By GP and Practice Principal, Dr Neda Meshgin and GP Pharmacist, Dr Kenny Lee, Canning Vale Medical Centre*
In this GP Connect Case Study, we hear from a Perth general practice on their success in using team based continuous quality improvement activities to improve the health of patients with poorly controlled non-insulin dependent diabetes mellitus (NIDDM). The project was driven by their non-dispensing pharmacist actively liaising with a credentialed diabetes educator to participate in MBS-funded multidisciplinary team case conferences.
Multidisciplinary teams within general practice are increasingly demonstrating their ability to reduce the pressure on GPs and contribute to improved patient care. Under the umbrella of a ‘health care home’, integrating the skills of varied allied health professionals can support GPs with managing their complex caseloads and provide opportunities to reflect on a patient’s care with the whole primary care team.
Dr Neda Meshgin with Dr Penny Daniels & GP Pharmacist,Katie Clarke (L-R)
Funding to implement quality improvement goals such as this can be scarce, but there are ways to optimise MBS funding through a team-based approach. I present one such example of a project within our practice where a GP, with the support of our non-dispensing pharmacist and visiting diabetes educator, was able to achieve improved glycaemic control in patients with poorly controlled NIDDM. Spanning 12 months during 2023, all patients identified were able to reduce their glycated haemoglobin (HbA1c), some significantly, with the median reduced from 8.7 per cent to 7.3 per cent across the group.
Using our clinical audit and reporting tool alongside practice management software, one of our GPs identified all their active patients who had a HbA1c over 7.5 per cent during the previous 12 months. A total of 17 patients (who had seen that GP at least three times in the previous 18 months), were identified for whom NIDDM control was suboptimal with the raw HbA1c data.
Ranging from 7.5 to 11 per cent at baseline, the median HbA1c across 17 patients was 8.7 per cent (interquartile range 8 to 9.2 per cent). By the end of 2023, the median HbA1c was down to 7.3 per cent (interquartile range 6.9 to 8.20 per cent), demonstrating a statistically significant improvement (p < 0.001).
The project was driven by our non-dispensing GP pharmacist actively liaising with a credentialed diabetes educator to visit the practice monthly and participate in an MBS-funded multidisciplinary team case conference. This involved the GP, GP pharmacist and diabetes educator each discussing two to three of these patients to identify:
- Barriers to compliance with medications and lifestyle changes
- Optimal medication management based on best practice guidelines.
Many patients identified did not initially see the value of seeing a diabetes educator, stating the following reasons for not booking an appointment:
- Cost;
- Lack of understanding of the possible contribution they could make;
- Lack of time; and/or
- Lack of Medicare-subsidised Chronic Disease Management allied health services available to them (often wanting to use them for other allied health providers instead).
Consenting to having their case discussed in the team case conference with the diabetes educator was an easy way to access this support and have a diabetes educator contribute to the patient’s care without the patient in attendance.
The GP Pharmacist also contributed to discussions on medication management during the team case conference, often focusing on other medications the patient was taking. This involved contacting the patient’s usual pharmacy to obtain a current list of medications to cross check against our software list and even recent hospital discharge lists. Following the team case conference, the GP pharmacist would feedback outcomes of discussions to the patient and the pharmacy when required. Medication management was often changed during these sessions, and this important feedback ensured all providers were informed to implement the changes.
During the year, the GP pharmacist also supported the practice with case coordination by obtaining consent from patients prior to the team case conferences, scheduling, and preparing relevant documentation for each member of the team.
Clever coordination of appointments often resulted in some corridor consults occurring with the patient and diabetes educator, who, having participated in the patients’ case conference was able to give some direct feedback and advice, often resulting in increased confidence of the patients to use their services. Some patients, for example, were fitted with glucose monitoring devices to help them identify times of day when blood glucose levels were too high or too low, which informed decisions around dosing and timing of insulin or oral medications. Others were supported with injection technique, food timing and medicine side effect management.
All in all, the practice team was able to work together to support the patient in making changes that led to improved diabetes control over the year. Some of the services (such as supporting patient education on injectables) were provided by our practice nurse utilising the 10997 MBS item numbers.
The GP found this opportunity to reflect on all the factors contributing to the patient’s diabetes with other allied health providers invaluable, and time spent by the GP was generally limited to consult times, team case conference times and care planning appointments, all funded through MBS appropriate item numbers.
There was a high level of satisfaction reported by all members of the clinical team and participating patients. The project was successful in not only achieving improved HbA1c in patients, but also in sharing the workload of caring for the patient with allied primary health care providers, increasing patient confidence in and engagement with a coordinated primary care team.
This case example highlights the benefits to GPs and patients in utilising the services of allied health professionals in the practice team.
The WA Primary Health Alliance (WAPHA) Quality Improvement (QI) team is available to work with practices identify and support opportunities for continuous QI and enhanced clinical outcomes, with both individual practices and communities of practice.
For further information or support to undertake QI activities, contact Practice Assist via practiceassist@wapha.org.au or phone 1800 2 ASSIST (1800 2 277 478).
*Acknowledgements by the author:
- Ms Katie Clarke, GP Pharmacist, Canning Vale Medical Centre for her contribution to the project as the lead in coordinating the team.