WESTERN SYDNEY DIABETES YEAR-IN-REVIEW 2017

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YEAR-IN-REVIEW 2017

mobilising public support, and are now ready to present these to State and Federal governments and other parties.

The October 2017 Productivity Commission Inquiry Report Shifting the Dial argues that primary prevention, secondary prevention and better health care management, integrated across the community and hospitals, will both improve health and save money – all core priniciples of the Western Sydney Diabetes Strategy. This report also states that current funding mechanisms, and the divide between State and Commonwealth, is inhibiting this implementation, and ‘assumes that few regions will be able to replicate the effectiveness of leading innovators in integrated care, such as the Western Sydney Diabetes initiative.’

With appropriate investment we would like to be an innovator and early adopter of these recommendations. While we were not at sufficiently large scale in 2017, we have continued to implement our framework with the resources at hand. This report documents some of these achievements.

Prof Glen MaberlyDirector, Western Sydney Diabetes

EXECUTIVE SUMMARYThe Western Sydney Diabetes 2017 Year-In-Review documents the achievements of the leadership, core team and partners working within our Framework for Action.

Our main accomplishment over the past year has been building an alliance of more than 70 partners within government, business and the community. This alliance helps us understand the problems, and develop solutions to address the epidemic of diabetes in our region.

There is increasing awareness around the scale of this issue. As Western Sydney Local Health District Chief Executive Danny O’Connor says: “This rising tsunami of diabetes in Sydney’s western suburbs threatens to overwhelm hospitals within 15 years.” As we strive to define the magnitude of this problem, it becomes increasingly clear that our current efforts will not achieve our goal of ‘taking the heat out of our diabetes hotspot’ within 5 years. A significant effort has therefore been directed towards articulating a more persuasive case for an urgent investment in a larger scale effort. We have produced the business case documentation for investments in primary prevention, secondary prevention and management, data for decision making and

FRAMEWORK FOR ACTION

PRIMARY PREVENTION SECONDARY PREVENTION AND MANAGEMENT

MONITORING • SURVEILLANCE • EVALUATION • ECONOMIC IMPACT • RESEARCH • PUBLICATION

ADVOCACY • MEDIA • SOCIAL MEDIA • PUBLIC AWARENESS • MOBILISATION • GRASS ROOTS SUPPORT

AN ALLIANCE OF 70 PARTNERS • ALL TIERS AND SECTORS OF GOVT • PRIVATE SECTOR • NGO • UNI & EDU

TAKING THE HEAT OUTOF OUR DIABETES HOTSPOT

INVESTMENT OPPORTUNITY:PRIMARY PREVENTION

INVESTMENT OPPORTUNITY:SECONDARY PREVENTION AND MANAGEMENT

BUILDING AN ALLIANCE AND TESTING THE STRATEGY

DATA FOR DECISION MAKING:BUILDING A SURVEILLANCE SYSTEM TO MONITOR AND EVALUATE

MOBILISING PUBLIC SUPPORT:BUILDING DIABETES AWARENESS AND ENGAGEMENT

HbA1c TESTING

LIFESTYLE COACHING

JOINT CASECONFERENCING

HEALTHPATHWAYS

GP SUPPORTLINE

WSD APP

COMMUNITYPHARMACY

PRACTICENURSE TRAINING

IMPROVING FOOD

CONSUMPTION

INCREASING PHYSICAL ACTIVITY

BUILDING HEALTHY

ENVIRONMENT

SAVE ALEG

COMMUNITYEYE PROGRAM

RAPID ACCESSCLINIC

CGM FORDIAGNOSTICS

INTEGRATEDCARE

HEALTH CARE HOME

IN-HOSPITALCARE

EDUCATIONCENTRES

SHARED HEALTHSUMMARY

BARIATRICOBESITY CLINICGOVERNMENT LEADING THE WAY

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Active Transport, Transport for NSW and Parklands Trust provided input into this planning.

• A Workshop was conducted on 27th April, with key individuals from government, non-government and NGOs who have the capacity to set up their own groups to guide and implement local environmental changes.

• Four themes of liveable communities, urban design and greening, transport, and promoting community engagement were analysed, and a strategy for developing these initiatives was progressed.

• Relevant individuals, including councils, have now taken ownership of these themes and provide updates on progress and achievements both independently and at scheduled meetings.

PROGRESSING INTERVENTIONS• Blacktown Focus has been launched by the Mayor and

General Manager of Blacktown and Mt Druitt Hospital (BMDH), with over 80 key stakeholders in attendance. The objective of this Focus is to implement a number of prevention and management interventions in a small area to demonstrate their efficacy, as well as enabling our stakeholders to work together and evaluate these interventions.

PRIMARY PREVENTIONThe 2017 focus for Primary Prevention was to refine our strategy, consolidate the alliance and define an investment opportunity. We also wanted to cement the value of the alliance by progressing some of the lower cost interventions. We therefore decided to take a smaller geographic area to focus our efforts, so we could harness the synergies of multiple interventions without overly stretching our very small team and limited resources.

Our Strategy and Interventions are documented in the 2017 “Taking the Heat Out of Our Diabetes Hotspot” and “Investment Opportunity: Primary Prevention” papers. The 2017 Plan focused on what we could do with existing resources, and the key outcomes against that plan are reported here.

URBAN PLANNING • Key expert consultation was carried out to define the

focus of the urban strategy approach of the Alliance, and decide upon the most feasible objectives of a subsequent workshop. Organisations including the Greater Sydney Commission, Councils, Heart Foundation, Western Sydney Regional Organisation of Councils (WSROC), universities,

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Top left: Alliance members exchanging information at stalls. Top right: Opening of the Blacktown Focus by the Mayor of Blacktown, Councillor Stephen Bali. Middle left: Sue-Anne Redmond, General Manager, BMDH. Middle right: Doug Thompson, DPC. Bottom: forum members: Sturt Eastwood, DNSW; Sue-Anne Redmond, BMDH; Councillor Stephen Bali, Blacktown Council; Doug Thompson, DPC; Charles Casuscelli, WSROC; Stephen Corbett WSLHD, Rajini Jayabulla, WSLHD, Amanda King, LLGA; Josephene Duffy, SAKGF; Dr Prabha Chandra, Blacktown GP Association; Walter Kmet, WSPHN.

BLACKTOWN FOCUS

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• In total, a series of 9 working groups (5 x food, 2 x physical activity, and 2 x urban planning) and 3 combined workshops and strategy meetings have been held. These have been conducted with co-leadership from the DPC since 2016. The outcomes of these meetings were endorsed at the Strategy Meeting held on 26th October 2016. PwC have provided outstanding assistance in the preparation and facilitation of these meetings, which have allowed the ongoing networking of members and the implementation of joint programs. The key reason for the meetings however, has been to produce an overall prevention strategy and cost benefit analysis of key interventions.

• Alliance members have contributed to this comprehensive prevention strategy as well as the identification of key interventions. This has been achieved through their attendance and contributions during planning meetings, along with the provision of commercial data in individual sessions. Their input has been paramount in enabling the production of a cost benefit analysis leading to an investment portfolio – thus providing the greatest opportunity for bringing the prevention efforts in Western Sydney to scale. This portfolio is now compiled and awaiting presentation to Government.

• All councils are now actively involved in the work of the Alliance, with scheduled regular information-sharing taking place. Blacktown Council, as well as attending all Alliance events, are actively contributing to the 2018 planning for the Alliance and the preparation of consumer engagement strategies. All councils are involved with GP Walking Groups, and Blacktown and Parramatta Councils meet with WSD on a bi-annual basis for updates.

• The low cost interventions being progressed include: GP walking groups, SALSA youth forum, Stephanie Alexander Kitchen Gardens and community cooking classes. These initiatives involve working with a number of Alliance members including WSPHN, Heart Foundation, Department of Sport, Education Department, Police, Councils, Vinnies and Jamie’s Ministry of Food.

• A School Working Group with multiple Alliance members has been assembled to provide programs to local primary schools. This group includes organisations committed to introducing amongst other things; school breakfasts, healthy canteens, healthy lunchbox, educational programs for parents and students, kitchen gardens and cooking classes for children.

STAFF HEALTH AND WELLBEING PROGRAM• A diabetes awareness campaign including talks,

demonstrations and screening took place, with over 200 staff being assessed for diabetes risk. High risk individuals were directed to the Get Healthy Service.

• Local inexpensive or free healthy living options have been identified, and a directory compiled for health professionals and consumers. This directory outlines an array of options associated with both healthy eating and physical activity. Local face-to-face programs and facilities, online programs, educational and community courses are described, which include relevant website links. This document appears on the Western Sydney Diabetes website and requests for hard copies have been received from GPs.

KEY COMMUNITY ENABLERS• Psychological expertise has been incorporated into the

Alliance through the addition of key personnel and NGOs. This is to address barriers to residents undertaking lifestyle modification, as well as helping to create referral pathways for programs.

• Community consultation has occurred in the development and identification of strategies and programs aimed at diabetes prevention. This has been achieved through active consumer participation in all meetings and workshops. Work has commenced with the WSLHD Consumer Council on training representatives to provide community education sessions.

• Membership of the Alliance has grown to 70 highly engaged members, with an average of over 80% attending all events. An additional 20 members have joined the alliance over the past 12 months.

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• A Diabetes Detection and Management Service (DDMS) nurse at BMDH was appointed to follow-up selected patients identified with pre-diabetes and diabetes. All patients and GPs were sent information about the NSW ‘Get Healthy’ program. The sign-up of patients identified from this program to ‘Get Healthy’ accounts for 50% of the provider promoted registrations in WSLHD.

PROMOTE DIABETES DETECTION AND COACHING BY THE GP• Increased annual HbA1c testing was promoted during the

Australian Diabetes Week and specifically with a number of GP practices located within Blacktown.

• There has been continued discussion regarding increased diabetes detection with GPs at case conferences, and this topic has been included as a Learning Objective for self-reported CPD points for GPs.

PROMOTE LIFESTYLE OPTIONS• ‘Get Healthy’ registrations were disappointingly low, so

the Prevention Team has developed a resource of over 20 ‘Healthy Living Options’ which is available on the Western Sydney website.

• Connections have been made with local primary prevention and coaching programs including the COACH program, a free telephone-based service; ‘SupportMe’ (a randomised trial of a text messaging service that provides practical information and lifestyle support); and through Integrated Care via the work of the Care Facilitators.

SECONDARY PREVENTION & MANAGEMENTIn 2017 we refined our strategy for Secondary Prevention and Management, bringing this work under one umbrella. In the 2017 ‘Taking the Heat Out of Our Diabetes Hotspot’ paper, we defined our work and described progress in each of our 18 interventions. We also elaborated in the ‘Investment Opportunity: Secondary Prevention and Management’ a proposal to consolidate the alliance and define an investment opportunity.

We report here on progress against our WSD 2017 Plan:

LINKING HBA1C MEASUREMENTS TO LIFESTYLE MODIFICATION• Diabetes testing (HbA1C) in Emergency Departments

(ED) within Blacktown and Mt Druitt Hospitals (BMDH) of 35,000 patients, found 17% of those tested had a diagnosis of diabetes and 30% had results consistent with pre-diabetes. Patients and General Practitioners (GPs) were notified of their results by mail. Patients were encouraged to discuss their results with GPs. Westmead Hospital similarly commenced HbA1C testing on patients presenting to the ED with blood sugar levels >10 mmol/L in the 4th quarter of 2017.

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• Development of a certificate for GPs and Practice Nurses allowing for 2 GP CPD points for each hour of JSCC has increased the numbers engaged in the service.

• Continue to engage and work collaboratively between the BMDH and WH diabetes teams. WH team is now delivering monthly JSCC.

EXPAND HIGH-RISK FOOT SERVICE & SAVE A LEG• Continued promotion of ’60 second foot check’ in

community and inpatients.• Organisation of a successful ‘Happy Healthy Foot Forum’

with strong level of interest, discussion and engagement from community podiatrists, Practice Nurses, GPs, Diabetes Centre staff and consumers.

• Regular collaboration with the multi-disciplinary high risk foot team, including vascular surgeon, infectious disease physicians, podiatrist, wound care nurses, diabetes educators, dieticians and endocrinologist.

• Setting up collaboration for multi-centre prospective research trial on Charcot neuroarthropathy.

ADVANCE COMMUNITY EYE PROGRAM• The Community Eye Care (C-EYE-C) project focusing on

diabetes and glaucoma, was award winner of the WSLHD Quality WentWest Partnership Award and the 2017 NSW Health Award for Delivering Integrated Care.

• The secondary referral centre in Blacktown is now open to GPs and Optometry services.

• Ongoing regular steering committee meetings with the ophthalmology group at Westmead to progress the community eye program.

PHARMACY ENGAGEMENT• Following a WSD Pharmacy Forum, a WSD Pharmacy

working group has been established and meets quarterly. • Continue to progress community pharmacy engagement

in Western Sydney through promotion of WSD events on Pharmacy Society of Australia (PSA) e–newsletters and bulletins.

• Presentations delivered by WSD team at State and National Pharmacy conferences.

• Continued close connection and collaboration with the Community Pharmacy team at WSPHN, and practices involved in Patient Centered Medical Home.

ADVANCE WSD PATIENT SELF-MANAGEMENT APP• 2017 has been a year to work with WSLHD Procurement

Services and NSW Health Share to use the formal tender process to find a replacement for TELSTRA HEALTH to progress a Western Sydney Diabetes self-management App. The process is drawing to a close with a preferred vendor identified.

• Collaboration has continued with the University of Sydney, School of Public Health, Health Literacy Group to develop the App content appropriate to the demographic of western Sydney. This includes pre-testing and interaction being conducted between the USyd group and target GPs group.

• The initial stock of one-line messages is now complete and has been reviewed. The development of video scripts for the content library has commenced and is being reviewed by USyd.

EXPAND JOINT SPECIALIST CASE CONFERENCING (JSCC)• By year end, 98 JSCC will have been conducted, including

13 new practices, 42 new GPs and over 500 patients.• Long-term follow-up of patients reviewed at JSCC showed

that the early statistically significant improvements in HbA1c were sustained after 3 years, with an absolute HbA1c reduction maintained at -0.93%.

• Successful engagement of additional Blacktown GP practices has been achieved through working closely with the Blacktown GP Association.

• Demonstration of a 10% increase in HbA1c screening using PEN CAT data across GP practices involved in JSCC.

• Promotion of JSCC has been achieved through direct communication with GPs, brochures and follow-up phone calls. Identification and engagement of Practices with larger numbers of patients identified with diabetes has been possible through the DDMS program.

TOTAL NUMBER OF JOINT SPECIALIST CASE CONFERENCING CONFERENCING 98NEW PATIENTS

SEENNEW PRACTICES

ENGAGEDNEW GPS REACHED

500 1342

JSCC Results for 2017

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CONTINUE TO DEVELOP DDMS AT BMDH• Continue to use HbA1c testing as a means to review

individuals with new and suboptimally controlled diabetes whilst admitted to hospital.

• Increase capacity to manage diabetes amongst hospital staff with ongoing education.

• Establish a live in-hospital surveillance system for individuals admitted with diabetes.

• Develop a process to engage and educate individuals that have not been admitted to hospital but identified as having diabetes, or pre-diabetes, by HbA1c testing in the Emergency Department.

CAPACITY BUILDING IN CARDIOLOGY• An audit of management, prevalence and incidence of

diabetes among admitted cardiology patients. • A successful forum on the interrelationship of Diabetes

& Cardiology was held in July 2017, connecting multi-specialty groups to discuss the varied impacts of diabetes in those areas and how to reduce these effects.

• Cardiology Case Conference – we have had 2 inter-departmental patient case conferencing sessions between Cardiology and WSD, and endeavour to have more this year and bi-monthly sessions next year.

• Upcoming collaboration to conduct a research trial to carry out diabetic retinopathy screening in outpatients and in ED for those identified via the DDMS data.

EXPAND PRACTICE NURSE CAPACITY BUILDING• Reassessment of Practice Nurse education and

development of a new model on-line component consisting of 10 modules, and face-to-face study day for skills assessment.

• Investigate learning needs of Community nurses with respect to diabetes, which will progress to working collaboratively to develop a program plan.

EXPLORE WAYS TO CONNECT WITH PSYCHOLOGICAL SUPPORT/MENTAL HEALTH• Continued engagement with the Mental Health team

both at Blacktown out patients service and Likeminds, Seven Hills.

• Successful delivery of a Diabetes & Mental Health Forum (May 2017), which was attended by 80 health and allied health professionals.

• We also presented an audit of JSCC intervention among Clozapine patients at an outpatient clinic, showing modest weight loss and improvements in diabetes control with a single visit.

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• Audit of CGMs performed to highlight value, especially in the context of hypo unawareness.

• Prepare and submit business case for routine use of CGM in outpatient clinic.

SUPPORT THE DEVELOPMENT OF OBESITY/ METABOLIC SERVICES AT BLACKTOWN• A multidisciplinary Metabolic & Weight Loss Clinic was

established in October 2017 to treat severely obese patients with associated complications from their obesity (majority have type 2 diabetes and/or fatty liver disease).

• We have seen nearly 20 patients, and 6-8 patients are being medically, psychologically and physically readied for metabolic-bariatric surgery.

• Many are on high doses of insulin with a multitude of obesity-related comorbidities that are likely to improve with weight loss.

• We await the full employment of our team (exercise physiologist, psychologist, and diabetes educator/nurse) to be able to highlight lifestyle intervention as a path to successful weight loss.

CONNECT WITH ROUSE HILL PLANNING• Continue to participate in discussion and planning for

Rouse Hill Hospital.

INTEGRATION OF CARE IN OUTPATIENT CLINICS• Trial to test benefits of using Health2sync App for insulin

stabilisation compared with traditional weekly phone consults. 20 patients to date have been included in the trial.

• Ongoing efforts to improve flow of activities in outpatients clinic to improve patient outcome, and experience with quarterly meetings to improve patient experience and adherence, as well as highlight major administrative hurdles.

• Multiple lists now combined to one list, with ongoing efforts to see urgent patients within a few days, as well as discharging patients back to GPs when appropriate. Direct contact with GPs via telephone to facilitate linking outpatients and the community.

• Addition of dietitian service to outpatient clinic.• Promoting follow-up of patients who did not attend the

clinic with phone calls to the patient, GP or referring practitioner.

USE CONTINUOUS GLUCOSE MONITORING (CGM)• Continued use of CGM for use in patients with complex

Type 2 diabetes.• Availability of ‘Real time’ CGM for use in specific patients.• Use of CGM to escalate stabilisation of patients and

discharge back to care of GPs.

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our 5 lead organisations. This includes building internal relationships with Centre for Population Health, Integration Partnerships and Enablers and Western Sydney Diabetes within the Integrated and Community Health Directorate, WSLHD. Expanding engagement with other Government Departments through the Greater Western Sydney Regional Leadership Executive, and closer working relationships with Councils, has progressed well this year. New Alliance members are hearing about our goal and approach, and are now approaching WSD to join and contribute to the initiative.

LEADERS ALLIANCELeadership of the Alliance moved from the Parliamentary Secretary for DPC to the EMT co-chairs, with meetings held twice a year. The first meeting was hosted by the Chair of WSLHD Board and the second by CEO of WSPHN. WSD Leaders Alliance has been formalised with over 70 partner organisations.

The 2017 Plan was reviewed at the first meeting and the second meeting focused on a report on implementations and plans for scaling up the investment. Members also reported on new initiatives, including collaborations initiated with other members. Meetings were held on 1st May and 25th October 2017.

BUILDING A STRONG TEAMThe WSD is now a Division within Integrated and Community Health Directorate in WSLHD. It has 10.9 FTEs and a core operating budget of $1.57M/year. Over the past year this core WSD team has been strengthened through the recruitment of additional people to improve the delivery of the initiative and enhance its goals and work practice.

ORGANISATIONAL AND PROGRAM ENABLERS

EXECUTIVE MANAGEMENT TEAM (EMT) Western Sydney Diabetes (WSD) now has five lead partner organisations: Western Sydney Local Health District (WSLHD), Western Sydney Primary Health Network (WSPHN), NSW Department of Premier and Cabinet (DPC), Diabetes NSW & ACT and PricewaterhouseCoopers (PwC). The CE of WSLHD and CEO of WSPHN co-chair an Executive Management Team, and other members include senior executives from the five lead organisations, Executive Director Integrated and Community Health, General Managers of Westmead and BMDH, Director Division 3 Ambulatory & Medicine BMDH, Heads of Endocrine and Diabetes Departments WH and BMDH, Director and Program Manager WSD.

Meetings were held on 22nd February, 24th May, 30th August and the meeting scheduled for 29th November will be rescheduled for 2018.

WORKING WITH OUR PARTNERS The success of WSD remains with its partnership approach. The achievements listed in this report are largely attributed to the work of these partners. Bringing together this network requires a supportive mindset by executives in our lead organisations, and considerable effort by the core team. This alliance is more than name-only, and means that organisations are meeting and aligning their work with WSD. An example of this is formalising the relationship of

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• Hon Dr (Geoff) Geoffrey Lee – MP Parramatta and Parliamentary Secretary to the Premier, Western Sydney and Multiculturalism. NSW Government.

• Hon Greg Hunt MP for Flinders, Minister for Health, Minister for Sport – through Wendy Black, Chief of Staff. Australian Government.

• Hon Ed Husic, Member of Parliament for Chifley, NSW. Australian Government.

INVESTMENT PORTFOLIOWSD has updated the Taking the Heat out of Our Diabetes Hotspot brochure, specifically aimed at supporting our investment strategy to take the WSD program to scale. In Part 3: ‘Our Interventions’, the work being done is already documented so will not be described in this report. This work is then supported by four additional documents, which make the business case and investment opportunities for core areas of work:• Primary Prevention – securing investment for primary

prevention programs and initiatives. • Secondary Prevention and Management – securing

investment for secondary prevention and management programs or initiatives.

• Data for Decision Making – building a supporting surveillance system to monitor and evaluate the WSD initiative and provide data for decision making, including population surveillance and key performance indicators.

• Mobilising Public Support – community awareness campaigns will inform the community on the risks of diabetes and engage action.

We are working to secure direct engagement with the NSW and Federal Government on this opportunity in 2018. Our 2018 work plan will look to implement as much of the above as possible using the resources at hand.

WORKING GROUPS As reported on in the previous sections, working groups were established to move interventions forward. These included:• WSD WSLHD weekly Core Team meeting.• WSLHD and WSPHN monthly meeting.• Food, Physical Activity, Urban Planning working groups.• WSLHD Health and wellbeing working group.• WSD App Tender Evaluation Committee and

Communication working group.• WSD Research Group.• C-EYE-C steering Group.• Community Pharmacy Working Group.• Consumer Engagement working group.• Clinical working group.• Primary Prevention Working Group.

PARLIAMENTARY SUPPORTWe have engaged positively with the following State and Federal MPs this year:• Hon Scott Farlow – Member of the Legislative Council,

Parliamentary Secretary to the Premier (Leader of the House) in the Legislative Council. NSW Government.

• Hon Ray Williams – Member Parliament for Castle Hill, Minister for Multiculturalism and Minister for Disability. NSW Government.

• Hon Stuart Ayres – MP for Penrith, Minister for Western Sydney, WestConnex and Sport. NSW Government.

• Hon Dr (Hugh) Paul McDermont – MP for Prospect. NSW Government.

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MONITORING SURVEILLANCE AND RESEARCHIn 2017 we developed a Monitoring System Strategic Plan with special support from PwC and our lead partner organisations, which lead to hiring a full-time Research, Monitoring and Surveillance Coordinator.

Some key highlights include:• Access to diabetes-related pathology results, with

geographic specificity of a 200 household level for our LHD and Sydney through an agreement with Douglass Hanly Moir in collaboration with UoW Powerlab. This work is covered under an ethics approval from WSLHD for ongoing surveillance of diabetes.

• Piloted increased annual HbA1C diabetes testing in 2 GP clinics, with more coming online in early 2018. More than 4,000 tests have been conducted through this system in 2017.

• Initiated evaluation for all ongoing projects, including case conferencing, CGM, clozapine clinics and Bydureon in clinical practice. This has resulted in 10 ethics applications submitted, with 7 approved so far in 2017.

• Grant applications prepared but not successful for Translational Research Grant Scheme and the Australian Research Council.

PRESENTATIONS AND PUBLICATIONS• Gideon Meyerowitz-Katz, Manimegalai Manoharan, Rajini

Jayaballa, Sian Bramwell, Ian Corless, Victoria Nesire, Emily Prior, Nathan Schlesinger, Glen Maberly. Integrated Care of people with Type 2 diabetes in Western Sydney: A business case for Joint Specialist Case Conference (JSCC) with General Practice. Integrated Care Conference. 11th of May Dublin 2017.

• Janine Dawson, Doug Thompson, Walter Kmet, Fay Bushell, Sue Loseby Nathan Schlesinger, Emily Prior, Victoria Nesire, Glen Maberly. Promoting the health and welfare of people, families and communities. Integrated Care Conference Dublin 2017.

• Rajini Jayaballa , Sian Bramwell, Maiyoori Jeyaprakash , Gideon Meyerowitz-Katz , Ramy Bishay, Xiaoqi Feng , Mark Mclean, Tien-Ming Hng, Glen Maberly. Real world experience with Exenatide ER (Bydureon) in Western Sydney. Poster ADS 2017.

• Ramy Bishay, David Chandrakumar, Gideon Meyerowitz-Katz, Maiyoori Jayaprakash, Rajini Jayaballa, David Burgess, Dilini Punchihewa, Tien-Ming Hng, Glen Maberly. Getting to the heart of the matter: Prevalence, glycaemic control and management of diabetes among patients admitted to the cardiology ward at a tertiary Sydney hospital. Poster ADS 2017.

WEBSITE AND COMMUNICATIONS The Western Sydney Diabetes website has evolved as a key enabler for the promotion and information portal for our partners and clinicians to share their successes. A listing of more than 20 options for lifestyle coaching and other support programs shows how we are using the site to share information in our area. Partners programs are also highlighted on the site.

MEDIA STORIES INVOLVING WSD• Major Problem: Initiative tackles type 2 diabetes

hotspot, Mt Druitt St Marys Standard, 24 May.• 2GB interview by Alan Jones with Danny O’Connor the

CE WSLHD, 14 July.• ‘Experts fear the worst’ Blacktown Sun, 18 July.• ‘Green Thumbs Sprout’ Blacktown Sun, 25 July.• ‘Far more diabetes’ Auburn Review, 31 July. • ‘Professor’s heavy diabetes warning’ Parramatta

Advertiser, 2 August.• ‘Specialist shortage as Australia faces diabetes

tsunami’ 9 News, 22 Nov.

This work was strongly supported by the WSLHD Communications Team.

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• Glen Maberly: Beating Diabetes Together in Western Sydney: A journey underway. Beat Practice in Diabetes Centres Symposium 2017

• Meyerowitz-Katz, G. M., M. Bramwell, S. Bishay, R. Corless, I. Ravi, S. Soars, L. Feng, X. Astell-Burt, T. Mclean, M. Jayaballa, R. Maberly, G. 2017. Integrated Care: Effectiveness of Joint Specialist Case Conferences in building general practice capacity to better manage diabetes. Journal of Integrated Care, Forthcoming.

FORUMS AND WORKSHOPS• WSD Prevention Strategy – Building Health Environment

Workshop. 27th April.• Diabetes and Mental Health Forum: Achieving a more

holistic approach. 4 May.• Diabetes and Ramadan community information session.

18 May.• LHD Employee Wellbeing Festival focused on diabetes

awareness. 29 May – 2 June.• Diabetes and Cardiology Forum: How Sweet is Your Heart?

13 July.• WSD Prevention Alliance: Beating Diabetes in Blacktown

launching Blacktown Focus. 24 July.• Diabetes and High Risk Foot Forum: Healthy Happy Feet.

14 November.• SALSA Youth Voices in the Community. 22 November.• GP education sessions at Kildare Road Medical Centre

and Pacific Medical Centre.

• Ramy Bishay, Mani Manoharan, Yolanda Assur, Tristan Nguyen, Sian Bramwell, Rajini Jayaballa, Glen Maberly. Risky Business: Screening and acting on metabolic disease in patients attending a Clozapine outpatient service in the ‘Diabetes Hotspot’ of Sydney west. Poster ADS 2017.

• Ramy Bishay, Gideon Meyerowitz-Katz , Mark McLean, Tien-Ming Hng, Rajini Jayaballa, Michael Edye, Clinton Colaco, Arif Uddin, Shaun Khanna, Carol Kodsi, Christophe Ng Kwet Pin, Heavenlia Rajendran, Alisha Shameem, Terence Sue, Lucinda Tran, Glen Maberly. The Overlooked: An inpatient hospital audit of obesity in one of Australia’s most obese populations. Oral presentation, ANZOS-OSSANZ-AOCO 2017.

• Tien-Ming Hng, Gideon Meyerowitz-Katz, Thomas Astell-Burt, Xiaoqi Feng, Mark McLean, Glen Maberly. The utility of HbA1c assessment in the Emergency Department. Poster ADS 2017.

• Sian Bramwell, Rajini Jayaballa, Gideon Meyerowitz-Katz, Shahana Ferdousi, Dilshan Mendis Xiaoqi Feng, Tien-Ming Hng, Mark Mclean, Glen Maberly. Diabetes in the community: Long-term patient and practice wide benefit of Joint Specialist Case Conference (JSCC) in General Practice. Poster ADEA 2017.

• Sian Bramwell, Integrated Care of people with Type 2 diabetes in Western Sydney: An evaluation of Joint Specialist Case Conference (JSCC) with General Practice. NSW state conference. ADEA 2017

• Glen Maberly: Using an App to engage and educate people with diabetes in western Sydney. Australian Diabetes Advancements and Technologies Summit (ADATS) 2017

Forum members: Cardiology Forum, July 15 2017

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AWARDS• 2017 Pemulwuy Prize, Western Sydney Leadership

Dialogue’s Out There Summit.• 2017 Productive Partnerships Award, Western Sydney

Leadership Dialogue’s Out There Summit.• Sian Bramwell Roche Best Poster Award, ADS-ADEA

Annual Scientific Meeting 30 August – 1 September 2017.• 2017 NSW Health Award for Community Eye Care in

western Sydney project for Delivering Integrated Care category.

• 2017 WentWest Partnership Award for Community Eye Care in western Sydney project. Winners of the Pemulwuy Prize: Glen Maberly, Sturt Eastwood,

Danny O’Connor and Walter Kmet

YEAR-IN-REVIEW 2017

We wish to acknowledge and thank Ian Corless (Director Integrated Care and Commissioning, Western Sydney Primary Health Network) for his contributions to Western Sydney Diabetes. We expect to have his engagement, in new ways, in the future.

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YEAR-IN-REVIEW 2017