Managing diabetes in regional Queensland

Diabetes represents perhaps the biggest challenge to Australia’s healthcare system. According to Diabetes Australia, around 1.7 million Australians have diabetes, with the total annual cost of diabetes estimated at $14.6 billion. And those rates are increasing rapidly, as diabetes has become the fastest growing chronic condition in Australia.

To support people with diabetes in Queensland’s Darling Downs region, the Diabetes Model of Care Project was developed to increase the efficiency of healthcare delivery and improve patient outcomes. The project provides tailored care for patients living with diabetes.

The project brought together the following partner organisations: Queensland Health’s Clinical Excellence Division; Darling Downs Hospital and Health Service (DDHHS); Goondir Aboriginal Medical Centre; Tunstall Healthcare; Queensland Ambulance Service (QAS); Darling Downs West Moreton Primary Health Network (DDWMPHN); and the Australian Centre for Health Services Innovation (AusHSI).

Diabetes Queensland reports that in the State, there are at least 200,000 people diagnosed with diabetes, and amongst adult Aboriginal and Torres Strait Islander people, the prevalence of diabetes is as high as 30 per cent. The DDHHS region in particular has a higher incidence of diabetes than any other region in Australia.

The Diabetes Model of Care Project consists of four key elements: QAS referral pathway; general practitioner led care; a patient journey coordinator for Aboriginal and Torres Strait Islander patients; and Tunstall Healthcare home monitoring.

Patients seen by the Ambulance Service as a result of a diabetes complication are referred on to a qualified diabetes educator, with ongoing care arranged by Toowoomba Hospital. This helps to reduce repeated presentations to hospital.

General practitioners are able to refer eligible patients on to the project, based on set referral criteria. They also receive education and support in managing their patients with diabetes.

Aboriginal and Torres Strait Islander patients identified by DDHHS are linked with suitable primary healthcare services, to help coordinate and deliver appropriate care.

Selected patients are set up with home monitoring of blood sugar and other vitals, alongside regular reporting and escalation protocols.

As a result, people have improved access to specialised health information, and a more coordinated and flexible healthcare experience.

Dr Sheila Cook, Toowoomba Hospital endocrinologist, said that the project was making a difference to people living with diabetes. “Our service is better matched to what patients need, and where they need it,” she said.

The project will continue to expand and develop improved healthcare management for patients, and perhaps provide a model of care for other regions across Australia.