| Abstrakt: |
Background: Diabetes Co-management in General Practice (DCGP) is a regional project being implemented in general practices in areas of Melbourne. Aims: To increase access to co-ordinated diabetes services and prevent avoidable diabetes-related hospital admissions through improved care, self-management, education and support. Methods: Credentialed Diabetes Educators (RN-CDEs) co-manage diabetes care with the patient and general practitioner, using evidence based management, care plans and referrals. Contact can be at the clinic, home visits, or via 24 hour phone support. Involvement of the RN-CDE within the general practice includes checking databases, establishing recall systems, and practice nurse support. Results: There is marked cultural diversity among patients (n=1571). The majority have non-English speaking backgrounds. Screening rates for HbA1c have improved (78.6% to 85.3%, p<0.05). Number of patients meeting HbA1cbelow 7% has increased (29,6% to 39.2%, p<0.001). There were significant reductions in diabetes related emergency department presentations at six month review (n=896, p<0.001), 12 month review (n=490, p<0.001) and 18 month review (n=215, p=0.013), and hospital admissions at six month review (n=896, p<0.001), 12 month review (n=490, p<0.001) and 18 month review (n=215, p<0.01). RN-CDEs have responded to 607 unscheduled contacts from patients and carers. Conclusion: This article describes the experiences and outcomes of a general practice based project using diabetes specialist nurses. The project is successful in providing coordinated education and care, integrating the role of the RN-CDE into general practice clinics, and improving health outcomes for people with diabetes. [ABSTRACT FROM AUTHOR] |
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