ABHI Primary Care Integration Program

Program aims:
The two interlinked components of this program are:
1. To encourage more integrated patient centred care for Type 2 diabetic patients by improved service coordination in the Wide Bay and Fraser Coast region.

Key objectives:
To achieve the aims of this program component a number of key objectives have been set:

1.1 Improve integration of health promotion strategies in the community sector
Link with local health agencies to promote Type 2 diabetes health.

1.2 Improve integration of resources for existing services and programs
Support GP and primary care by coordinating timely and responsive access to existing services, patient education, lifestyle and self management programs.

1.3 Improve communication and collaboration between diabetes networks
Develop a Diabetes Network Peer Support Group linking current provider networks.

2. To improve the health outcomes for diabetic patients within the whole of the Wide Bay Fraser Coast region by prototyping best practice, sustainable practice based diabetic clinics that will serve and be promoted as a model for all general practices within the region.

Key objectives:
To achieve the aims of this program component a number of key objectives have been set:

2.1 Increased workforce capacity of Diabetes Educators
The provision of appropriate healthcare services to diabetics in the general practice setting will reduce the current excessive demand on both the community allied health services and on the services being provided in the acute healthcare setting.

2.2 Improved health outcomes for patients
This project will demonstrate that the care and management of diabetic patients can be appropriately delivered in the community setting of general practices. This project will facilitate patient access to primary health care and move appropriate diabetic patient care to the more appropriate community setting.

2.3 Improved patients’ understanding of their health
The establishment of general practice based diabetes clinics staffed by appropriately skilled practice nurses will improve the education of patients with diabetic in the awareness and self-management of their condition.

2.4 Increased efficiency in use of GP’s time
The delivery of appropriate nurse-led care in the general practice based diabetes clinics will allow general practitioners to focus their time and efforts on their particular areas of expertise and skill.

2.5 A coordinated approach to diabetes management
Closer cooperation and collaboration between existing services and the practice diabetes clinics will lead to a more coordinated, integrated, patient focussed service. Formal linkages will be established between service providers to ensure streamlined pathways of care that will lead to a more equitable and responsive service.

Program contact:
Martin Ridge
Project Officer,
GP Links Wide Bay
Fraser Shores Shopping Centre
79 Boat Harbour Drive
Hervey Bay
Qld 4655

Program governance:
Program governance is provided by the Diabetes Advisory Group that meets as required. The purpose of the advisory group is to provide advice and support to ABHI Primary Care Integration Program on all matters relating to the program’s aims.

Due to geographic separation the DAG has been divided into two Working Groups:

• Wide Bay Diabetes Working Group
• Fraser Coast Diabetes Working Group

These working groups allow local priorities and needs to be focussed upon. They meet bi-monthly or as deemed necessary by their members. The membership of the working groups have been drawn from Health Service clinical staff, allied health professionals, the local GP community, and GP Links Wide Bay staff.

Communication to the Diabetes Working Groups can be made through the program contact above.