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The problems facing Australians because of diabetes are well known. They are also significantly more prevalent in rural than in metropolitan areas1. This presents a huge challenge to rural and remote health services where crisis management of chronic problems is all too common. The shortage of GPs in rural and remote locations in Australia has led to a lack of continuity in medical supervision, which ultimately results in poorer patient outcomes2. Nurse led models of chronic disease management can be a solution to the predicted inability of the GP workforce to meet growing demand for chronic disease care both in urban and rural settings3. The Chronic Care Model4 identifies key elements of self-management as changing patients from passive to active and encouraging health professionals to be more proactive in changing patient behaviour. Recent evidence has shown that diabetic patients who completed a cycle of care using a GP management plan had improved process and clinical outcomes5. The South East Sector of the Royal Flying Doctor Service (RFDSSES) considered these factors when planning how to reduce the growing demand for retrievals and acute management of chronic conditions. It is working on developing more effective chronic disease management to help reduce acute presentations and improve the health of its community. Best-practice care in diabetes is known to involve patients completing the Annual Cycle of Care (ACC)6 but this can be challenging in a remote setting without resident health workers. As a way of addressing the difficulties of implementing the ACC, the RFDSSES introduced a pilot study to test the feasibility of a nurse led cycle of diabetes care and to explore the factors that patients indicated were important in diabetes self-management.
The nurse led diabetes pilot program, following the ACC specified by the Royal Australian College of General Practitioners6, was provided in three remote New South Wales locations: one town with resident services and two small townships with outreach services provided intermittently. The diabetes nurse drove or flew in the RFDSSES clinic aircraft for 3-monthly visits to remote townships. The nurse visits encompassed: relevant pathology, smoking-nutrition-alcohol-physical activity counselling; physical examination; foot care; and arrangements for ophthalmologist consultation in Broken Hill. Issues arising in the management of the patient were discussed subsequently with the responsible GP. Patient clinical outcomes after a 1-year cycle with the 21 patients in the pilot program showed that the majority of patients were able to self-manage their diabetes and institute changes in diet and exercise with the support of the nurse. All patients reported that they trusted the nurse and that they thought her advice was pitched at their level. Moreover, because the nurse had longer consultations than the GPs, their understanding of diabetes and the medications and confidence in their ability to self-manage were improved compared to GP-only management. The majority of patients had comorbidities and complex needs requiring specialist input, which was arranged by the diabetes nurse. Two patients had type 1 diabetes managed by the nurse with specialist input when necessary. The diabetes nurse taught patients commencing insulin how to monitor blood sugar levels and provided telephone support between visits when needed.
What is needed to implement nurse led diabetes management in the bush? Obviously, funding for transport and logistic support! However, the essential ingredient for a successful nurse led diabetes program is the right nurse with highly developed clinical and chronic disease self-management support skills in whom patients and GPs have confidence. This allows for the vital collaborative relationships to develop.
All elements of the ACC were delivered in this remote nurse led diabetes program. The important aspects of the pilot were that patients managed their diabetes and implemented lifestyle changes. The new way of working was acceptable to the GPs and, as a result of the pilot study, the nurse led program has now been incorporated into routine practice in the RFDSSES. The success of this pilot program can encourage other organisations to use a similar approach.
References
1. Diabetes Australia. Diabetes: the silent pandemic and its impact on Australia. (Online) 2012. Available: https://www.diabeteswa.com.au/UserDir/Documents/14814%20Diabetes%20management%20booklet%205%20Mar_FINAL.pdf (Accessed 30 July 2014).
2. Australian Institute of Health and Welfare. General practice activity in Australia 2004-2005. (Online) 2005. Australian Institute of Health and Welfare: Canberra. Available: http://www.aihw.gov.au/publication-detail/?id=6442467786 (Accessed 30 July 2014).
3. Eley D, Del Mar CB, Patterson E, Synnott RL, Baker PG, Hegney D. A nurse led model of chronic disease care - an interim report. Australian Family Physician 2008; 37: 1030-1032.
4. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs (Millwood) 2001; 20: 64-78.
5. Wickramasinghe LK, Schattner P, Hibbert ME, Enticott JC, Georgeff MP, Russell GM. Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews. Medical Journal of Australia 2013; 199: 261-265.
6. The Royal Australian College of General Practitioners and Diabetes Australia. General practice management of type 2 diabetes - 2014-15. (Online) 2014. Available: https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/5ed214a6-4cff-490f-a283-bc8279fe3b2f.pdf (Accessed 30 July 2014).