Authors (including presenting author) :
Hung SY, Chan YLT, Lam SKS, Chou PK, Lo YM, Chan WMS, Leung WCW, Li HLF, Kwan WYW, Tsui PN, Cheung PH, Cheung YHK, Leung WMW, Wong MSM, Wong MYM
Affiliation :
Department of Family Medicine and Primary Healthcare, Hong Kong East Cluster
Introduction :
Diabetes Mellitus (DM) is a common chronic disease that requires lifelong care. As of 2021/22, there were 31,712 DM patients under the care of General Out-patient Clinics (GOPC) of the Hong Kong East Cluster. This accounted for a 50.4% increase compared with a total of 21,088 DM patients in 2011/12. With the rapid increase in DM prevalence, a well-designed and systematic service enhancement with measurable goals is essential to empower patients to achieve optimal disease control and reduce complications.
Objectives :
-Improve key performance index (KPI) of DM patients -Enhance self-management of DM patients -Enhance skill and knowledge of nursing staff in DM patient education -Enhance service for DM patient followed up in Sunday clinics to fill in the service gap
Methodology :
In 4/2020, A focus group comprising doctors and nurses was formed to discuss the strategies and implementation. KPI concept was shared in clinic meetings. Comprehensive service enhancement framework was designed for the whole patient care process i.e. before, during and after consultation. e.g. supporting staff reminded patients to get ready their self-monitoring record before consultation. Training was provided to nursing staff on how to conduct more focused patient education. Patient education material was gathered, updated and standardized, e.g. DM education poster and leaflet with QR code for easy access of information. Pre-consultation patient education by nurse for young DM patients with borderline control, e.g. HbA1c 7%-8%, was started from July 2020. In 2021, 2 sessions of lunch seminars were conducted to update nurses on DM management.Extended nurse education and support to DM patients in Sunday clinic was started from May 2021. Furthermore, there was regular performance review to assess compliance with the new implementation.
Result & Outcome :
From 2019/20 to 2021/22, the annual capture rate of HbA1c increased from 92.4% to 95.3%. DM patients with HbA1c <7% increased from 60.2% to 68%. Capture rate of annual Low density lipoprotein – cholesterol (LDL-C) increased from 89.5% to 91.2%. Percentage of DM patients achieving optimal LDL-C control (<2.6mmol/L) increased from 81.6% to 85.2%. Structured DM care is essential to improve patient’s clinical outcome.
