New Model of Care Improves Lives of Those with Diabetes and Kidney Disease

A new model of care for those with diabetes and kidney disease, co-designed by those living with the conditions, has been shown to reduce death rate and the average length of hospital stay.

Named the Diabetes Kidney Service, the care model is managed by Monash Partners’ lead health services and brings patients and their carers together with an integrated multidisciplinary service of general practitioners, endocrinologists, nephrologists, and nurse practitioners.

“The Diabetes Kidney Service was codesigned to improve patient self-management and optimise collaboration between carers and patients. Although the rate of hospitalisation was higher in patients engaged in the new model of care, length of hospital stay was shorter and death rate was lower,” said Professor Zoungas, Project Lead.

Improvements in best practice including statin use, foot and eye examinations were also observed.

Quality of life for those with kidney disease and diabetes was also maintained over a 12-month period. 

Professor Sophia Zoungas says the results are significant because past data usually showed a deterioration in quality of life over time in this population.

“Diabetes and kidney disease are among the top five co-existing chronic diseases in Australia. Each year, two out of every five Australians who commence kidney replacement therapy are affected by these conditions,” said Professor Zoungas.

“Current health-care models are ill-equipped for managing people with co-morbidities including diabetes and chronic kidney disease. They have significant gaps between best practice guidelines and received care and limited patient engagement in the co-design of services. They often leave patients to navigate complex and confusing health services that are not designed for patient-centred care.”

“This new model of care has been co-designed by patients with diabetes and kidney disease lived experience and their carers. We also extensively engaged stakeholders including patient advocacy groups Diabetes Australia and Kidney Health Australia, and health professionals in tertiary and primary care, to explore barriers and implement improvements over existing health services.”

“Staff members, referring general practitioners and attending patients felt that a co-designed integrated diabetes kidney service improved integration of care, and also improved health in terms of all-cause mortality, kidney function, glycaemic control, self-care and management of health,” said Professor Zoungas.

One patient reported that attendance of the Diabetes Kidney Service improved his health-care access by decreasing appointments. “So, they put both the kidney and diabetic clinic together for me so that I don’t have to go to two places. You know, it’s always appointments, appointments”.

Another patient praised the support provided by the service toward self-management of their health: “So I have to control all that. And by doing all this, I think I can achieve it. The support, what you get from the Diabetes Kidney Service is fantastic. These people are not our regular GPs but I feel that they are taking interest in our case, in whatever type of diabetes you have and however many years you have had it for.”

“Given the benefits of the Diabetes Kidney Service model of care, there is scope for sharing learnings and implementation across other health networks and settings within Australia,” said Professor Zoungas.

This project is supported by the Australian Government’s Medical Research Future Fund (MRFF) as part of the Rapid Applied Research Translation program through Monash Partners Academic Health Science Centre.

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