Interventions/Initiatives	KPIs/Milestones
10.1 Establishing a leadership hub for in-hospital service integration and reducing harm from diabetes complications A forum is required to provide guidance on in-hospital and integration issues relating to diabetes complications from involved specialties. Note: this may be a new forum or grafting this responsibility on an existing clinical leadership group. The integration leadership group would have a complimentary role with the DCAG role.	From Sept 2005, leadership hub established and operational.
10.2 Developing Whitiora Diabetes Service’s role as clinical centre of excellence and supporter of system-wide capacity development The 5 year strategic review (2005-2010) for Whitiora development suggested the following key points for the service: increased audit cycles increased roll-out of primary care support/community clinics more active peer review encourage internships (Doctors/Nurses/others) between primary care and Whitiora greater funded training role more group education, and enhanced practice flexibility Develop effective clinical leadership for the delivery of integrated diabetes management. This includes increased non-clinical time to develop resource and QA/research activities. Increased resource to upskill and support primary care, secondary care services Support research in service delivery design as it relates to the prevalence and progression of complications. Note: implementation of strategic review recommendations not explicitly part of LBD and are mostly part of normal service development. However, some aspects have overlap with LBD as they relate to specific new initiative programmes. Note: also links between Whitiora and LBD, with the medical director of LBD also the clinical director of Whitiora. Key partners CMDHB Primary Care Development (including Chronic Care Management programme – CCM). Key linkages  LBD action area 5; LBD action area 8; action area 10; and the evaluation.  Whitiora Diabetes Service.	By May 2006, audit of clinical practice completed.
10.3 Ensuring diabetes management activities across primary and secondary care are implemented in a consistent manner Aligning to 8.2 to ensure the management activities and framework developed in primary care is consistent with that developed for secondary; and that there is consistency in their approach and implementation. Key partners DCAG, CMDHB Primary Care Development (including Chronic Care Management programme – CCM). Key linkages LBD action area 5; LBD action area 8; action area 10; and the evaluation.
10.4 Improving the integration of primary and secondary care diabetes IT systems This area includes improved functionality for access to patient information, care co-ordination and clinical decision support. It will, to some extent, be dependent on broader issues such as development of the diabetes secondary care database at WDHB and Enigma services. Area of interest during 2005/2006, with more active involvement in 2006/2007. Key partners DCAG, CMDHB Primary Care Development (including CCM). Key linkages LBD action area 5; LBD action area 8; action area 10; and the evaluation.	Oct 2005, develop clear view on CMDHB response to WDHB diabetes secondary care database developments regarding migration to Middlemore.
10.5 Improving clinical data and ethnicity data collection and analysis in order to provide regular performance reports relating to indicator outcomes by ethnicity Clinical reports will provide key feedback to LBD whether strategies are having an impact – especially in relation to reducing inequalities. Areas of data collection include (by ethnicity where possible): glycaemic control management guidelines met  % given lifestyle management advice/self management education rates of hospitalisation due to diabetes or complications rates of renal dialysis, and rates of premature mortality (using Get Checked, CCM, Census and NMDS data) Key partners DCAG, CMDHB Primary Care Development (including Chronic Care Management programme – CCM). Key linkages LBD action area 5; LBD action area 8; action area 10; and the evaluation.  CMDHB Planning and Funding; Pacific Health; Maori Health; Primary Care Development (including CCM).	By April 2006, development complete and reporting begins.
10.6 Supporting Diabetes in Pregnancy Develop service integration for comprehensive care in diabetes in pregnancy, including; lead maternity provider, women’s health, secondary care diabetes service, cultural support, community support and primary care. Specific components of the service review and development to include: external review database development along CCM framework, and review of cultural support quality and availability Data capture and audit processes developed to cover the following: proportion of mothers with diabetes (gestational or chronic) during pregnancy 100% post-pregnancy GTT-performed in women with diabetes diagnosed in pregnancy 100% diabetic (gestational or chronic) woman referred to and followed by primary care post pregnancy 80% + post-pregnancy contraceptive/preconceptive counselling rates of neonatal hypoglycaemia (analysed by DM and GDM) rates of Macrosomia (BW > 4500g, or 90%) (analysed by DM and GDM) rates of perinatal death (analysed by DM and GDM) operative delivery rates (analysed by DM and GDM) rates of Birth Trauma (baby and mother) (analysed by DM and GDM) rates of congenital defect/anomaly (analysed by DM and GDM) rates of developing (permanent) T2DM (for GDM mothers) Note: LBD is supporting the external review and service process and some data capture issues. However, it is seen that the actual service improvements will be supported by mainstream funding sources. Key partners DCAG, CMDHB Primary Care Development (including Chronic Care Management programme – CCM), CMDHB Pacific Health. Key linkages LBD action area 5; LBD action area 8; action area 10; and the evaluation.  CMDHB Planning and Funding; Pacific Health; Maori Health; Primary Care Development (including CCM); Whitiora Diabetes Service.	Nov 2005, external review completed.  May 2006, database development.
10.7 Supporting Diabetic Eye Disease Support diabetic eye disease identification and treatment into a more integrated service design by redesigning the service of retinal screening for example DNA management and follow-up. LBD will also support improved service capacity planning, modelling disease progression to develop a retinal screening algorithm and integrating screening information back into chronic care support intelligence. Note: retinal screening advisory groups already exist. Key partners DCAG; CMDHB Primary Care Development (including CCM). Key linkages LBD action area 1.2 – 1.5; action area 2; 5.2 – 5.5; action area 8; action area 9; and the evaluation.  CMDHB community DRS.	May 2006, retinal screening status reports to CCM record. Aug 2005, reduced DNA and effective recall section.
10.8 Supporting Diabetic Renal Disease Supporting diabetic renal disease through: Implementation of National Guidelines (T2DM) Predictive modelling of for service capacity planning (within LBD modelling) and dialysis review (Regional Review), and Research in service delivery, prevalence and progression of complications. Key linkages LBD action area 1.2 – 1.5; action area 2; 5.2 – 5.5; action area 8; action area 9; and the evaluation.  CMDHB renal.	90%= application of treatment guidelines for prevention of progressive renal disease.
10.9 Diabetes and Mental Health Supporting the links between diabetes and mental health by: developing a management resource for prevention, detection and management of diabetes in people with mental health problems supporting the implementation of the depression module in CCM in 3 pilot PHOs providing psychological/mental health support for patients with diabetes, and developing a screening/assessment tool for depression. Key partners Key linkages  LBD action area 1.2 – 1.5; action area 2; 5.2 – 5.5; action area 8; action area 9; and the evaluation. CMDHB Mental Health.	By May 2006, widespread (90%+) implementation of ADA/APA/AACE recommendations for screening. Nov 2005, implementation of pilot depression module in CCM. July 2005, development of Health, Psychologist Role in Acute Care.  Development of Health Psychologist Role in Primary Care. Oct 2005, implementation of Depression assessment tool.
10.10 Supporting Therapeutics Supporting best practice utilisation of medication by: Community Pharmacy - Advice  - Adherence Advocacy for best treatment  - Representation to Pharmac Encouraging clinical research in CMDHB population. Key partners CMDHB Planning and Funding. Key linkages LBD action area 1.2 – 1.5; action area 2; 5.2 – 5.5; action area 8; action area 9; and the evaluation.  CMDHB Pharmacy Strategy.	June 2006, development of pharmacy advice resource.  June 2006, evaluation and research.
10.11 Texting Trial Trial a text-based reminder system at one clinic, evaluate impact on DNAs and client perceptions of the service. Key partners Key linkages  LBD action area 1.2 – 1.5; action area 2; 5.2 – 5.5; action area 8; action area 10; and the evaluation.	By May 2006, trial completed and evaluated.

Progress Updates

Click here for progress updates on these interventions/initiatives