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.

The new 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.

DCAG continues to meet on a monthly basis

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.

Andrew Old (public health registrar) is nearing completion of his dissertation - granted an extension (to 14 July) by the University (Rod Perkins). Report will be presented to DCAG in September.

Supporting activity:
CM Sport - Could Green Prescription be an outcome of this? Green Prescription Area Manager has been contacted by Pat Flanagan to investigate this partnership further.

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.

 Finished enrolling patients for six months support and monitoring as part of CNP
 Support ongoing for trainees
 Reassessing trainee's core competencies - completed eight to date
 Six month trainee post knowledge questionnaires completed - data to be analysed
 Initial base line patient data collected and being analysed by SoPH

Supporting activity:
CM Sport - Could Green Prescription be an outcome of this? Green Prescription Area Manager has already talked through the possibilities with Barbara Docherty from TADS.

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.  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.

Ongoing visits/meetings with PHOs by Project Manager. Further Workshop organised for 8 August with PHOs and other stakeholders.
Paper presented to DCAG summarising GPHO meeting and seeking endorsement on the following:
• revised implementation timeframe (1 November rollout
• delivery model parameters in terms of Facilitator skills, size of groups, location and access to SME group sessions
• KPIs (draft list only - enhanced list will come back to DCAG for final approval)
• concept of a PHO based SME Working Group as an effective support group for the Project Manager in this development/ implementation phase.
DCAG agreed to above recommendations but asked for more work to be done on the KPIs. Also asked for a patient flowchart.

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.

Maori pilot - back on track; Hui scheduled for 19 July. Caran Barratt-Boyes to work with replacement team member and psychologist to complete outputs (navigation tool, focus groups, analysis report) in original proposal.

Pacific proposal - revised proposal attached

In 2006/07 this action area will focus on considering innovative ways to increase Whanau/ family/group participation within mainstream primary care. We may be asking PHOs to submit proposals to implement suitable pilots in 06/07.

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 
  - systems interventions (including IT) 
  - practitioner interventions 
  -  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).

DCAG received and discussed Jocelyn Tracey's report on implementing diabetes and CVD risk screening in primary care. It endorsed the following recommendations:

1. Screening will be for CVD and diabetes
2. A mixed opportunistic and systematic (recall) approach will be required
3. A one step programme may be viable for systematic screening but a multi-step approach may be necessary for opportunistic screening
4. Financial incentives may be useful although there appears to be no correlation between funding and success rates
5. Workforce issues are significant and effect rate of change

DCAG also endorsed the first draft of CVD/Diabetes Risk Screening Implementation Guidelines paper by Tom Robinson. DCAG proposed these draft implementation guidelines should be submitted to GPHO for comment.