Specialised Consultation and Enhanced Model of Care in Hospitals

A pilot study was conducted in 2014 under the guidance of the Western Sydney Diabetes initiative. The results confirmed the high rate of diabetes and is now the basis for recommending HbA1c testing as a routine approach. It will be part of an enhanced diabetes model of care which will enable patients with diabetes to be identified when admitted through ED for more appropriate hospital management.

The blending of this program with the current in-hospital diabetes service and the Western Sydney Integrated Care demonstrator project described in the next section allows better hospital management of patients with diabetes and with the more comprehensive community-based part of the service.

Since 40% of patients admitted from ED have diabetes, it is important that the capacity of all clinical services to better manage diabetes be enhanced. This is currently being piloted with the Mental Health Service (especially patients requiring Clozapine and more long-term follow-up) and geriatric and rehabilitation services. Endocrinologists and Diabetes Educators are seeing patients in joint consultation with care teams from these services to build their capacity to manage patients with diabetes - similar to the GP case conferencing approach.

This is working well and will soon be extended to other services. Patients and general practices will be notified of the result of HbA1c testing allowing for earlier lifestyle coaching and better management of diabetes in the community. A collaboration with NSW Health 'Get Healthy' program is being developed to encourage patients with pre-diabetes and recently diagnosed diabetes to enrol in this program.

PHN Western Sydney PwC Diabetes NSW NSW Health