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Workstream Goals
An ongoing program is under development with the PHN with Diabetes Integrated Care components across the LHD area:
- Integrated diabetes clinic including: (i) facility for diabetes teaching among undergraduate students from medicine, nursing and eleven School of Health sciences disciplines, including podiatry and gp/practice nurses; (ii) step down diabetes foot clinic; (iii) primary care annual review facility; and (iv) development of clinical database from patients attending clinic
- Endocrinologist virtual clinics within general practices
- Benchmarking and decision support tool for primary care and pipeline development for primary care support and clinical studies
- Online and face to face primary care health care professional education
- Joint governance development
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Wollondilly
The Wollondilly Health Alliance has funded until 30/6/2017 an integrated diabetes programme for the 43,000 people (2000 with diabetes) of the Wollondilly district. This includes:
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Primary care support through community diabetes educator and endocrinologist practice virtual clinics and telephone support
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Patient care closer to home through educator, dietitian, podiatry and videoconferencing endocrinology clinics, along with general practice based case conferencing
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Patient education
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Use of Health pathways and risk stratification
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Creation of a diabetes register including use of the diabetes passport
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Online education for all health workers
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Oversight committee
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Diabetes Peer Support for those with diabetes
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Prevention
- Range of media approaches
- Risk assessment
- Diabetes Peer Support for those at high risk of diabetes
- Food supply options/choices
- Activity venues
- Feedback approaches
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Staffing: 1.0 educator, 0.4 dietitian, 0.2 podiatry, 0.2 endocrinologist 0.5 admin
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Pre-post comparison and process measures
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Extension of integrated care across SWS
- HCP education
- AusCDEP
- Case conferencing
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Bowral
The LHD has funded new educator and dietitian in the area. The PHN would like an integrated approach in the area.
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Oran Park
Not worked up.
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Interdisciplinary clinic
On Campbelltown campus: step down foot clinic, interdisciplinary diabetes teaching, primary care teaching and assessment service for primary care-planning underway-Charles Sturt University and PHN contributing
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Visiting endocrinologist
PHN wish 0.2FTE for each of the 3 services: Macarthur, Liverpool-Fairfield and Bankstown-Lidcombe-to be worked up
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