Interventions/Initiatives	KPIs/Milestones
8.1 Establishing a leadership structure to guide improvements of diabetes management in the primary care sector A new advisory group will established to: merge previously separate diabetes and CVD groups; assume the responsibilities and accountabilities of the previous Diabetes Advisory Group (which is disbanded); and assume an expanded terms of reference that includes the previous CCM activity and the LBD primary care action area. This advisory group (called DCAG) will provide advice on interpretation of evidence/analysis, programme design, implementation and performance. DCAG and its work programme will be managed by co-funded project management position. (Note: The accountability for implementation of LBD within the primary care environment sits with the CMDHB primary care team. LBD is represented on DCAG while primary care is represented on the LBD Partnership Steering Group). Key partners CMDHB Primary Care Development (including CCM). Key linkages LBD action area 8; LBD action area 10; and the evaluation. CMDHB Primary Care Development (including CCM).	July 2005, new DCAG terms of reference completed. Aug 2005, initial DCAG meeting. Sept 2005, work programme signed off. From Oct 2005, DCAG monthly progress reports provided to GPHO.
8.2 Developing a Diabetes care framework for Counties Manukau Develop a model for implementing the NZGG Type 2 Diabetes guidelines from screening to management of people with complications, and identify key areas for improvement. The model is to include: translation of the guidelines into an explicit model of primary care service provision  incorporation of learnings from CCM and other DHBs approaches identification of the degree to which current practice differs from this goal model identification of a few key intervention points that will lead to improved services  development of proposals for projects to address these key areas, and identification of key clinical indicators that are collected through current data systems and can be used to monitor progress. Resources will be required for expert advice and activity in developing care model and implementing. Likely to involve training and capacity development for practices. CMDHB Maori and Pacific Health will provide input to ensure appropriateness for Maori and Pacific populations. Key partners CMDHB Primary Care Development (including CCM), CMDHB Pacific Health and CMDHB Maori Health. Key linkages  LBD 5.2 – 5.4; action area 8; LBD action area 10; and the evaluation.  CMDHB Primary Care Development (including CCM).	By Nov 2005, Care model developed to cover all of diabetes (adapt WDHB model) - with action recommendations. Feb 2006, service provision process outlined and provider identified. April 2006, recommendations implemented
8.3 Improving use of brief interventions for modifying obesity risk factors Develop, pilot and evaluate use of brief intervention in primary care setting, based on work undertaken by the Community Nutrition Project and business case development for surgical and pharmacological interventions for morbidly obese people. Project components to include: needs assessment of training needs and current practices in weight management in primary care recruitment of PHOs for pilot study recruitment of Practice Nurses and Community Health Workers to complete training development of training programme (including nutrition curriculum, screening and selection, brief intervention, group sessions, goal setting, motivation, teaching toolkit) development of supporting educational resources for trainees delivery of training programme evaluation of training programme ongoing support of trainees recruitment of clients for weight management, and evaluation of client outcomes. business case development for surgical and/or pharmacological interventions for morbidly obese people and establishment of an integrated care team across provider arm and CCM. Key partners CMDHB Primary Care Development (including CCM), Primary Health Organisations (PHOs), CMDHB Pacific Health. Key linkages LBD 5.2 – 5.4; action area 8; LBD action area 10; and the evaluation. CMDHB Primary Care Development (including CCM); Primary Care Workforce Development.	July 2005, PHOs and Practice Nurses recruited. Sept 2005, recruitment of clients for weight management. Dec 2005, evaluation commences.
8.4 Improving uptake of best practice post diagnosis education Develop criteria for, and implement, Diabetes Self Management Education (DSME) programme in primary care. Approach to include: a stock take of existing DSME programmes/providers will be done. This will include the package being developed by Waitemata DHB. Programmes will be assessed against criteria estimates of the incidence of new type 2 diabetes will be obtained by ethnicity and geographical area. This will be linked to the delivery framework to establish what capacity is required to deliver DSME (internal) a delivery framework for DMSE will be developed (or adapted) based on the above and other evidence of best practice. Likely resource availability will also be considered in its development and in light of evidence on effective health education approaches and techniques targeting culturally diverse groups, and a provider contracted to develop training of facilitators for DSME using the new delivery framework and provide this training to an initial group of facilitators. CMDHB Maori and Pacific Health will provide input to ensure health education appropriate for Maori and Pacific populations. Key partners CMDHB Primary Care Development (including CCM), CMDHB Pacific Health, CMDHB Maori Health. Key linkages LBD 5.2 – 5.4; action area 8; LBD action area 10; and the evaluation.  CMDHB Primary Care Development (including CCM); Primary Care Workforce Development.	Nov 2005, stock take completed. By March 2006, delivery framework completed, with PHO buy in. April 2006, training underway.
8.5 Trialling and evaluating increased use of family/whanau/group support for obesity risk factors and diabetes management Contract a provider to run focus groups with people with diabetes and their families to find out what the pilot programme should include. Group members to be obtained through CCM or Whitiora. Review of current information and literature on effective interventions and approaches to working with families centred care from minority and/or ethnically diverse groups, the workforce skills required to ensure safe family centred practice and resources to support this work. Develop a survey aimed at people with diabetes (via Whitiora, CMDHB Maori and Pacific Health) to explore: their perception of family risk their ability to influence this risk their ability and interest in taking this role, and their needs for family support. Develop and run at least 2 pilot programmes based around CCM families (priority Maori and Pacific). Evaluate the success of the pilots to see if this model should be developed further. Key partners CMDHB Primary Care Development (including CCM), CMDHB Pacific Cultural Support Unit, CMDHB Maori Health. Key linkages LBD 1.2 – 1.5; action area 2; 5.2 – 5.4; action area 8; LBD action area 10; and the evaluation.  CMDHB Primary Care Development (including CCM); Primary Care Workforce Development.	March 2006, survey of 200 patients completed and report written. By 2006, pilot sessions run and evaluation completed.
8.6 Investigating and developing whole system approach to improving rate of diagnosed type 2 diabetes to expected population with diabetes A proposal has been made that from 1 July 2007, there is a proactive approach to support increased diabetes/CVD risk screening. This would be supported by social marketing and health promotion programmes. Before any such action, however, a number of issues require further analysis: consider NZGG recommendations on CV risk screening and whether diabetes screening needs to occur beyond these groups consider methods of improving primary care implementation of screening including o systems interventions (including IT) o practitioner interventions o patient interventions consider implications of increased screening on primary care, wider CMDHB services, and patients including: increased numbers of type 2 diabetes diagnosed - people diagnosed with IFG or IGT  - people identified with other CV risk factors  - people who are not identified as being at risk but who still need to be aware of their lifestyle risks (avoiding false reassurance).	By Oct 2005, DCAG makes decision in principle about Counties Manukau’s approach to screening. By March 2006, design completed. By June 2006, implementation started.