98 STARS 2018. NWAU Non-admitted app. Filtered for clinic: ‘CANT-Antenatal GDM.

99 RPAHH Diabetes Centre Annual Report 2017.

100 RPAHH Diabetes Centre CRS 2016.

101 NSW Ministry of Health 2017. Information Bulletin: Non-admitted Patient Establishment Type Definitions Manual, IB2017_021. Available: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/IB2017_021.pdf.

102 NSW Ministry of Health 2017. Guideline: Non-admitted Patient Classification Principles, GL2017_014. Available: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_014.pdf.

103 NSW Ministry of Health 2017. Guideline: Non-admitted Patient Reporting Rules, GL2017_017. Available: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_017.pdf.

104 NSW Ministry of Health Innovation, People’s Choice Award 2017.

105 Kritharides L, Chow V, Lambert TJ. Cardiovascular disease in patients with schizophrenia. The Medical journal of Australia. 2017;206:91-95.

106 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

107 Western Sydney Diabetes 2017. Taking the Heat Out of Our Diabetes Hotspot. Available: https://www.westernsydneydiabetes.com.au/themes/default/basemedia/content/files/WSD_TakingHeat_DiabetesHotspot.pdf.

108 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft, p. 21.

References

36 Sydney Local Health District 2018. HealthPathways Sydney. Available: https://sydney.healthpathways.org.au/index.htm.

37 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

38 Diabetes Australia. About diabetes. Available: https://www.diabetesaustralia.com.au/are-you-at-risk-type-2.

39 ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: biomedical results for chronic diseases, 2011–12. ABS cat. no. 4364.0.55.005. Canberra: ABS. Available: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.005main+features12011-12.

40 Oguma, Y, Sesso, HD, Paffenbarger, Jr, RS and Lee, I-M 2005. Weight Change and Risk of Developing Type 2 Diabetes. Obesity Research, vol. 13, no. 5, pp. 945–951.

41 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

42 Baker IDI Heart & Diabetes Institute 2012. Diabetes: the silent pandemic and its impact on Australia. Available: https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/e7282521-472b-4313-b18e-be84c3d5d907.pdf.

43 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

44 Lean, MEJ, Leslie, WS, Barnes, AC, Brosnahan, N, Thom, G, McCombie, L, Peters, C, Zhyzhneuskaya, S, Al-Mrabeh, A, Hollingsworth, KG, Rodrigues, AM, Rehackova, L, Adamson, AJ, Sniehotta, FF, Mathers, JC, Ross, HM, McIlvenna, Y, Stefanetti, R, Trenell, M, Welsh, P, Kean, S, Ford, I, McConnachie, A, Sattar, N & Taylor, R 2017. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, vol. 391, no, 10120, pp. 541–551.

45 ‘Chronic disease’ refers to a wide group of conditions, illnesses and diseases. Chronic diseases are generally characterised by their long-lasting and persistent effects, which distinguish them from ‘acute’ conditions—that is, conditions that first manifest over a short period, and often with potentially intense and severe effects. Eight chronic diseases namely arthritis, asthma, back pain and problems, cancer, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes and mental health conditions were selected because they are common, pose significant health problems, have been the focus of ongoing national surveillance efforts, and action can be taken to prevent them. Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

46 Baker IDI Heart & Diabetes Institute 2012. Diabetes: the silent pandemic and its impact on Australia. Available: https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/e7282521-472b-4313-b18e-be84c3d5d907.pdf.

47 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Diabetes prevalence in adults. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/dia_prev_age/dia_prev_lhn?&topic=Diabetes&topic1=topic_dia&code=dia%5b_.

48 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Potentially preventable hospitalisations by condition. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/bod_acshos_cond/bod_acshos_cond_lhn_trend.

49 The principal diagnosis is classified according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) and is defined as the ‘diagnosis established after study to be chiefly responsible for occasioning the patient’s episode of care in hospital’.

50 Centre for Epidemiology and Evidence 2017. HealthStats NSW: Diabetes as principal diagnosis: hospitalisations. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/dia_pcohos/dia_hos_lhn_snap.

51 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

52 Bach, LA, Ekinci, EI, Engler, D, Gilfillan, C, Hamblin, PS, MacIsaac, RJ, Soldatos, G, Steele, C, Ward, GM & Wyatt, S 2014. The high burden of inpatient diabetes mellitus: The Melbourne Public Hospitals Diabetes Inpatient Audit. Medical Journal of Australia, vol. 201, no. 6, pp. 334–338.

53 Data derived from NSW Perinatal Data Collection. Centre for Epidemiology and Evidence 2017. HealthStats NSW: Maternal medical conditions. Sydney: NSW Ministry of Health. Available: http://www.healthstats.nsw.gov.au/Indicator/mab_mmedi_cat/mab_mmedi_cat_lhdhos.

54 Patients can choose to register for NDSS services and the number of registrants does not necessarily represent the true burden of diabetes in SLHD.

55 The NDSS delivers diabetes-related products at subsidised prices and provides information and support services to people with all types of diabetes.

56 Diabetes Australia (2016), Atlas of Diabetes Prevalence by LGA. Available: http://www.diabetesmap.com.au/#/

57 In 2016 Canterbury LGA merged with Bankstown LGA to form the Canterbury-Bankstown LGA. For this paper the area of the former Canterbury LGA has been used as this is the catchment population of The Canterbury Hospital.

58 Diabetes Australia 2018. National Diabetes Services Scheme: Australian Diabetes Map. Available: http://www.diabetesmap.com.au/#/. Accessed: 15/03/2018.

59 NSW Ministry of Health (2003) Preferred Terminology to be used when referring to Aboriginal and Torres Strait Islander Peoples Ministry of Health. North Sydney (PD2005_319): Note that within NSW Health, the term ‘Aboriginal’ is used in preference to ‘Aboriginal and Torres Strait Islander’, in recognition that Aboriginal people are the original inhabitants of NSW

60 NSW Ministry of Health (2003) Preferred Terminology to be used when referring to Aboriginal and Torres Strait Islander Peoples Ministry of Health. North Sydney (PD2005_319):

61 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Available: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true.

62 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes.

63 Australian Institute of Health and Welfare 2018. Diabetes compendium. Available: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes. Accessed: 12/01/2018.

64 Australian Institute of Health and Welfare 2015. Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Aboriginal and Torres Strait Islander people. Available: https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/cardiovascular-diabetes-chronic-kidney-indigenous/contents/summary

65 Australian Institute of Health and Welfare 2015. Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Aboriginal and Torres Strait Islander people. Available: https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/cardiovascular-diabetes-chronic-kidney-indigenous/contents/summary

66 Colagiuri, R, Thomas, M & Buckley, A 2007. Preventing Type 2 Diabetes in Culturally and Linguistically Diverse Communities in NSW. Sydney: NSW Department of Health. Available: https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/68e22e06-4281-4fb1-8d06-59af53719d85.pdf.

67 Thow, AM & Waters A-M 2005. Diabetes in culturally and linguistically diverse Australians: identification of communities at high risk. AIHW cat. no. CVD 30. Canberra: Australian Institute of Health and Welfare. Available: https://www.aihw.gov.au/getmedia/ebe47968-5b5a-47fe-bb7c-2f695770e7d8/dclda.pdf.aspx?inline=true.

68 SLHD. Public Health Observatory: A demographic and social profile of Sydney Local Health District. May 2018. Available: https://www.slhd.nsw.gov.au/PopulationHealth/pdf/slhd_demography_2016.pdf.

Diabetes Strategic Plan44

109 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

110 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

111 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

112 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

113 NSW Agency for Clinical Innovation, Health Economics and Evaluation Team 2017. Inpatient Management of Diabetes Mellitus: Monitoring and evaluation plan. Available: http://collaborate.aci.health.nsw.gov.au/files/file/180-evaluation-plans/.

114 NSW Agency for Clinical Innovation, Health Economics and Evaluation Team 2017. Diabetes High Risk Foot Services: Monitoring and evaluation plan. Available: http://collaborate.aci.health.nsw.gov.au/files/file/180-evaluation-plans/.

115 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

116 Commonwealth of Australia 2015. Australian National Diabetes Strategy 2016–2020. Available: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/Australian%20National%20Diabetes%20Strategy%202016-2020.pdf.

117 NSW Ministry of Health 2016. NSW Diabetes Prevention Framework. Available: http://www.health.nsw.gov.au/heal/Publications/Diabetes-Prevention-Framework-Paper.PDF.

118 NSW Agency for Clinical Innovation 2018. Leading Better Value Care Program. Available: http://www.eih.health.nsw.gov.au/lbvc/about/leading-better-value-care-program..

119 NSW Agency for Clinical Innovation 2014. ACI Endocrine Network: NSW Model of Care for People with Diabetes Mellitus – draft.

References

Planning for your future slhd.nsw.gov.au

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