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Team effort to control diabetes |
 Physician Stephen Moore performs an eye check on Judy Torrens at the Tabulam outreach clinic.
The Primary Health Care Network Project - Diabetes (PHCNP) is a partnership involving Dharah Gibinj Aboriginal Medical Service, Casino, the Northern Rivers Division of General Practice and the Northern Rivers Area Health Service.
A key part of its work is to provide outreach services to local Aboriginal communities, including Jubullum, near Tabulam, between Casino and Tenterfield, where Robin Osborne photographed the multi-disciplinary team in action.
These are exciting times in Goori health, with the Tabulam Health Post, Jubullum, recently hosting the travelling Diabetes Complication and Assessment Clinic (DCAC).
The patients were all referred to the clinic by their local GP. On the day each case was discussed and the skills and knowledge of the clinic came together. The sum proved itself to be greater than the parts.
The coordinator of the project, Jo Cooper, has been able to bring together different health professionals from the NRAHS and the AMS Casino to create an excellent and innovative working team.
Several of the team had never been to an Aboriginal community before and appreciated the opportunity to meet with some of the locals and experience some Goori culture. From the community's point of view, many had never seen a specialist physician or a podiatrist before showing that obstacles to access can be overcome using such a model.
In addition the clinic contributes to the Goori communities it visits in other ways, with initiatives such as the Goori art competition.
Collated reports from the DCAC are made for each patient and copies sent to the referring GP, the local diabetes educator and the patient.
From the GPs’ viewpoint the DCAC report, overseen and signed by Dr Stephen Moore, provides an extremely useful framework for the management of what is always a very complex condition. The clinic also affords the opportunity to work side by side with other colleagues something not always seen in general practice.
The goal remains the assessment and prevention of the frequently seen complications of diabetes such as lower limb amputations and end stage renal failure for individual patients. The findings gathered will assist with planning and preventative efforts at the community level.
The patient contact with the doctors is assisted by access to the electronic files kept at the Casino AMS using ‘PC Anywhere’ software. This was one of the positive outcomes of the division's virtual amalgamation project of 2002 and a precursor to the broader Aboriginal IT project.
The Aboriginal IT project, run by the division, will provide a centralised Aboriginal database housed and maintained in Lismore and will cover areas from Cabbage Tree Island and Ballina in the east to Tabulam and Muli in the west. It will make available clinical information to the doctor and clinics such as the DCAC where ever the point of contact.
The Primary Health Care Network Project and the Diabetes Complication and Assessment Clinic is supported by the division, NRAHS, and Casino AMS. The project is funded by NSW Health. It will return to Tabulam twice more this year and will also visit Casino, Muli and Coraki.
Joanne Cooper, PHCNP coordinator:
When the Primary Health Care Network Project commenced in September 2003 we visited all the communities to introduce ourselves, asking people what services relating to diabetes they felt they required. Their responses were usually kidney and feet related, as many community members had relatives that had either had renal dialysis or had an amputation due to the complications of diabetes.
We also spoke to Aboriginal health workers, Aboriginal health education officers as well as other health professionals - GPs, practice nurses, diabetes educators and dietitians - and asked them what they saw as gaps to service provision to these communities.
The gaps identified were issues relating to transportation and understanding the problems associated with medication compliance: very few community members had visited a specialist or understood their role in health. Their ability to access these services, even once referred, were often very difficult due to transportation issues.
As we researched we also found very little culturally appropriate health promotion material: the Bundjalung Nation is made up of many tribes and call themselves ‘Goories’. They have difficulties relating to health promotion material made for other Aboriginal groups.
The Goorie Diabetes Complication and Aseessment Clinics were established, and a multidisciplinary team of health professionals assembled: physician, Dr Stephen Moore, ophthalmologist, Dr Malcom Tester, GPs, Dr Anthony Solomon & Dr Thomas Sebastian, diabetes educators, Adrielle Carrasco, Maryann Young, Cheryl Ducat, registered nurses, Jenny Horsely, Nadine Coker, Aboriginal health professionals, Marlene Binge, Graeme Walker, Karen Day, Christine Williams, Tim Torrens, Evelyn Robinson, Ellie Bradshaw, Podiatrists, Helen McGregor, David Shaw, NRAHS Pathology’s Lyndal Palmer.
They attended to ‘point of care testing’ at clinics established as team members in January 2004. The clinics offer to the diabetic client an assessment of the complications from diabetes and the findings to date are as follows –
Body mass index
BMI >25 - 85%*
BMI >30 – 77%*
Blood pressure
B/P> 120/80 – 85%
B/P>130/85 – 72%
Glycated haemoglobin
HbA1c>7.5% – 56%
HbA1c>9% - 33%
Cholesterol
>5.5mmol/L -10%
Cholesterol HDL ratio
>4.5 – 59% *
Triglycerides
>1.82mmol/L – 74% *
Microalbumin creatinine
Ratio
>3.0mg/mmol - 44%
Serum creatinine
>120 - 15% *
Eosinophils
> .5 - 26%
History of heart disease
33%
Diabetic retinopathy
13%
Cataracts
11%
High risk foot disease
10%
* (Age & sex variations taken into account for results.)
Ongoing support of the client is offered through the GP to discuss case conference findings, along with individual sessions from a diabetes educator, and support from the Aboriginal vascular health workers regarding exercise advice and smoking cessation.
The Goorie Diabetes Complication and Assessment Clinic also offers the Aboriginal communities testing for the early identification of diabetes in line with the NHMRC’s document National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus in consultation with the clients GP (pp 128-9 & 201).
Mick Roberts, Director, Dharah Gibinj Aboriginal Medical Service:
Since its beginning the PHCNP has built on the partnership to deliver effective strategies and facilitate in identifying gaps in service delivery for Aboriginal people with diabetes.
The PHCN coordinator and her team of health professionals (diabetes educator, vascular health nurse and Aboriginal health workers interact with specialists to deliver a coordinated care service to Aboriginal people in remote areas of the Richmond Valley and around Casino.
With the three Diabetes Complication and Assessment Clinics (DCAC) held so far in Casino, Jubullum Village and Muli Muli there has been a good response from local people seen at the clinics.
A multi-disciplinary team approach of care is the best way for this network project to deliver this service and the number of Aboriginal people attending is an indication of the hard work the team puts into every clinic.
With the evidence Coordinator Joanne Cooper has gathered from the three clinics it will be interesting to start viewing the overall picture being addressed by this much needed service.
Anthony Solomon, GP, Dharah Gibinj, AMS.
The Tabulam Health Post recently hosted the travelling diabetes complication and assessment clinic with 13 local residents moving through the clinic. All had been referred by their local GP.
There was a festive atmosphere at the clinic with smiles all around.
Each person was seen by every member of the team.
In the afternoon the skills and knowledge of the team came together when a case conference was held for each patient. The sum proved itself to be greater than the parts!
Coordinator, Jo Cooper, kept a running summary of the contributions and collated reports with a copy sent to the referring GP, the local diabetes educator, the local hospital, and the patient as a framework for their future diabetes care.
Modern technology was evident on the day, with the mobile pathology lab from NRPS providing ‘point of care’ urine and blood results including HBA1c results for each patient.
This technology is used by the AMS in its outreach service to the communities of Muli, Tabulam, Coraki-Box Ridge and Lismore.
For details or more information call Jo Cooper on 6662 3514.
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