Models of care for co-morbid diabetes and chronic kidney disease

Clement Lo, Edward Zimbudzi, Helena Teede, Alan Cass, Greg Fulcher, Martin Gallagher, Peter G. Kerr, Stephen Jan, Greg Johnson, Tim Mathew, Kevan Polkinghorne, Grant Russell, Tim Usherwood, Rowan Walker, Sophia Zoungas

    Research output: Contribution to journalReview articleResearchpeer-review

    Abstract

    Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.

    Original languageEnglish
    Pages (from-to)711-717
    Number of pages7
    JournalNephrology
    Volume23
    Issue number8
    Early online date5 Feb 2018
    DOIs
    Publication statusPublished - 1 Aug 2018

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    Chronic Renal Insufficiency
    Health
    Delivery of Health Care
    Primary Health Care
    Morbidity
    Patient-Centered Care
    Self Care
    Focus Groups
    General Practitioners
    Caregivers
    Population
    Health Services
    Chronic Disease
    Interviews
    Psychology
    Kidney

    Cite this

    Lo, C., Zimbudzi, E., Teede, H., Cass, A., Fulcher, G., Gallagher, M., ... Zoungas, S. (2018). Models of care for co-morbid diabetes and chronic kidney disease. Nephrology, 23(8), 711-717. https://doi.org/10.1111/nep.13232
    Lo, Clement ; Zimbudzi, Edward ; Teede, Helena ; Cass, Alan ; Fulcher, Greg ; Gallagher, Martin ; Kerr, Peter G. ; Jan, Stephen ; Johnson, Greg ; Mathew, Tim ; Polkinghorne, Kevan ; Russell, Grant ; Usherwood, Tim ; Walker, Rowan ; Zoungas, Sophia. / Models of care for co-morbid diabetes and chronic kidney disease. In: Nephrology. 2018 ; Vol. 23, No. 8. pp. 711-717.
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    abstract = "Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.",
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    author = "Clement Lo and Edward Zimbudzi and Helena Teede and Alan Cass and Greg Fulcher and Martin Gallagher and Kerr, {Peter G.} and Stephen Jan and Greg Johnson and Tim Mathew and Kevan Polkinghorne and Grant Russell and Tim Usherwood and Rowan Walker and Sophia Zoungas",
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    Lo, C, Zimbudzi, E, Teede, H, Cass, A, Fulcher, G, Gallagher, M, Kerr, PG, Jan, S, Johnson, G, Mathew, T, Polkinghorne, K, Russell, G, Usherwood, T, Walker, R & Zoungas, S 2018, 'Models of care for co-morbid diabetes and chronic kidney disease', Nephrology, vol. 23, no. 8, pp. 711-717. https://doi.org/10.1111/nep.13232

    Models of care for co-morbid diabetes and chronic kidney disease. / Lo, Clement; Zimbudzi, Edward; Teede, Helena; Cass, Alan; Fulcher, Greg; Gallagher, Martin; Kerr, Peter G.; Jan, Stephen; Johnson, Greg; Mathew, Tim; Polkinghorne, Kevan; Russell, Grant; Usherwood, Tim; Walker, Rowan; Zoungas, Sophia.

    In: Nephrology, Vol. 23, No. 8, 01.08.2018, p. 711-717.

    Research output: Contribution to journalReview articleResearchpeer-review

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    AU - Lo, Clement

    AU - Zimbudzi, Edward

    AU - Teede, Helena

    AU - Cass, Alan

    AU - Fulcher, Greg

    AU - Gallagher, Martin

    AU - Kerr, Peter G.

    AU - Jan, Stephen

    AU - Johnson, Greg

    AU - Mathew, Tim

    AU - Polkinghorne, Kevan

    AU - Russell, Grant

    AU - Usherwood, Tim

    AU - Walker, Rowan

    AU - Zoungas, Sophia

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    Lo C, Zimbudzi E, Teede H, Cass A, Fulcher G, Gallagher M et al. Models of care for co-morbid diabetes and chronic kidney disease. Nephrology. 2018 Aug 1;23(8):711-717. https://doi.org/10.1111/nep.13232