Type 2 Diabetes is best managed by general practice and allied health in the community, leaving the specialised hospitalised services to manage the more complex cases of type 2, type 1 and gestational diabetes. 

However, when the patients need specialist care or hospitalisation, the journey should be better connected. In Western Sydney, we have developed an innovative approach involving a more integrated healthcare system that includes the components described below.

The key focus of Secondary Prevention & Management work is earlier detection of diabetes, better self-management and optimum management of diabetes in the community and hospital in a more appropriate, connected and supportive way. 

Secondary prevention initiatives aim to slow or stop the development of diabetes complications. They focus on early detection of diabetes and better management through the life cycle of diabetes and closing the gap between evidence-based guidelines and the real-world management of diabetes.

This component was dependent upon leveraging a more connected medical neighbourhood to deliver the best care at the right time and place.

A strong guiding principle was healthcare delivered in a way to support the healthcare quadruple goals of servicing patient needs to get quality health outcomes in a cost-effective manner with high provider-satisfaction.

Initiatives are divided and delivered under: 

  • Detection; 
  • Clinical Engagement; 
  • Education; 
  • Dietetics
  • Digital Solutions; and 
  • Connect with Hospital Services.

The development of a health-care system that delivers better care to patients in the community supported by improved linkage with hospital-based care when needed has been a major focus. 

This is supported by building the eHealth systems and the capacity of healthcare workers to better manage diabetes. This is a coming together of routine healthcare with the Western Sydney Integrated Care Demonstrator project and the WSD initiative to build an enhanced model of care. 

This model of care is consistent with, and an exemplar for, the Agency for Clinical Innovation (ACI) new diabetes model of care.