In January 2021, our practice began a Continuous Quality Improvement (CQI) project focused on improving care for patients with Type 2 Diabetes. Our goal was to help patients achieve better blood sugar control (HbA1c), ensure access to best practice and up to date diabetes medications, and realise equitable outcomes for all members of our community.

We selected a small group of patients to work with.  Each patient underwent a comprehensive diabetes review.  Their medication was reviewed and, in most instances, a new medication regime put in place.  The Registered Nurses tailored education for the patients around diet, lifestyle, and supporting patients to self-manage their health. We also worked closely with specialist diabetes clinicians, a dietitian, and a pharmacist to ensure the best possible care.

Equity was a key focus of the project. We used targeted funding to remove cost barriers and ensured support was available for patients with additional needs, including interpreter services where required.

After two years, the majority of patients in the project experienced meaningful improvements in their HbA1c levels, with an overall average reduction of 14% (a lower HbA1c level is better). While we did not fully reach our original target, the project highlighted clear improvements in care and helped shape lasting changes in how we care for those patients who have diabetes at our practice and is shaping how we move forward for supporting patients with Type 2 Diabetes.

Because of the success of this project, we have now extended this care approach to all our patients with Type 2 Diabetes.  We support all diabetic patients to have an annual diabetes review.  We also monitor the blood sugar levels.  Medications are also reviewed annually to ensure the most up to date medications are used and the appropriate regime.  We have a Diabetes Clinical Nurse Specialist and a Registered Dietician who hold a clinic at the Health Centre every 6-8 weeks.  We support early referral to these clinical staff. 

This project has reinforced our commitment to continuous improvement and providing high-quality, patient-centred diabetes care for our community.