2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...

2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...


An Australian Government Initiative
2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
Diabetes Advisory Group
Diabetes Plan Steering Group
50 participants in diabetes planning day including staff from Central Coast Local Health
District, Hunter New England and Central Coast Primary Health Network, Yerin – Eleanor
Duncan Aboriginal Health Centre, Diabetes NSW, Wyong Shire, NSW Health and
104 staff who completed surveys regarding diabetes care on the Central Coast
Six clients, some with carers for participating in interviews about their care experiences
including how care could be improved.

ABS                Australian Bureau of Statistics
ACI                Agency for Clinical Innovation
AIHW               Australian Institute of Health and Welfare
CDM                Chronic Disease Management
CHS                Central Coast Community Health Survey
CKD                Chronic Kidney Disease
Diabetes Ad Gp     Diabetes Advisory Group
ED                 Emergency Department
HEAL               Healthy Eating Active Living
Int Care           Integrated Care
LHD                Central Coast Local Health District
MBS                Medicare Benefits Schedule
NRT                Nicotine Replacement Therapy
PHN                Hunter New England Central Coast Primary Health Network
PHU                Public Health Unit
RACGP              Royal Australian College of General Practitioners
SAPHaRI            Secure Analytics for Population Health Research and Intelligence
Yerin              Yerin – Eleanor Duncan Aboriginal Health Centre
2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...

Executive Summary

1.   Diabetes – A Case for Action

2. Diabetes on the Central Coast
     2.1) Diabetes and diabetes risk factors in the Central Coast Community
     2.2) Diabetes in Primary Care
     2.3) Diabetes Secondary and Tertiary Care

3. Diabetes Service Profile on the Central Coast
     3.1) Prevention services
     3.2) Primary Care services
     3.3) Secondary and Tertiary Care services

4. The Central Coast Approach to Diabetes Care
     4.1) Central Coast Diabetes Model of Care

5. Central Coast Diabetes Plan
     5.1) Priority Areas
     5.2) Actions

                                         Diabetes Care on the Central Coast   1
2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...

    This is the first Diabetes Plan and     The Central Coast Regional             The specialist services provided by
    Model of Care for the Central Coast     Leadership Executive                   the Central Coast Local Health
    created in partnership between the      Implementation Plan to Reduce          District are challenged by
    Central Coast Local Health District,    Childhood Obesity and Promote          increasing demands for their
    the Hunter New England Central          Healthy Eating and Active Living       services, implementing
    Coast Primary Health Network and        reinforces the role of sectors         improvements in technology in
    Eleanor Duncan Aboriginal Health        outside health to reduce the rates     diabetes care, and the strategic
    Services, with input from               of overweight and obesity among        imperative to support generalists
    consumers.                              Central Coast residents.               to work at the top of their scope of
                                                                                   practice – in order to maximise
    The Central Coast Local Health          For people with diabetes, much of      health outcomes for all people with
    District’s previous Diabetes Plans      their care occurs in the community     diabetes.
    have guided the development of          setting with their family doctor and
    services for people with diabetes       a range of other health                Our three organisations are
    on the Central Coast. These plans       professionals. Work continues to       committed to working together as
    have set a strong foundation for        ensure person-centred care, care       one system to improve the health
    this new population-based and           coordination, and improved health      and wellbeing of the Central Coast
    collaborative approach to               literacy and self-management           community, and to provide person-
    diabetes care.                          happens throughout the social and      centred care for people with
                                            health care system. This approach      diabetes on the Central Coast. We
    The new Diabetes Plan and Model         requires strengthening of              look forward to showing how this is
    of Care are important to address        relationships at a local or regional   achieved over the next five years.
    the increasing rate of diabetes on      level, with specialists supporting
    the Central Coast – about 10 per        general practitioners and other
    cent of adults living in the region     generalist workers so all people
    have diabetes, mostly type 2            with diabetes get the care they
    diabetes.                               need, when they need it, in a place
                                                                                   Dr Andrew Montague
                                            that feels safe to them. The
    Lifestyle related risk factors,                                                Chief Executive
                                            Primary Health Network, Yerin –
    including overweight and obesity,                                              Central Coast Local Health District
                                            Eleanor Duncan Aboriginal Health
    are major contributors to the
                                            Centre, the Local Health District,
    prevalence of type 2 diabetes. The
                                            general practitioners and other
    Central Coast Local Health District’s
                                            community-based workers are all
    Health Promotion Unit and Eleanor
                                            stakeholders in this work.
    Duncan Aboriginal Health Services                                              Richard Nankervis
    have a range of programs in place                                              Chief Executive Officer
    in the community to increase                                                   Hunter New England and Central
    physical activity levels, increase                                             Coast Primary Health Network
    fruit and vegetable consumption
    and ultimately, reduce levels of
    overweight and obesity in children
    and adults.

                                                                                   Belinda Field
                                                                                   Chief Executive Officer
                                                                                   Yerin Aboriginal Health Services

2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
Diabetes Care on the Central Coast   3
2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
Executive Summary

    Diabetes Care on the Central Coast       The guiding principles behind this    The vision for diabetes care on the
    2017-21 outlines the Central Coast       approach are:                         Central Coast is for the community,
    Diabetes Model of Care and Central                                             people with diabetes, their families
    Coast Diabetes Plan to be                • Prevention - health promotion       and carers, and health professionals
    implemented over the next five             programs to reduce incidence of     to work collaboratively to prevent
    years.                                     risk factors of diabetes and        diabetes and achieve better health
                                               proactive care to minimise the      outcomes for people with diabetes.
    Diabetes has become one of the             impact of diabetes and prevent
    most challenging problems for              complications.                      The Diabetes Model of Care
    public health. A global epidemic,        • Person-centred care and             identifies key responsibilities for
    the prevalence of diabetes is              supporting self-management          people and workers in the
    increasing and affecting on health         throughout the life of a person     community, primary care, and
    care systems worldwide.                    with diabetes and their carer.      secondary and tertiary care
                                                                                   settings. The Model of Care
                                             • Access - diabetes care to be
    In Australia, the prevalence of                                                promotes person centred care with
                                               provided as close to home as
    types 1 and 2 diabetes has risen                                               particular consideration for high
    over the last three decades1. The                                              risk groups including Aboriginal
    number of people with type 2             • Coordination and integration of
                                                                                   and Torres Strait Islander people(s).
    diabetes is growing, most likely due       diabetes care across services,
    to increases in overweight and             settings, technology and sectors.   The Diabetes Plan consists of 13
    obesity rates, poor nutrition, lack of   • Equity - with particular            priority areas across the
    physical activity and an ageing            consideration for Aboriginal and    community, primary care,
    population – all risk factors for type     Torres Strait Islander people and   secondary and tertiary settings,
    2 diabetes2.                               other marginalised people at        including early detection of
                                               higher risk.                        diabetes, specialist support for
    On the Central Coast, around 10%                                               primary care, and reducing the
                                             • Effectiveness - evidence based
    of adults live with either type 1 or 2                                         impact of diabetes among children,
                                               care, best practice initiatives.
    diabetes or high blood glucose3.                                               older Australians, those with
                                             • Quality improvement –
    This rise in prevalence coupled with                                           mental health issues, and
                                               measurement of health
    complications arising from late                                                Aboriginal and Torres Strait
                                               behaviours, treatments and
    detection and suboptimal                                                       Islander people.
                                               outcomes, and feedback to
    management of diabetes are
                                               providers and the community.
    placing significant burdens on                                                 The Central Coast Local Health
    primary, secondary and tertiary                                                District, Hunter New England
    care in the region. To address this                                            Central Coast Primary Health
    concern, a Central Coast-wide,                                                 Network and Yerin – Eleanor
    whole-of-population and whole-of-                                              Duncan Aboriginal Health Centre.
    system approach is required. The                                               (in consultation with the local
    Central Coast Local Health District,                                           community and key service
    Hunter New England Central Coast                                               providers) are committed to
    Primary Health Network and Yerin                                               working collaboratively to
    – Eleanor Duncan Aboriginal Health                                             implement the Central Coast
    Centre. in consultation with other                                             Diabetes Plan and Model of Care.
    service providers and consumers
    have developed a coordinated and
    integrated approach to diabetes
    care for the Central Coast.

2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
The Central Coast Local Health         The Hunter New England Central       Yerin – Eleanor Duncan
District is committed to:              Coast Primary Health Network is      Aboriginal Health Centre is
                                       committed to:                        committed to:
• providing specialist services
  aligned to community need,           • supporting general practices to    • ensuring community
• working collaboratively with           effectively manage diabetes,         engagement to achieve best
  primary care to support the          • working collaboratively with         health outcomes for the
  provision of integrated and            secondary and tertiary care, and     Aboriginal and Torres Strait
  effective diabetes care, and                                                Islander community, and
                                       • collecting and feeding back data
• developing health promotion            to general practices to enhance    • demonstrating high quality care
  strategies leading to a decline in     the culture of demonstrable          for the Aboriginal and Torres
  new cases of diabetes.                 improvement in patient care.         Strait Islander community in the
                                                                              primary care setting.

                                                                            These are key elements of diabetes
                                                                            care on the Central Coast that will
                                                                            help improve health outcomes for
                                                                            the Central Coast community as a
                                                                            whole, and for people with
                                                                            diabetes. There are more action
                                                                            areas, and more detailed activities
                                                                            to be found in the body of the plan.
                                                                            The partnership between the three
                                                                            organisations provides the forum
                                                                            for monitoring the progress of the
                                                                            plan, and tracking the health
                                                                            outcomes we see for the future.

                                                                            Diabetes Care on the Central Coast     5
2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
1. Diabetes – A Case for Action

    Diabetes represents one of the           The prevalence of type 2 diabetes      Risk of type 2 diabetes is greatly
    most challenging public health           increases with age, and is higher in   increased if people display a
    problems of the 21st century4. The       the Aboriginal and Torres Strait       number of modifiable lifestyle
    disease and its associated               Islander community. According to       factors. These include high blood
    complications contribute                 the Australian Institute of Health     pressure, overweight or obesity,
    significantly to mortality, morbidity,   and Welfare5, in 2014-15               insufficient physical activity, poor
    poor quality of life of sufferers and    self-reported rates of diabetes        diet and extra weight carried
    carers, and the cost of health care3.    among 65-74 year olds were three       around the waist9. In approximately
                                             times as high than for 45-54 years     58% of cases of type 2 diabetes the
    In Australia, the prevalence of          olds. The ageing population in         condition can be delayed or
    diabetes is rising, affecting around     NSW is likely to influence these       prevented by reducing weight,
    1.2 million people in 2014-152. In       rates; the population of 65+           increasing physical activity,
    New South Wales in 2016, 8.9% of         years old in the state has increased   improving diet and stopping
    people aged 16+ were told they           over the past 20 years from 12% in     smoking10. With this in mind, there
    had diabetes or high blood glucose       1996 to an estimated 15.3% in 2016,    is opportunity to promote healthy
    levels, up from 6.5% in 20023.           and is projected to increase even      eating and active living across
                                             more rapidly6.                         organisations on the Central Coast
    Although rises are seen in both
                                                                                    to help reduce prevalence of the
    types 1 and 2 diabetes, type 2           Appropriate management of              disease. This is of particular
    diabetes accounts for 85% of all         diabetes is essential. If left         relevance on the Central Coast,
    cases. Cases like these are expected     undiagnosed or poorly managed,         where around 60% of adults are
    to rise; within 20 years, the number     type 2 diabetes can lead to            currently overweight or obese3.
    of people in Australia living with       coronary artery disease, stroke,
    type 2 diabetes may increase from        kidney failure, limb amputation and    To help reduce diabetes prevalence
    an estimated 870,000 in 2014 to          blindness2. There are more than        and its consequent impact on
    over 2.5 million2.                       4,400 amputations every year as a      Australian public health services
                                             result of diabetes, of which 85% are   and systems, health promotion is
                                             preventable if diabetes is detected    important. The Diabetes Model of
                                             early and managed appropriately7.      Care and Diabetes Plan aim to
                                                                                    address health promoting
                                             Diabetes is a major cause of           environments and education
                                             chronic kidney disease (CKD).          among communities and health
                                             People receiving dialysis treatment    professionals.
                                             for CKD in Australia increased by
                                             3% from 2013 to 20148. If CKD is
                                             detected early and managed
                                             appropriately, the otherwise
                                             inevitable deterioration in kidney
                                             function can be reduced by as
                                             much as 50% and may even be

2017-21 DIABETES CARE ON THE CENTRAL COAST - Central Coast Local ...
2. Diabetes on the Central Coast

 2.1 Diabetes and diabetes risk factors
     in the Central Coast Community
 The NSW Population Health Survey (SAPHaRI) found, in the past seven
 years, the percentage of persons on the Central Coast aged 16+ who were
 told by a doctor or at hospital that they had diabetes or high blood glucose
 levels to fluctuate around 9 to 10%3. In 2014, the estimated prevalence of
 diabetes was 10.9% (7-14.7, 95% CI) and in 2016, it was 9.6% (6.9-12.3, 95%
 CI). Trend lines from 2002-2016 show an overall increase in diabetes rates on
 the Central Coast and in NSW, with rates on the Central Coast higher than in
 NSW. (Figure 1).

 Figure 1. Diabetes or high blood glucose rates for persons aged 16 years and over,                               Central Coast
 Central Coast LHD, NSW, 2002-2016                                                                                NSW
                                                                                                                  Linear (Central Coast)
                                                                                                                  Linear (NSW)
























Source: NSW Population Health Survey                              YEAR
(SAPHaRI). Centre for Epidemiology and
Evidence, NSW Ministry of Health
                                                                                        Diabetes Care on the Central Coast                 7
The Central Coast population has a      The Central Coast Community               For this report, we refer to the
     high estimated population               Health Survey (CHS) (Miles et al)         prevalence of diabetes in Central
     proportion of 16+ year olds with        allows us to compare diabetes             Coast adults as being 10%.
     diabetes lifestyle risk factors. In     rates in Gosford and Wyong. The
     2016, 30.8% of 16+ year olds on the     CHS (2014) estimated that 10.3% of        The prevalence of type 2 diabetes
     Central Coast were overweight,          Central Coast adults (18+ years)          increases with age, and the number
     26.5% were obese, 60.2% did not         had reported being told by a              of people aged 65+ on the Central
     do the recommended amount of            doctor or at hospital that they had       Coast is increasing. The ABS (2016)
     physical activity, and 20.1%            diabetes (approximately 26,000            estimated 20% of the Central Coast
     smoked3. Over the last 10 years,        people), with a slightly higher           population was 65+ years old in
     overweight and obesity rates have       proportion of adults estimated with       2015, an increase from 18% in 20106.
     increased, inadequate physical          diabetes in Wyong (10.7%) than in
     activity rates have levelled and        Gosford (9.8%). This has increased
     current smoker rates have               from 7.9% in 2006. The study also
     decreased.                              found diabetes lifestyle risk factors
                                             higher in Wyong than Gosford
                                             (Figure 2).

     Figure 2. Diabetes and risk factors, persons aged 18 years and over, Gosford, Wyong and
     Central Coast, 2014

              60                                                                                                 Source: Central
                                                                                                                 Coast Local Health
                                                                                                                 District. Central
                                                                                                                 Coast Community
                                                                                                                 Health Survey:
                                                                                                                 Analysis of
                                                                                                                 Telephone Survey

                                                                                                                 Community Health
                                                                                                                 Survey smoking data
                                                                                                                 inconsistences due
                                                                                                                 to rounding




                   diabetes    overweight         obese          inadequate          current       high blood
                                                                  p.activity         smoker         pressure

     Gosford         9.8            34              21.8             45                14.2            28.5

      Wyong          10.7          33.1            29.9              49.5              14.5            31.9

Central Coast        10.3          33.8            25.7              46.7              14.7            29.7

2.2 Diabetes in Primary Care
The Hunter New England Central
Coast Primary Health Network
(PHN) offers practice support and
development to general practices
on the Central Coast. This includes
use of the practice data extraction
and analysis tool PEN/PATCAT. In
2016, 61 (57%) Central Coast
practices had data agreements
with the PHN to use this tool. For
those practices who provide
aggregated de-identified clinical
data using PEN/PATCAT, quarterly
reports are produced and provided
to general practices, benchmarking
where possible - activity with peer
group-comprising general practices
in the same remoteness area (as
identified by ABS – RA1, 2 etc). The
tool also allows for the analysis of
data to assist with population         This cohort of patients includes     Key observations
health and services planning.          those coded as having diabetes
                                       and those indicated by the PEN/      • From this population, 11% of
The data following is based on         PATCAT tool who are likely to have     people have diabetes, which is
aggregate data from 51 (48%)           diabetes. Those likely to have         similar to that estimated for the
practices on the Central Coast that    diabetes have glycated                 Central Coast population
provided data extracted from PEN/      haemoglobin (HbA1c) >=6.5 or,        • For people with diabetes,
PATCAT in the 6-month period to        HbA1c recorded AND on an anti-         the measure of blood sugar
the end of February 2017 (for more     diabetic medication or, fasting        control over the last 3 months,
data see Appendix 1). More than        blood glucose (FBG) >7.                HbA1c, was 7% or less for 56%
95% of the data summarised was                                                of people, >7% for 29% of
provided in the January-February                                              people, and was not recorded
2017 period. The data is for active                                           for 15% of people
patients 18 years and over only.
                                                                            • For people with diabetes,
Active patients are defined by The
                                                                              31% had high blood pressure.
Royal Australian College of General
                                                                              Blood pressure was not recorded
Practitioners (RACGP) and includes
                                                                              for 7% of people
those patients who have visited a
                                                                            • For people with diabetes,
general practice three or more
                                                                              65% were overweight or obese
times within the last two years.
                                                                              and for 25% of people BMI was
                                                                              not available

                                                                            Diabetes Care on the Central Coast    9
Table 1: Summary data provided by General Practices in the Central Coast relating to
     diabetes, PEN/PATCAT extracts, 6 months to Feb 2017

                                                                               Gosford      Wyong    Central Coast
      Number of general practices                                              57           50       107
      Practices who have provided data                                         23           28       51

      Total active patients                                                    99394        108721   208115
      Total patients with diabetes*                                            10482        12352    22834
      Total patients with diabetes (%)                                         10.5         11.4     11.0

      Total patients with Diabetes Type 1 (%) **                               8.4          7.3      7.7
      Total patients with Diabetes Type 2 (%)                                  71.0         76.1     74.4
      Total patients with Diabetes Other (%)                                   20.6         16.5     17.9

      Total patients with diabetes, HbA1c > 7 (%)                              28.7         29.8     29.3
      Total patients with diabetes, HbA1c > 8 (%)                              14.0         15.3     14.7
      Total patients with diabetes, HbA1c not recorded in last 12 months (%)   16.9         13.1     14.8

      Total patients with diabetes, with high blood pressure                   29.1         32.7     31.1
      (>140 over 90) (%)
      Total patients with diabetes, blood pressure not recorded (%)            7.0          7.1      7.1

      Total patients with diabetes, overweight (%)                             21.6         22.1     21.8
      Total patients with diabetes, obese (includes morbidly obese) (%)        39.6         46.8     43.5
      Total patients with diabetes, BMI not available (%)                      27.2         22.7     24.7

      Total ATSI patients (%)                                                  2.1          6.1      4.2
      Total ATSI patients with diabetes (%)                                    9.5          7.6      8.5

     * Unless otherwise specified, the term
        ‘patients with diabetes’ in this table refers
        to the combined group of patients coded as
        having diabetes and indicated as likely to
        have diabetes
     ** Denominator for rates of diabetes types
        includes patients with both Type 1 and Type
        2 diabetes

Medicare data

                Medicare data gives limited                      ten activities completed over a 12
                knowledge of activity due to a                   month period and a full eye check
                limited number of diabetes-specific              every 24 months for diabetic
                Medicare Benefits Schedule (MBS)                 patients which can be claimed
                item numbers (see Appendix 2 for                 every 12 months.
                MBS item details). MBS items 701-
                707 can be claimed for health                    Data in Figure 3 and 4 may indicate
                assessments for seven specified                  an increase in service counts and
                target groups, including patients                practitioners performing health
                aged 40-49 years who are at risk                 assessments. It may also indicate
                of developing diabetes as assessed               no increase in the number of
                by the Type 2 Diabetes Risk                      annual cycles of care being
                Assessment Tool. MBS item 715                    performed and no increase in the
                can be claimed for health                        numbers of practitioners
                assessments for Aboriginal people.               performing an annual cycle of care.
                The diabetes annual cycle includes
                Figure 3. Number of Medicare item health assessments and annual diabetes cycle of care,                                         2014
                Central Coast, 2012-15                                                                                                          2015



Service Count




                                 701                    703                705                707                 715                 annual cycle
                                                                                                                                        of care
                         Source: Australian Government Department
                                                                               Medicare item
                         of Health, Medicare Benefits Schedule Data

                                                                                                       Diabetes Care on the Central Coast              11
                 Figure 4. Number of GPs claiming Medicare health assessment and annual cycle of care,                   2014
                 Central Coast, 2012-15                                                                                  2015


Number of GPs’




                                 701                    703            705           707                 715   annual cycle
                                                                                                                 of care
                          Source: Australian Government Department
                          of Health, Medicare Benefits Schedule Data     Medicare item

2.3 Diabetes in Secondary and Tertiary care
                              Hospitalisations where diabetes is the main cause

                              There were 742 hospitalisations due to diabetes (main reason for
                              admission) among Central Coast residents in 2015-163. This represents a rate
                              of hospitalisation per 100,000 population per year of 225 for males (432
                              admissions) and 162 for females (310 admissions). The same rates for NSW
                              in 2015-16 were 168 per 100,000 for males and 133 per 100,000 for females.
                              Figure 5 shows the Central Coast rates for persons with diabetes as a
                              principal diagnosis were above the state average.

                              Figure 5. Diabetes as a principal diagnosis, hospitalisations, Central Coast LHD, NSW
                              2010-11 to 2015-16

                                 250                                                                                                                       Central Coast

Rate per 100,000 population




                                          2010-11           2011-12          2012-13          2013-14          2014-15            2015-16

                              Source: NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI).
                              Centre for Epidemiology and Evidence, NSW Ministry of Health. Accessed 4.9.17

                                                                                                                                Diabetes Care on the Central Coast         13
Amputations due to diabetes

                               From 2012 to 2016, among Central Coast residents and due to diabetes, there were on average, per year:

                               • 11 below knee amputations
                               • 62 toe/foot/ankle amputations, and
                               • 6 above knee amputations.

                               The rates of amputations were about 16%, 16%, and 37% higher than the state average for below knee, toe/foot/ankle,
                               and above knee amputations respectively (though not statistically significantly different, as some of these numbers
                               are relatively small).

                               Figure 6. Amputations due to diabetes, hospitalisations by site of amputation: Below the
                               knee, Comparison by LHD, NSW, 2013-16
 Rate per 100,000 population

























































                               Figure 7. Amputations due to diabetes, hospitalisations by site of amputation: Toe/foot/
                               ankle, Comparison by LHD, NSW 2013-2016
 Rate per 100,000 population

























































                               Source: NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI).
                               Centre for Epidemiology and Evidence, NSW Ministry of Health. Accessed 4.9.17

3. Diabetes Service Profile on the Central Coast

3.1 Prevention services
There are many organisations on        Healthy Eating Active Living: the    Other organisations involved in and
the Central Coast that implement       health promotion service has a       supporting health promotion
strategies to address the lifestyle    strong commitment to promoting       initiatives include PHN, Yerin –
risk factors for diabetes and other    healthy eating and active living     Eleanor Duncan Aboriginal Health
chronic diseases. Examples include     across the Central Coast             Centre, CC Council, NSW
implementing health promotion          community. There is enhanced         Department of Education and
policies and practices in the          focus on achieving the NSW           Communities, Broken Bay Diocese
workplace (no smoking worksite         Premier’s Priority (2015) of         Catholic Education Commission,
and Nicotine Replacement Therapy       reducing overweight and obesity      Association of Independent
(NRT) for those attempting to quit,    rates in children by 5% over 10      Schools, NSW Ministry of Health,
healthy food at staff cafeteria),      years. The Central Coast Healthy     Office of Preventive Health, Healthy
providing structural support for       Eating & Active Living (HEAL)        Kids Association, CC Primary
good health (Council shared            Delivery Plan also addresses adult   School Principals and teachers,
pathways) and running programs         overweight and obesity at a local    Central Coast School Education
that encourage good health             level and supports the NSW HEAL      Region, early childhood education
(exercise classes for older adults).   Strategy 2013-2018. Key actions      and care services, TAFE NSW, Early
                                       include:                             Childhood Training and Resource
The Central Coast Local Health                                              Centre, WorkCover (Gosford), NSW
District (LHD) Health Promotion        • Develop, implement and             Business Chamber (CC), Local
Service is a key service using a         evaluate a Central Coast HEAL      Chambers of Commerce, private
population health approach and           Delivery Plan that engages and     gyms and pools, walking groups,
working in partnership with others       mobilises relevant stakeholders    Cancer Council NSW, Heart
to improve the health of the             across sectors.                    Foundation NSW, Diabetes NSW.
Central Coast community.               • Continue the tailored local
                                         delivery of state-wide programs
Work led by the Health Promotion
                                         and supporting strategies that
Service to address chronic disease
                                         promote healthy eating and
risk factors includes:
                                         active living for children and
                                         adults, such as Munch and Move,
                                         Live Life Well at School, Go4Fun
                                         and referral to the Get Healthy
                                       • Continue advocacy for health
                                         promoting environments by
                                         working with planning agencies
                                         to ensure population health is
                                       • Integrate and emphasise
                                         physical activity in all
                                         appropriate projects.

                                                                            Diabetes Care on the Central Coast     15
3.2 Primary Care services
     General Practices

     In 2016 the Central Coast had an estimated population of 333,11912. There were approximately 447 GPs,
     with a total full service equivalent (37.5 working hours per week) of 281 across 106 general practices (PHN).
     In 2015, the rate of supply of general practitioners in Australia was 114 per 100,00013 based on full-time
     equivalent defined as working 40 hours per week. Central Coast has less than the national average of GPs
     per 100,000 population.

     In 2016 there were approximately 228 Practice Nurses on the Central Coast working in 73 general practices

     Table 2. General Practice’s in Gosford, Wyong and Central Coast, 2016

                                                               Gosford Wyong              Coast
      General Practices                                        54            52           106
      GP total                                                 237           210          447
      GP full service equivalent                               163.5         117.5        281
      GP FSE per 100,000 population                            94            73.8
      Registrar                                                29            12           41

     Source: Estimates from HNECC PHN ChilliDB workforce data, Nov 2016
     Note: GP hours are missing from two practices in Gosford and seven in Wyong so number FSE hours and FSE per 100,000 would be higher, provided by
     Preliminary GP and Registrar numbers only. Headcounts only, does not account for GPs or Registrars who may work in more than one general practice

     Allied Health Services

     Allied Health information was most recently collated by Central Coast Medicare Local in mid-2015 and should be
     used with caution. Allied Health professionals employed at LHD and Gosford Private Hospital are not included here.
     Data gives an indication of relative workforces in 2015.

     Table 3: Allied Health professionals in private practice and service in Gosford, Wyong and Central Coast, 2015

      Health Professionals /Services                           Gosford Wyong              Coast
      Podiatrists                                              41            38           79
      Pharmacies                                               36            37           73
      Pharmacists                                              63            58           121
      Diabetes Educators                                                                  3
      Dietitians                                                                          26
      Exercise physiologists                                                              29

     Source: Information from CC Medicare Local collected in mid-2015 and no longer updated

Yerin – Eleanor Duncan Aboriginal       Hunter New England Central Coast Primary Health Network
Health Centre
                                        The PHN is a not-for-profit            • PENCAT feedback to practices;
Yerin – Eleanor Duncan Aboriginal       organisation funded by the               summary of practice activity and
Health Centre. (Yerin) is a             Commonwealth Government to               patient outcomes provided to
community controlled integrated         improve the efficiency and               practices to assist with
primary health care service located     effectiveness of the primary health      identifying areas of need
at Wyong and Gosford on the NSW         care system.                           • Hunter Alliance Diabetes
Central Coast, Darkinyung country.                                               Integration Project; high risk
Yerin – Eleanor Duncan Aboriginal       The PHN works in collaboration
                                                                                 diabetes patients attend a case
Health Centre is the only               with its partners and stakeholders
                                                                                 conference at the GP practice
community controlled Aboriginal         to deliver better health outcomes.
                                                                                 with at least a GP, practice nurse,
Health Service on the Central           Diabetes management forms part
                                                                                 endocrinologist and diabetes
Coast. Services provided in relation    of this vision. Key initiatives
                                                                                 educator in attendance.
to diabetes include:                    currently in place that support
                                                                                 Education for GPs and practice
                                        diabetes management and care
                                                                                 nurses also takes place. Six and
• clinical services by GPs, practice    coordination include:
                                                                                 12 month outcomes are
  nurses and Aboriginal health
                                                                                 favourable and a similar project
  practitioners,                        • HealthPathways; an online
                                                                                 is being considered for piloting
                                          health information portal for GPs
• a Medical Outreach Indigenous                                                  on the Central Coast.
                                          and other primary health
  Chronic Disease Program which
  comprises of monthly services
  including a visiting                  • Patient Info; a website with
  endocrinologist, diabetes               trusted health information likely
  educator, podiatrist and dietitian,     to be helpful for patients with
                                          diagnosed conditions
• an optometrist visiting one other
  day a fortnight,                      • Practice Support and
                                          Development; this team provides
• an Integrated Team Care service
                                          direct support to general
  that assists clients with chronic
                                          practices in areas such as
  health issues to receive the
                                          Practice Management,
  health care they need, such as
  organising doctors’
                                          Development, Digital Health,
  appointments, transport to and
                                          Quality Improvement/
  from appointments, following up
                                          Accreditation, Chronic Disease
  with clients on their health plan,
                                          Management, Preventative
                                          Health, Workforce Support,
                                          Immunisation, Practice data
                                          extraction and analysis
                                        • Better health care planning for
                                          our region
                                        • Practice data analysis; collective
                                          de-identified practice data
                                          analysed to assist with
                                          identifying area needs, service
                                          gaps and enhance service

                                                                               Diabetes Care on the Central Coast      17
3.3 Secondary and Tertiary Care services
     Members of the LHD diabetes specialist team include:

     • 1.5 FTE LHD endocrinologists, approximately 50% of time diabetes related
     • 7 FTE LHD diabetes educators
     • 2.2 FTE LHD dieticians diabetes related
     • 8.2 FTE LHD podiatrists, approximately 90% of time diabetes-related

     In total there are seven endocrinologists working publicly and/or privately on the Central Coast.

     Private allied health professionals have been included under Primary Care Services.

     A summary of LHD services available for diabetes clients is presented in Table 4.

     Table 4. Diabetes services available for diabetes clients

     Diabetes services                                      Endo        D Ed         Diet         SW     Pod
     Inpatient services                                     x           x            x            X      x
     Paediatric Outpatient Appointments                     Paed Endo x              x            x
     Paediatric Diabetes Clinic                             Paed Endo X              X            x
     Team T1 Adolescent Insulin Adj and CHO Count                       x            x
     Paediatric School visits                                           x
     Antenatal Endocrine Clinic                             x           x            x
     GDM Group                                                          X            x
     Antenatal Insulin Stabilisation Program                            x
     Young Persons Transition Clinic                        X           X            X            x
     Insulin Stabilisation Program                                      x
     Type 1 Group                                                       x            x
     Type 2 Group                                                       x            x
     Adult Outpatients Appointments                         x           x            x            x
     DM Outpatient Clinic; DEd and Diet                                 x            x
     DM Outpatient Clinic; Diet only                                                 x
     T1 Insulin Pump Clinic                                 x           x            x            x
     Continuous Glucose Monitoring Service Clinic           x           x
     Complications Clinic                                   x           x            x                   x
     Foot Wound Clinic                                                                                   x
     Diabetes Foot Assessment Clinic                                                                     x
     High Risk Foot Clinic                                                                               x
     48 hr follow up                                                    x
     Home Visits                                                        x
     External Education                                                 x
     Staff Diabetes Education                                           x
     National Aborigines and Islanders Day                  x           x            x            x      x
     Observance Committee (NAIDOC)

Additional diabetes related
LHD services

Nunyara Aboriginal Health Unit
provides a range of health services
for Aboriginal and Torres Strait
Islander people. The Chronic Care
Manager and CNS Chronic Care for
Aboriginal People implement the
Chronic Care program which
includes but is not limited to
following up patients who have
been admitted to hospital and
identified as having one or more
chronic disease/s, and coordinating
an annual NAIDOC celebration
including an extensive health

The Chronic Care self-management
program consists of community
voluntary leaders running the
Stanford Better Health
Management Program at various
Central Coast locations for
community members with chronic

Ongoing and Complex Care
supports a CNS2 within Diabetes
for Chronic Disease Management
(CDM). Diabetes is one of five of
the targeted diagnostic areas for
the selection of CDM patients.
These complex patients may be
offered case management or
coaching within the work of care
coordination and complex care.

                                      Diabetes Care on the Central Coast   19
4. The Central Coast Approach to Diabetes Care

     The vision for diabetes care on the   The LHD, PHN and Yerin – Eleanor      A proposed Diabetes Model of
     Central Coast is for the community,   Duncan Aboriginal Health Centre in    Care to be adopted and a Diabetes
     consumers and health professionals    consultation with other service       Plan to be implemented over the
     to work collaboratively to prevent    providers and consumers have          next five years have been
     diabetes and achieve better health    worked collaboratively to develop a   developed. Both the model and
     outcomes for those with diabetes.     coordinated and integrated            plan range from diabetes
                                           approach to diabetes care. The        prevention through to
     The incidence of diabetes and         planning process identified service   management of complications in
     diabetes risk factors is high and     gaps and opportunities, and           the community through to the
     increasing. A Central Coast wide,     consumer and community needs.         tertiary setting.
     whole-of-population and whole-of-     The Australian National Diabetes
     care approach is required to          Strategy 2016-202014 was used as
     address this concern.                 a framework to develop this local
                                           plan. Other regional, state and
                                           international approaches have also
                                           been considered15-20.

     4.1 Central Coast Diabetes Model of Care

     The proposed Central Coast            The model promotes:
     Diabetes Model of Care (graphic
     follows) provides a framework for a   • Consumer centred care with          • Secondary and tertiary setting;
     coordinated and integrated              particular consideration for          diabetes specialists provide care
     approach to diabetes prevention         Aboriginal and Torres Strait and      for complex diabetes and
     and management to achieve better        other marginalised people to          support to primay care
     health outcomes for our                 reduce inequalities in care.          providers.
     community. The model includes         • Community setting; prevention       • Further development and
     key elements of care in the             and health promotion to               implementation of this Model of
     community, primary care, and            improve the health of the whole       Care falls within the scope of this
     secondary and tertiary care             community and may focus on            plan.
     settings and acknowledges that          identified target groups.           • This model acknowledges that
     care overlaps between settings.       • Primary care setting; general         there is variability among
                                             practice has the central role in      practitioners and a need for
                                             diabetes identification and           some flexibility; some GPs may
                                             management. Specialists assist        wish to extend their role into
                                             with complex diabetes and             more complex care, others may
                                             provide health professional           need greater support for their
                                             education updates. Primary            patients.
                                             Health Network provide regional
                                             and practice specific data
                                             analysis and support practice

Model of Care

                                                                  Community Setting
                                                                  1. Prevention and Health Promotion
                                                                     a. Building healthy public policy
                                                                     b. Supportive environments
                                                                     c. Promoting healthy lifestyle
                                                                     d. Partnership and planning with services,
                                                                        organisations, consumers and communities

                                                             2. Consumer and community
                                                                engagement: Across all settings

                                                             3. Reduction of health inequalities:
     Primary Care Setting
                                                               Target Aboriginal & Torres Strait
     4. Primary Care: General health and wellbeing             Islander people and other
                                                               marginalised people
     5. Primary Care relating specifically to
        diabetes: “The Necessary Nine”
                                                                                  Secondary & Tertiary
         a. Screening
                                                                                  Care Setting
         b. Prevention
         c. Regular reviews / surveillance                                        7. Complex Care: “The Super Seven”
         d. Prescribing                                                             a. In-patient care
         e. Insulin                                                                 b. Insulin pumps
         f. Patient & carer self-management                                         c. End stage renal
            education                                                               d. High risk foot
         g. Cardiovascular                                                          e. Children/ adolescents
         h. Housebound / care homes                                                 f. Pregnancy
         i. Outcomes / audit                                                        g. Type 1 / rare / complex / unstable

     6. Specialist support for Primary Care

Adapted from: Leicestershire Clinical Commissioning Groups
                                                                                        Diabetes Care on the Central Coast   21
5. Central Coast Diabetes Plan

     The Central Coast Diabetes Plan
                                              Priority Areas
     (pp 23-40) identifies 13 priority
     areas across the community,              All Settings
     primary care, secondary and              1     Enhance consumer involvement
     tertiary settings.
                                              2     Align workforce capacity with community need
     Priority areas across all settings       3     Further develop and enhance utility of information and
     include enhanced consumer                      communication technology
     involvement, aligning workforce
     capacity with community need,            Community Setting
     and use of information and               4     Promote healthy eating and active living across the Central Coast
     communication technology. These
                                              Primary Care Setting
     are essential for coordinated,
     integrated and best practice             5     Maximise the early detection of diabetes
     diabetes care.                           6     Strengthen primary care management of diabetes and local care
     Prevention and health promotion
     priority areas include promoting         7     Implement a consistent approach to patients diabetes education and
     healthy living and active living in            self-management
     the community.
                                              8     Strengthen and expand specialist support for Primary Care
     Early detection and optimal              9     Reduce the impact of diabetes among Aboriginal and Torres Strait
     diabetes management takes place                Islander people
     predominantly in general practice
                                              Secondary and Tertiary Care Setting
     with support from diabetes
     specialists. Priority actions focus on   10    Further develop and enhance diabetes services to better outcomes
     early detection, self-management,              for people with newly diagnosed or complex diabetes
     marginalised and priority groups,        11    Reduce the impact of diabetes among Aboriginal and Torres Strait
     and best practice diabetes                     Islander people
                                              12    Reduce the impact of pre-existing and gestational diabetes in
     Enhanced services are provided by              pregnancy
     the diabetes specialist team to          13    Reduce the impact of diabetes among children with diabetes, older
     manage complex diabetes, support               Australians, and those with mental health and wellbeing issues
     general practices to manage
     complex patients and to provide
     education updates to health

5.2 Actions

All Settings
LHD, PHN and Yerin – Eleanor Duncan Aboriginal Health Centre will work collaboratively to provide evidence-based,
comprehensive, accessible, efficient and coordinated diabetes prevention and management services for all people on
the Central Coast reflective of community need.

Key Priority Area 1: Enhance consumer involvement

Actions                                Performance Indicators               Responsible                 Timeframe
1.1 Engage existing avenues for        Meetings with:
consumer involvement in identifying
                                       CCLHD Community                      Diabetes                    Mar 2017,
gaps, health planning and service
                                       Engagement Committee                 Advisory Group              ongoing
delivery including PHN and LHD
Clinical Councils, PHN Central Coast   CCLHD Clinical Council                                           Jul 2017
Community Advisory Committee,          HNECCPHN Clinical Council                                        Oct 2017
LHD Consumer and Community
                                       HNECCPHN Community                                               Aug 2017
Engagement Committee, PHN and
                                       Engagement Committee
LHD Collaboration Unit GP Panel,
Yerin – Eleanor Duncan Aboriginal      CC GP Collaboration Unit                                         Ongoing
Health Centre’s men’s and women’s      – GP Panel
                                       Yerin – Eleanor Duncan Aboriginal                                Ongoing
                                       Health Centre’s men’s and
                                       women’s groups
1.2 Identify and implement best        (a) Consumer(s) on Diabetes          Diabetes                    Jun 2017, ongoing
consumer feedback mechanisms for       Advisory Group                       Advisory Group
diabetes services and programs
                                       (b) ACI Patient Journey              LHD Public                  Oct 2017
including but not limited to:
                                       – Diabetes Education Centre          Health/Int Care
(a) consumers on Diabetes
                                       (b) Existing service evaluation/                                 Ongoing
Advisory Group
                                       feedback                             Service managers
(b) feedback from people attending                                          in each
diabetes services                                                           organisation
                                       (c) CCLHD survey and report,                                     Oct 2017
(c) survey LHD employees with          with recommendations                 LHD Public
diabetes and those with family /                                            Health/Int Care/
friends with diabetes                                                       Yerin – Eleanor
                                                                            Duncan Aboriginal
                                                                            Health Centre

                                                                               Diabetes Care on the Central Coast           23
Key Priority Area 2: Align workforce capacity with community need

     Actions                                 Performance Indicators           Responsible         Timeframe
     2.1 Analysis of service use data,       Population need identified and   LHD Planning/       2017-18
     population health data, best            reported                         Public Health/
     practice guidelines to define/                                           Performance,
     estimate community need.                                                 PHN, Yerin –
                                                                              Eleanor Duncan
                                                                              Aboriginal Health
     2.2 Determine workforce capacity,       Workforce capacity report        LHD Workforce/      2017-18
     and how they relate to the Central                                       Planning/Public
     Coast population’s needs – across                                        Health, Diabetes
     LHD, PHN, General Practice and                                           Services, Yerin –
     Yerin – Eleanor Duncan Aboriginal                                        Eleanor Duncan
     Health Centre’s range of health                                          Aboriginal Health
     workers                                                                  Centre, PHN
     2.3 Identify areas of need and          Workforce analysis report and    Workforce/          2018
     actions required for the Central        recommendations                  Planning/Public
     Coast health workforce, including                                        Health/Diabetes
     but not limited to diabetes                                              Services, PHN,
     education for health workers in                                          Yerin – Eleanor
     hospital and community settings;                                         Duncan Aboriginal
     clinical care options for people with                                    Health Centre
     type 1 and type 2 diabetes, and
     higher risk populations. Identify the
     types of skills, and workforce
     required to deliver the Diabetes
     Model of Care for the Central Coast
     2.4 Explore options to increase         (a) private providers included   (a) PHN, LHD        2018
     access to diabetes services in the      in HealthPathways
     community, e.g. community health,
                                             (b) roles of private providers   (b) PHN
     community pharmacies, private
                                             identified and supported
     allied health providers.

Key Priority Area 3: Further develop and enhance utility of information and communication technology

Actions                                   Performance Indicators                 Responsible                    Timeframe
3.1 Fully utilise existing information    Strategies implemented and
and communication systems such as         activity monitored
eMR, CHOC, ComCare, Argus, MHR
and PENCAT to deliver better clinical
and operational performance and
support improved patient outcomes
and experience
(a) Develop ComCare to receive and        (a) ComCare receives electronic        (a) External                   TBA
send messages directly from and to        faxes. Receiving and sending out       provider/LHD
primary care via secure messaging         Argus messages in development.         ComCare
(b) ComCare to use patient                (b) Exists for new patients.           (b)                            Ongoing
demographic data from eMR                 Else manual updates
(c) Enable patients notes to be           (c) Functionality now in place         (c) LHD ComCare/               July 2017
shared between CHOC, ComCare                                                     eMR support
and eMR                                                                          teams
(d) Investigate the possibility to        (d) Assess functionality of Audit 4,   (d) LHD Diabetes               2018
enable interface between Audit 4          connectivity                           services
and CHOC, ComCare and eMR
(e) eMR referral to Diabetes              (e) Feasible. For consideration.       (e) LHD ComCare/               Dec 2017
Educator (via ComCare)                                                           eMR teams
(f) Pilot GPs sending health              (f) Feasible. In progress.             (f) LHD Int Care               2018
summaries directly to ED
(g) Investigate the possibility for the   (g) Functional requirements            (g) LHD Diabetes               2018/19
Citrix platform to enable software        to be determined.                      services, NSW
changes rather than making changes                                               Health State wide
to individual computers.                                                         service desk
(h) Discharge summaries from              (h) Update from Obstetrix              (h) LHD                        Dec 2017
maternity to GPs                                                                 eMaternity
(i) Discharge summaries from              (i) Update from relevant working       (i) LHD eMR team               2019
hospital to residential aged care         group
(j) Promote use of My Health              (j) Request update from PHN            (j) PHN                        2018
(k) SMS to patients for (i)               (k) (i) Feasible.                      (k) LHD ComCare/               k.i) 2018
appointment reminders and (ii)            For implementation.                    eMR teams
capacity to respond
                                          (k) (ii) Assess feasibility                                           k.ii) 2019

                                                                                       Diabetes Care on the Central Coast    25
     Actions                                 Performance Indicators              Responsible        Timeframe
     3.2 Investigation and investment        Emerging technologies               LHD IT, PHN
     into emerging technologies              identified and implemented
     including but not limited to (a) 3D
                                             (a) For review                      (a) LHD Podiatry   2020
     scanning and printing for diabetes
     wound orthoses, (b) electronic          (b) patient portal – not yet        (b) LHD ComCare    2020/21
     appointment system for patients,        available
     (c) e-referrals (Argus), (d)            (c) feasible – review business      (c) LHD            2018
     telehealth (e) use of apps (f) social   model
     media. Modifications also required
                                             (d) feasibility on Central Coast,   (d) PHN            2018/19
     to better support Model of Care.
                                             MBS item nos
                                             (e) assess functionality of apps    (e) LHD Diabetes   2019

Community Setting
A population approach is used to prevent people developing type 2 diabetes. Programs are aimed at targeted
populations rather than individuals and are delivered in partnership with other services, organisations and
communities. Working in partnership ensures that health promotion practices are embedded into other settings,
other professionals are up skilled in health promotion and programs are subsequently more sustainable. There is
enhanced focus on achieving the NSW Premier’s Priority (2015) of reducing overweight and obesity rates in children
by 5% over 10 years.

Key Priority Area 4: Promote healthy eating and active living

Actions                                 Performance Indicators                 Responsible                 Timeframe
4.1 With Dept. Premier and Cabinet,     Sub-committee had first meeting        LHD Health                  2017 - 2025
lead on the development of a            June 2017.                             Promotion, Dept.
whole-of-government regional                                                   Premier and
                                        Cross-agency action plan
approach to address childhood                                                  Cabinet
                                        completed and agreed upon at
overweight and obesity on the
                                        June 2017 meeting. For annual
Central Coast. Establish Central
                                        progress report to NSW Health.
Coast Regional Leadership
Executive Sub-committee for cross-
agency collaboration on reducing
obesity and promoting healthy
eating and active living. Develop
cross-agency action plan to address
childhood overweight and obesity
in the region
4.2 Enhanced focus on tailored local                                           LHD Health                  Ongoing
delivery of state-wide programs                                                Promotion reports
promoting healthy eating and                                                   on each of these
active living in early childcare                                               programs
settings, schools, community sports,                                           quarterly to NSW
workplaces and community settings                                              Health
(a) foster healthy habits in children   (a) Support provided to, and
and young people at school              ‘uptake measures’ for 79 primary
                                        schools, 29 high schools
(b) provide a supportive                (b) Measures of capacity for 127
environment for healthy eating,         early childhood education and
physical activity and reducing small    care services
screen recreation for children in
early childcare settings
(c) increase referrals to Get Healthy   (c) Annual report provided to LHD
Service and Go4Fun                      for Get Healthy Service (including
                                        tailored Type 2 Diabetes
                                        Prevention program and Get
                                        Healthy in Pregnancy) including
                                        number of referrals, weight loss
                                        and waist circumference. Target
                                        for 2017-18, 383 referrals by Health
                                        Professionals; target for 2017-18
                                        Go4Fun to deliver 12 programs

                                                                                  Diabetes Care on the Central Coast     27
     Actions                             Performance Indicators                  Responsible        Timeframe
     4.3 Advocate for health promoting   Develop planning strategies             LHD Health         Ongoing
     environments and provide            for safe walking, cycling, public       Promotion/Public
     submissions to planning agencies    transport and chilled water             Health Unit
     and development processes to        stations
     ensure population health is
                                         Implement healthier food and
     prioritised. Promote environments
                                         drink policy initiative for staff and   LHD                2017, ongoing
     that support healthy eating and
                                         visitors in NSW Health facilities.
     active living.

Primary Care Setting
Around one in five adults with diabetes do not know they have the condition21. If left undiagnosed or poorly
managed, diabetes can lead to coronary artery disease, stroke, kidney failure, limb amputations and blindness. Early
detection and optimal management of diabetes can improve access to necessary care and reduce complications,
improving quality of life among people with diabetes and reduce the escalating burden on health resources. General
practice has the central role in type 2 diabetes management across the spectrum, from identifying those at risk right
through to caring for patients at the end of life2, and is supported by specialty services.

Key Priority Area 5: Maximise the early detection of diabetes

Actions                                 Performance Indicators                Responsible                  Timeframe
5.1 Address risk factors for disease,   (c) Annual report provided to LHD     LHD Health                   2017, ongoing
in the whole population and for         for Get Healthy Service including     Promotion
people with diabetes by extended        referrals and weight loss and waist
promotion of Get Healthy Service        circumference. Target for 2017-18,
utilisation to health professionals     383 referrals by Health
5.2 Promote strategies aimed at
screening and early detection of
people at risk of developing
(a) implementation, evaluation and      (a) ‘Over 40? Check Your Risk!’       LHD Health                   2017-18
review the diabetes prevention          implemented                           Promotion/Public
campaign, ‘Over 40? Check Your                                                Health, PHN, Yerin
                                        # hits on Health Promotion Check
Risk!’ (a program that includes                                               – Eleanor Duncan
                                        Your Risk site
education about diabetes risk                                                 Aboriginal Health
factors and the promotion of            # Health Assessments (MBS) via        Centre                       2018
diabetes screening by GPs)              PENCAT/MBS

(b) Assess feasibility of trial to      Review with recommendations
                                                                              LHD Public
undertake BSL on every patient to       (b) Brief report on feasibility,                                   2018-19
ED or admitted to hospital,             expected outcomes and                 Promotion
including impact for services           recommendations
providing follow-up and benefits                                              LHD Diabetes
                                                                              Advisory Group

                                                                                  Diabetes Care on the Central Coast       29
Key Priority Area 6: Strengthen primary care management and local care pathways

     Actions                                 Performance Indicators               Responsible         Timeframe
     6.1 Build on the Diabetes Model of      GP and practice nurse education –    Diabetes Advisory   May18 ongoing
     Care (from this plan) to consolidate    annual forum                         Group, PHN
     roles and responsibilities of primary
                                             Range of HealthPathways exist        PHN                 Ongoing
     care providers, and implement
                                             for diabetes care
     strategies to support primary care
                                             Number of times accessed,
     providers. Including education for
                                             unique users
     general practitioners and practice
     nurses, use of care guidelines          Review of pathways every 2 years     PHN                 Ongoing
     (HealthPathways), referral pathways     Develop mechanisms to monitor        PHN/Diabetes        2019-20
     and options to access diabetes          referrals, specialist feedback and   Advisory Group
     specialist advice and transition        GP feedback, appropriateness
     6.2 Support quality improvement
     processes in general practice,
     including mechanisms for primary
     care providers to use their clinical
     data to compare with peers and
     care guidelines.
     (a) PHN practice support team to        (a) Number of practices receiving    PHN                 Annually
     provide clinical data feedback to       clinical feedback report
     GPs                                     % of GPs/patients achieving care     PHN                 Annually
     (b) PHN assisting/ training GPs to      (b) Number of practices using        PHN                 Annually
     use clinical software to generate       recall/reminders
     recalls and reminders, pro-actively     Number of practices prioritising     PHN                 Annually
     manage people with complex issues       complex cases

Key Priority Area 7: Implement a consistent approach to diabetes education and self-management

Actions                                 Performance Indicators                Responsible                 Timeframe
7.1 Continue to implement and           Number of Stanford program            LHD Chronic Care            Annually
promote the various health self-        attendees with diabetes               Self Management
management and support
                                        Get Healthy Service Diabetes –        LHD Health                  Annually
programs offered on the Central
                                        activity report                       Promotion
Coast including but not limited to
the Stanford Better Health              LHD Diabetes and Nutrition            LHD Diabetes                Annually
Management program offered by           education                             Services/Nutrition
LHD and run by community                                                      Services
volunteers, Get Healthy Service         Other peer support programs,          LHD,PHN,Yerin –             Annually
Diabetes offered by NSW Health,         including Diabetes NSW                Eleanor Duncan
peer support programs run by            volunteers and community led          Aboriginal Health
Diabetes NSW volunteers, Aunty          groups                                Centre, Diabetes
Jean’s Chronic Disease Outreach                                               NSW, CC Primary
Program run by CCPC, Integrated                                               Care
Team Care program run by Yerin –
                                                                              Diabetes Advisory
Eleanor Duncan Aboriginal Health
Centre, and web-based patient
education and self-management
programs, e.g. patientinfo
7.2 Ensure education is provided to     (a) Survey general practices and      PHN                         2017
patients and their carer (where         private allied health providers re
applicable) in a form that is           roles, perceived needs
accessible and relevant to individual
                                        (b) Survey community nurses as        LHD, PHN                    2017
goals. Review the capacity of
community nurses, practice nurses,
Aboriginal Health workers/              (c) Incorporate these findings into   Diabetes Services,          2018
Practitioners and GPs and what          delivery of diabetes education on     PHN
roles they have in providing and        Central Coast
reinforcing diabetes education and
key messages, including people
newly diagnosed and after hours
Consider redistributing some
aspects of diabetes education to
different roles. This may assist
credentialed diabetes educators
taking on expanded roles in
diabetes management, e.g. insulin

                                                                                 Diabetes Care on the Central Coast   31
Key Priority Area 8: Strengthen and expand specialist support for Primary Care

     Actions                                 Performance Indicators                Responsible         Timeframe
     8.1 Provide education and support       (a) Needs assessment of general       PHN                 2018
     for general practice to deliver the     practice in relation to ‘Necessary
     Model of Care.                          Nine’ functions within the Model of
                                             (b) Content and locality targeted     PHN, LHD, Yerin –   2017-18 and
                                             education and specialist support      Eleanor Duncan      ongoing
                                             (diabetes educators,                  Aboriginal Health
                                             endocrinologists)                     Centre
     8.2 Develop mechanisms for GPs to
     access specialist support for their
     patients and carers
     (a) telephone advice for immediate      (a) Implementation/promotion          LHD, PHN            Oct 2017
     issues                                  of telephone advice
     (b) review GP needs for outpatient      (b,c) LHD Outpatient clinic options   LHD                 2018
     clinic support in terms of timeliness   to be informed by GP needs
     and nature of consultations as part     assessment (10.3)
     of needs assessment (10.3)
     (c) incorporate GP needs into types
     and timing of outpatient clinics
     (d) GP, endocrinologist, diabetes       (d) Trial with 3 practices on         LHD, PHN, Yerin –   2018/19
     educator shared consultation in         the Central Coast (10.1)              Eleanor Duncan
     general practice setting (Hunter                                              Aboriginal Health
                                             (e) Monitor appropriateness                               2018
     model) (10.1)                                                                 Centre
                                             of referrals

                                                                                   LHD, PHN

     8.3 Develop strategies to support       Business case for case                PHN                 2018
     GPs caring for young people with        conferencing/telehealth
     Type 1 diabetes. Involves GP,
                                             Service model developed               PHN, LHD            2018-19
     paediatric endocrinologist,
                                             and trialled
     paediatrician, endocrinologist,
     diabetes educator, practice nurse.      Monitor person, carer, health         PHN                 2018-19
     Consider shared care arrangements,      worker experience of care
     telehealth, case conferencing,
     integrated care model (13.1)

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