1. Learning Session 2 October 31st, 2016
Diabetes Collaborative
Learning Session 2 October 31st, 2016
Mangere Health Centre

2. Care Bundle Data

3. What does the data say? What does it mean for you
The care bundle showed that there was a decline in the assessment for the risk & presence of complication of diabetes.
What does it mean for your patient
Patient will slip through the gaps.
What does it mean for the work within your practice
We have in our PMS a form called “Diabetes Nurse Form”. This form is not always utilised correctly. We have now implemented a protocol to use this form at our Nurse 6mnthly Diabetes check to ensure all aspects of diabetes risk & presence of diabetes complications are checked and reviewed.

4. Diabetes form to prompt thinking to ensure complete package of care is provided

5. Diabetes Education

6. Changes currently being tested
Describe the changes you are testing based on the learning's from the Care Bundle / Practice / PHO or DHB data
Initiation of Diabetes Nurse Clinic (Weds & Thurs morning/flexible)
Pt own medical team to initiate conversation/referral to nurse clinic
Pt own nurse to be present during diabetes nurse clinic appointment to hand over knowledge/skills set to PN with the hope they will continue plan of care post-discharge from clinic & to keep immediate team in the loop (not possible all the time due to time constrains with PN responsibility)
Establishing set times for each practice to have focused dedicated time for DCIP management (contact pt/refer to Harri’s clinic/book in own clinic etc)
Mobile phone telecommunication/ s
Monthly meeting for all nurses to share current results from the care bundle & follow up on DCIP progress from last meeting
White board in Staff Room (HbA1c results)

7. Learnings Key learnings from the changes you tested
Pt ENGAGEMENT is the key to success
LISTEN CAREFULLY TO THE PT.
Read between the lines (enabler)
Health Literacy (enabler)
Relationship/Trust (enabler)
Pt empowerment (enabler)
2) Making holistic judgment calls (know your pt lifestyle well & mould your treatment plan to fit. Eg: cultural diet, affordability, habits)
Never change your vibe regardless of your mood.
Never base TODAY’s treatment plan on historical facts.
Go into the engagement with a FRESH LENS (no pre-conceive judgement)