Effectively Combining People, Systems and

Technology to Achieve Improved Quality of Care,

Patient Safety and Cost Efficient Care Delivery

Integrating Technology into Practice

Benefits:

• Improving access, efficiencies and equity in

health care,

• Better management of chronic disease,

• Increased focus on prevention,

• Improved quality, safety, performance and

accountability of health care services.

Type 2 Diabetes

• Type 2 diabetes is the most rapidly growing health

problems in Australia (AusDiab, 2012)

• 1 in 4 Australians either have diabetes or the signs

that they will develop diabetes. (AusDiab, 2012)

• 280 adults develop diabetes daily, 1 every 5 mins

• Estimated: for every 5 diagnosed cases, there are 4

undiagnosed cases. (Valentine et al., 2011 – in Shaw & Tanamas 2012)

Diabetes prevalence has risen

from 8.5% to 12% over 12 years

Source: AusDiab Study 12-year follow-up, 2012.

Australia’s diabetes prevalence has

already exceeded forecasts (IDF 2006)

Serious complications arising from

diabetes are increasing

Source: Diabetes: The silent pandemic and its impact on Australia (2012).

Annual number of people with diabetes commencing

dialysis or having a kidney transplant.

Diabetes will be the highest

contributor to the disease

burden in Australia by 2017

Source: A National Diabetes Strategy and Action Plan: Federal Election 2013. Diabetes Australia.

Trends in leading causes of burden of disease

(Australian Institute of Health and Welfare, 2010).

What can we do about it?

Annual incidence of diabetes, by BMI

Source: AusDiab Study 12 year follow-up, 2012.

Source: AusDiab Study 12 year follow-up, 2012.

Annual incidence of diabetes, by activity

What are we doing about it?

12% spent on primary health care

Australian General Practice Consultations

'Exercise Is Medicine‘: Curbing the Burden of Chronic Disease and Physical Inactivity. Jeff S. Coombes et al.

Published online 9 April 2013 Asia Pac J Public Health

4.2% provided advice on

nutrition and weight

1.3% included counseling

advice on exercise

Diabetes treatments:

Change over the past 12 years

Use of treatments for diabetes: the AusDiab Study 12-year follow-up. 2012.

The Health Care System

Process

Disease SystemConventional medical care

Health SystemPrimary care

Testing

(Diagnostic)

Markers of disease

•Pathology

•Scan (e.g. endoscope)

•Scope (e.g. x-ray)

Determinants of health (poorly

measured)

•Smoking, Nutrition, Alcohol, Physical

activity, Obesity, Mental Health, Sleep

Diagnosis Medical Practitioner Medical Practitioner

Treatment Focus: Disease (Cure)

What: pharmaceuticals, injections,

surgery.

Who: Medical Practitioner

How: Episodic

Focus: Health (Prevention)

What: SNAPOMS

Who: Patient/GP/PN/AHP

How: Uncoordinated & episodic

Testing

(Diagnostic)

Markers of disease Determinants of health

Capacity & Capability of our front line Medicine in

Chronic Disease Management

Knowledge │ Skill │ Resources │ Drive

Key pad questions

What’s your competency?

I am confident that I can calculate an individual’s energy requirement.

a) True

b) False

Integrating Technology into Practice

to better manage Chronic Disease

People

Systems Technology

Replicable Accessible

Scalable

Measurable

Health

outcomes

MeasurementDISEASE HEALTH

Keeping Score changes the

way we play the game

Better Measurement…Better Management

The ability to tangibly measure a range of primary health indicators (mental health, physical and functional health, sleep, social health and nutrition)

– WILL engage the individual to have a conversation with their health practitioner about addressing the determinants of health, rather than SUPERVISE THEIR DECLINE until they can be diagnosed with a disease

– WILL focus practitioners on improving primary health indicators and prevent lifestyle-related disease rather than burden acute medical treatment services (Prevention focused).

– WILL enable the individual and their health practitioner to direct and prioritise (integrate & coordinated) an intervention according to the cause, patient’s needs, preferences and motivation (client centred approach).

– WILL create an ability to measure changes in outcomes with Primary Health care intervention (outcomes focused, evidence-base, accountable)

– WILL create a drive to improve scores for the client (client centred) as consistently (replicable model) and efficiently as possible (innovation). Interventions that lead to demonstrated and exceptional outcomes can then be communicated to target markets, professions, industry and government for better health outcomes (leadership and universal recognition).

Management: Integrating People, Systems, Technology

Timeline Face-to-face Appointments Outcome MeasuresOnline Learning Module #

Start-up GP Blood pressure

Pathology referral for:HbA1c, Fasting BGL, Lipids

Week 1 Dietitian (AHP)

Health Risk Assessment (online) ***

Weight & Height (to calculate BMI)

Introduction to food and activity tracker

Introduction & getting started

Week 2 Dietitian (AHP) Weight & BMI

Review food & activity tracker

Energy balance

Week 3 Carbohydrates

Week 4 Exercise Physiologist (AHP) Weight & BMI

Review food & activity tracker

Exercise

Week 5 GP Review test results

Review medication

Portion control

Week 6 Dietitian (AHP) Weight & BMI

Review food & activity tracker

Creating a healthy environment

Week 7 Resistance & stretching exercises

Week 8 Dietitian (AHP) Weight & BMI

Review food & activity tracker

Shopping & Nutrition Labels

Week 9 GP Review test results

Review medication

Goals & barriers

Week 10 Meal planning

Week 11 Support

Week 12 Dietitian (AHP)

Weight & BMI

Review food & activity tracker

Health Risk Assessment 2 (online) ***

Future: What now?

Post-program GP Blood pressure

Pathology Review medication

Accessible

Accessible

Scalable, Replicable

Diet & exercise trackingClear, practical and visual resources

Master: Measurable Outcomes18mths of usual care in 12 weeks

* p-value<0.05 ** p-value<0.01 *** p-value<0.001

Blackberry ID, et al. Effectiveness of a general practice based, practice nurse led telephone

coaching on glycaemic control of type 2 diabetes: the PEACH pragmatic cluster randomised

controlled trial. BMJ 2013;347:f5272 (Published September 2013).

Thankyou