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Learning Session 2 October 31, 2016

Diabetes Collaborative. Learning Session 2 October 31, 2016. PHO and Facilitator: ProCare Team members: Dr Selvakumar, Dr Hamid Al-Bahadly, Dr Mekala Pushparajah. Nurses: Lisa, Sunita, Gomeeta, Savita, Nancy. Reception: Lesley, Evelyn, Tehoo, Kelleigh, Sokunna & Janine.

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Learning Session 2 October 31, 2016

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  1. Diabetes Collaborative Learning Session 2October 31, 2016

  2. PHO and Facilitator: ProCare • Team members: • Dr Selvakumar, Dr Hamid Al-Bahadly, Dr Mekala Pushparajah. • Nurses: Lisa, Sunita, Gomeeta, Savita, Nancy. • Reception: Lesley, Evelyn, Tehoo, Kelleigh, Sokunna & Janine.

  3. Care Bundle Data

  4. Aim: • Quality Improvement in Diabetes Care • To achieve at least 10% reduction of HbA1c in all poorly controlled Diabetics by June 2017. Strategies: • Appoint a Practice Diabetes Champion – RN Sunita. • Provide professional development in Diabetes and patient communication. - MIT Diabetes Course, HINT (Healthy Innovative Neutral training) • Encourage patients to see the Doctor 3 monthly for scripts.

  5. Change Tested • On review of monthly audit of 10 random poorly controlled diabetic patients- we identified low number of Foot Check. • We planned a PDSA focusing on improving the Diabetic foot checks done by the patients. • A Query builder was developed to identify Diabetic patients without Foot check in last 12 months. • Change idea: TXT msgs sent to patients to attend for Foot Check. Results: • On reviewing the practice data of diabetes patients it was found that 312 patients were due for their foot check. • Audit were conducted in a span of 2 & 4 weeks post the TXT messages • 66 foot checks completed in the 2 weeks. An increase of 44 foot checks compared to the 2 weeks prior. And 111 foot checks were completed in total in 4 weeks. • Foot check appts also identified patients due for HbA1c and retinal screening.

  6. What does the data say? • Rate of patients treatment being reviewed within last 3 months is improved by encouraging patients to see the GP for their 3 monthly prescriptions. • This provides increased opportunity for assessment of risk and presence of diabetic complications. Resulting in improved outcomes for diabetic patients.

  7. Future: • Enhance our system to identify patients overdue for HbA1c. • Utilise DCIP monthly audit results and PHO data for poorly controlled patients to identify target areas . Change Ideas: What impact do you hope to have from this change? • Improved Patient Diabetes Care. • To overall reduce HbA1c in our poorly controlled Diabetic population.

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