Regional Primary Care Team to Deliver Best-Practice Diabetes Care

Transcription

1 Clinial Care/Eduation/Nutrition/Psyhosoial Researh O R I G I N A L A R T I C L E Regional Primary Care Team to Deliver Best-Pratie Diabetes Care A needs-driven health workfore model refleting a biopsyhosoial onstrut of health LEONIE SEGAL, PHD 1 MATTHEW J. LEACH, PHD 1 1 ESTHER MAY, PHD CATHERINE TURNBULL, MPA 2 OBJECTIVEdBest-pratie diabetes are an redue the burden of diabetes and assoiated health are osts. But this requires aess to a multidisiplinary team with the right skill mix. We applied a needs-driven evidene-based health workfore model to desribe the primary are team required to support best pratie diabetes are, paying partiular attention to diverse lini populations. RESEARCH DESIGN AND METHODSdCare protools, by number and duration of onsultations, were derived for twenty distint ompetenies based on linial pratie guidelines and strutured input from a multidisiplinary linial panel. This was ombined with a previously estimated population profile of persons aross 26 patient attributes (i.e., type of diabetes, ompliations, and threats to self-are) to estimate liniian ontat hours by ompeteny required to deliver best pratie are in the study region. RESULTSdA primary are team of 22.1 full-time-equivalent (FTE) positions was needed to deliver best pratie primary are to a athment of 1,000 persons with diabetes with the attributes of the Australian population. Competenies requiring greatest ontat time were psyhosoial issues and dietary advie at 3.5 and 3.3 FTE, respetively (1 FTE/;300 persons); home (distrit) nursing at 3.2 FTE; and diabetes eduation at 2.8 FTE. The annual ost of delivering are was estimated at just over 2,000 Australian dollars (;2,090 USD) (2012) per person with diabetes. CONCLUSIONSdA needs-driven approah to primary are servie planning identified a wider range of ompetenies in the diabetes primary and ommunity are team than typially desribed. Aess to psyhosoial ompetenes as well as medial management is required if linial targets are to be met, espeially in disadvantaged groups. D iabetes is a signifiant global health issue. In Australia, ~4% of the population (818,200 persons) were diagnosed with diabetes in 2008 (1), with a further 3.6% estimated undiagnosed ases. Globally, the prevalene of diabetes is estimated at 150 million (2), whih is expeted to limb to.366 million by 2030 (2). Diabetes is assoiated with high rates of ompliations that affet all organ systems and inlude ardiovasular disease, kidney disease, diabeti retinopathy, neuropathy, and sexual dysfuntion (3). Diabetes is assoiated with substantial disease burden, aounting in Australia for 5.5% of all disability-adjusted life years lost due to disease and injury (4). Advaned disease adds to health system osts (5,6). Diabetes is lassified as ambulatory are sensitive, refleting strong evidene that best-pratie primary and ommunity are an avert hospitalizations (7). There is also evidene that multidisiplinary team are onsistent with bestpratie guidelines is both effetive and ost-effetive relative to soietal standards for funding of health servies (8,9). From the 1 University of South Australia, Adelaide, South Australia; and the 2 Department of Health and Ageing, Adelaide, South Australia, Australia. Corresponding author: Leonie Segal, leonie.segal@unisa.edu.au. Reeived 5 September 2012 and aepted 21 Deember DOI: /d by the Amerian Diabetes Assoiation. Readers may use this artile as long as the work is properly ited, the use is eduational and not for profit, and the work is not altered. See lienses/by-n-nd/3.0/ for details. Delivery of best-pratie, guidelineinformed are an markedly improve linial outomes in patients with hroni disease (10). However, it is also noted that linial pratie guidelines do not over all major influenes on are outomes, suh as psyhosoial issues, patient preferenes, and other influenes on self-are apaity (11). Effetive diabetes are depends in part on self-are apaity, whih is influened by fators suh as health literay, physial limitations, omorbid illness, ognitive ability, nonnative language profiieny, mental well-being, and exposure to soial insults (12). Patients haraterized by these threats to self-are are linked to poorer adherene to reommended diabetes treatment (13 18), worse glyemi ontrol (16,17,19), and inreased rates of ompliations (15). In addition, these patient attributes have been assoiated with poorer quality are (15). An approah to patient management that is ognizant of patient harateristis that an threaten self-are apaity (attributes most ommon in disadvantaged groups) may attenuate the poor health outomes observed in disadvantaged groups. Ideally, the primary are team should inorporate the mix of skills needed to address the diverse attributes of the lini population. This should reflet not only the linial diagnoses but also attributes that threaten self-are apaity. Study findings that the provision of an appropriately skilled, multidisiplinary team an deliver better outomes at lower osts of are ompared with usual are provided by a medial team (20,21) support this approah. Theaimoftheresearhreportedhere was to define the ompetenies and skill mix required to deliver best-pratie diabetes are in the primary and ommunity are setting, taking into aount a wide range of patient harateristis that an affet are outomes. The results of this researh ould then be used by servie planners to identify the desirable omposition of the diabetes primary are team are.diabetesjournals.org DIABETES CARE 1 Diabetes Care Publish Ahead of Print, published online February 7, 2013

2 Ideal regional diabetes primary are team and the regional health workfore to support optimal diabetes management. RESEARCH DESIGN AND METHODSdThe researh approah overs three phases desribed in a previously published health workfore model developed by Segal, Dalziel, and Bolton (22): 1) a ompeteny and skillbased needs analysis, 2) estimationofa loal health servie and health workfore requirement, and 3) exploration of poliy impliations. In this artile, we report on the appliation of the workfore model to diabetes, with a speifi fous on phases 1 and 2. Phase 1: needs analysis The needs analysis has previously been desribedindetail(23).inbrief,itonsists of three tasks. 1. Identifiation of patient attributes that require unique primary are team ompetenies: Twenty-six patient attributes were identified aross three levels (stage of diabetes, ompliations, and threats to self-are). The levels and patient attributes are desribed in the Workfore Evidene-Based (WEB) planning model for diabetes (Fig. 1), a unique oneptual model developed for this projet. The WEB model ontains more than one million possible ombinations of attributes or subpopulations. 2. Estimation of population prevalene by attribute in the study region: Pertinent datasets were interrogated to populate the WEB model. The numbers for thirteen attributes were drawn from the Australian Bureau of Statistis (ABS) National Health Survey (1) and the Australian National Hospital Morbidity Database (24), with the other attributes based on international surveys of persons with diabetes (23). The estimated number of persons with diabetes with eah of the twenty-six attributes is reported in Fig Defining best-pratie are: Best-pratie are objetives were defined for eah of the 26 patient attributes desribed in levels 2 4 of the WEB model, based on the most omprehensive published linial pratie guidelines for diabetes (25 27). These objetives were brought to three linial expert panels, and with use of a modified nominal group tehnique, linial are protools were derived to deliver the are objetives. The linial panels omprised twenty liniians, overing fifteen disiplines (ommunity nursing, dentistry, diabetes eduation, dietetis, endorinology, exerise physiology, general pratie, oupational therapy, pharmay, physiotherapy, podiatry, pratie nursing, psyhology, publi health, and soial work). The linial panel members were hosen to over the eighteen ompetenies listed in Table 1 that undersored diabetes management. A number also had diabetes and ontributed views of the patient. The outputs of this proess were linial protools desribed in terms of number of onsultations per year by length aross eighteen ore ompeteny fields,listedintable1,foreahofthe26 patient attributes aptured in the WEB Figure 1dWEB planning model for diabetes. Number of persons by attribute per 1,000 persons with diabetes (reflets the Australian population [modified from Segal and Leah, 2011, ref. 23]). Level 1: exluded, as workfore estimation restrited to persons with diagnosed diabetes. *Newly diagnosed or established. T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus. 2 DIABETES CARE are.diabetesjournals.org

3 Segal and Assoiates Table 1dDistint ompeteny areas for delivering best-pratie diabetes are in the primary are setting Competeny Case management and are oordination Clinial medial are Dental are Diabetes eduation Dietary advie and management Enabling funtional independene Ethni/migrant health Exerise presription and management Eye are Home nursing Indigenous health Lower-limb are Orthoti support Perinatal are Preventative are and surveillane Psyhologial are Soial support Speialist pharmaeutial management Definition Ability to plan and oordinate are for a person with diabetes and to review pertinent health outomes, the diabetes-management plan, and existing team are arrangements. Ability to assess, diagnose (through the use of advaned linial assessment tehniques and pathology tests), treat (using primarily pharmaeutial agents), and monitor diabetes and its ompliations. Ability to assess, diagnose, treat, and prevent dental and periodontal disease. Ability to deliver advaned eduation to a person with diabetes (of all ages and learning abilities), using appropriate learning tehniques, on topis suh as diabetes pathophysiology and ompliations, blood gluose monitoring, and pertinent self-are praties. Ability to advise on good nutritional habits and to develop and monitor individualized dietary management plans for persons with diabetes with or without ompliations or threats to self-are. Ability to enable persons to develop, restore, and/or maintain ativities of daily living to assist them in performing ativities or tasks neessary for self-are. Ability to deliver ulturally appropriate are and support to persons with diabetes from ethni/raial minority groups and to failitate patient aess to pertinent health and welfare servies. Ability to presribe and monitor a suitably developed exerise program for a person with diabetes. Ability to diagnose, monitor, treat, and prevent diabeti eye disease, inluding diabeti retinopathy, atarat, glauoma, and maulopathy. Ability to assess, plan, implement, and evaluate nursing are in patients with diabetes in the home, inluding the provision of wound and mediation management. Ability to deliver ulturally appropriate are and support to Aboriginal and/or Torres Strait Islander people with diabetes and to failitate patient aess to pertinent health and welfare servies. Ability to assess, diagnose, and manage diabetes-related disorders of the foot, ankle, and lower leg, inluding diabeti foot uleration, peripheral neuropathy, and peripheral vasular disease. Ability to measure, design, fabriate, fit, and servie orthoses to assist persons in performing physial ativities or tasks neessary for self-are Ability to monitor signs of ompliations of diabetes in pregnany and to deliver appropriate perinatal eduation and support to a person with gestational diabetes mellitus or diabetes in pregnany. Ability to sreen and monitor omorbidities, ompliations, pertinent risk fators, and threats to self-are; monitor onordane with the management plan and ondut annual review/yle of are; and reall patients. Ability to apply psyhologial assessment and therapy to relieve psyhologial distress and assist with adaptation to illness or life-threatening/highly distressing events. Ability to identify pertinent (psyho)soial onstraints in persons with diabetes and to work to find solutions to identified issues that will meet the patient s (psyho)soial needs. Ability to provide advie on the safe and proper use of diabetes mediations in ombination with other mediines. model. Competenies were used in this exerise rather than oupations to enhane the flexibility of the model and its value for workfore planning, servie delivery planning, and disussion about primary are team omposition. The output of this ativity (one page for eah of the 26 patient attributes) is available through the Health Eonomis and Soial Poliy Group Web site (28). Phase 2: loal health servie/health workfore requirement: defining the omposition of the primary are team The seond phase of the projet was estimation, by ompeteny, of the loal or regional health servie/health workfore requirements for the delivery of best-pratie diabetes are. The output of this phase was the omposition of the primary are linial team, defined by ompetenies, for the delivery of bestpratie management of people with diabetes. For this appliation, we used population attributes for Australia as a whole, thus determining the primary are team requirements for a patient athment with attributes similar to those of the Australian population with diabetes. This researh ativity ombined the results of the individual-level needs analysis for eah attribute with the estimated number of persons with eah attribute. Rather than simply adding total linial input aross all patient attributes, it was neessary to devise a logial approah to summation that reognized the ability of liniians to deal with issues related to more than one attribute in the onsult. We developed a six-step proess to sum annual ompeteny hours aross attributes and people as follows: 1. Where individual linked data were available (as was the ase for thirteen attributes reported in the ABS National Health Survey), we adopted the onservative position of searhing by individual, within levels 2 4, for the attribute that attrated the highest value onsultation time per year for eah ompeteny and using that as the estimated annual time input for the ompeteny at that level. For example, if an individual presented with poor mental well-being and major soial issues (e.g., death of a family member, marriage break up, vitim of violene, evition, loss of job) as the are.diabetesjournals.org DIABETES CARE 3

4 Ideal regional diabetes primary are team only two threats to self-are in level 4 of the WEB model, and the total annual onsultation time for these attributes for the ompeteny area soial support is 240 min to manage major soial issues and 210 min for poor mental well-being; 240 min would be seleted from level 4 for that individual. 2. For persons identified with poor English-language profiieny (4.4% from the ABS National Health Survey), 10% was added to the total onsultation time for eah ompeteny to allow extra time assoiated with the use of interpreters. 3. The estimated onsultation time for eah ompeteny by level for eah person was then summed aross levels (as eah level deals with distint types of needs) to yield the total annual linial requirement for eah person with diabetes for the thirteen attributes with linked data. 4. For the remaining (thirteen) attributes for whih individual linked data were not available, annual onsultation times for eah ompeteny were simply multiplied by the estimated prevalene, assuming prevalene onsistent with the best Australian or international evidene. 5. Total of required ontat hours for eah ompeteny for a regional/loal population with diabetes was obtained by summing aross individuals for the thirteen attributes for whih linked data were available and adding to this the estimates for the other thirteen attributes derived from survey data. For example, in the ase of neuropathy this was assumed to affet 10% of people with diabetes (29), who would then require 210 min/year of lowerlimb are (based on our needs analysis), thus adding a mean 21 min/year of ompeteny in lower-limb are aross all people with diabetes. 6. The final step involved a downward adjustment in relation to the nonlinked attributes for whih adjustment at the individual level for expeted effiienies of dealing with more than one attribute-related set of issues in the one onsult was not possible. This was not an issue for level 2 attributes: either they are mutually exlusive or liniian input is stritly additive (as for pregnany in people with type 1 or type 2 diabetes). This leaves eight attributes for whih possible effiienies in management might be an issue, seven of whih sit at level 3. However, of these, three relate to an event (e.g., ardia event) that requires management at the time, leaving only four with possible overlap. We onsidered eah of these and the potential for effiienies by ompeteny and adjusted onsultation time down by 20% for lower-limb are, dietary advie, diabetes eduation, exerise presription, and linial medial are in level 3. This method was used to derive an estimate of the primary are team required to deliver best-pratie diabetes are to a hypothetial 1,000 persons with diabetes, with the same mix of attributes as the Australian population (as reported in the ABS National Health Survey and seleted international datasets). The total onsultation requirements by ompeteny developed through this proess were then reviewed by the same ross-disiplinary expert panel who informed the needs analysis, revisiting the assumptions driving the results. These assumptions were either onfirmed or adjusted by onsensus using a modified nominal group tehnique, with disagreements resolved by disussion. The requirement in hours by ompeteny for 1,000 patients with diabetes was then realulated. Hours were translated into full-time-equivalent (FTE) positions for eah ompeteny, based on 1,530 h onsultation time per FTE position. (This presumes a 40-h week 3 45 weeks per year, allowing 4 weeks annual leave, 2 weeks publi holidays, 1 week family leave, and 15% for nonlinial ativities suh as administration and professional development). The alulations were ompleted using Mirosoft Exel. Core elements of the spreadsheets are available online (28). Finally, we mapped ompetenies onto oupations to illustrate the impliation of model outputs for possible membership of the primary are team by oupation and to estimate the ost of delivering best-pratie diabetes are. For this task, we mapped ompetenies refleting urrent pratie, defined as the oupation holding the highest level of ompeteny, based on the eduational objetives of undergraduate training in the urrent (2012) Australian linial eduation and training environment. RESULTSdThe delivery of best-pratie diabetes are in the primary and ommunity are setting to a athment of 1,000 persons with diabetes is estimated to require a multidisiplinary team that an olletively demonstrate ompeteny aross 18 areas and be able to deliver 33,780 linial ontat hours per annum. The results are presented in Table 2. This is equivalent to a mean ontat hours per person with diabetes per year aross all linial areas or just under 40 min per person per week. There is onsiderable variation around this mean. For example, a person with type 1 diabetes experiening major life stresses (e.g., reently widowed) and needing assistane with mediations (e.g., beause of ognitive impairment) requires an estimated 135 min per week, while a person with established type 2 diabetes but no ompliations or threats to self-are requires an estimated 13 min of liniian time per week on average. The ompeteny areas that required the greatest linial ontat times in mean hours per person per year were dietary advie and management (5 h), home nursing (4.8 h), diabetes eduation (4.2 h), preventative are and surveillane (3.1 h), psyhologial are (3.0 h), and exerise presription and management (2.9 h) (Table 2). Nearly 40% of ontat time is attributed to ore diabetes management (level 2), 23% to the management of ompliations (level 3), and 37% to addressing threats to self-are (level 4). Aross the three levels of the WEB model, the required linial ontat time varied for eah ompeteny (Table 2). For level 2, linial demand assoiated with basi diabetes management was, as expeted, dietary management, preventative are and surveillane, diabetes eduation, ase management and are oordination, exerise presription and management, and speialist pharmay management. Total ontat time for medial are was not high, despite high numbers of onsultations, owing to short onsultation time. For level 3, diabetes ompliations or events, highest ompeteny requirements related to psyhologial are, home nursing, lower-limb are, diabetes eduation, and exerise presription and management. For level 4, whih addresses fators impating on self-are apaity, the greatest demand was for ompeteny in home nursing (predominantly related to wound management and mediation support), dietary advie and management, soial support, exerise presription and management (assoiated with physial disability), and psyhologial are. 4 DIABETES CARE are.diabetesjournals.org

5 Segal and Assoiates Table 2dTotal ontat hours per ompeteny per annum required to deliver best-pratie diabetes are in the primary are setting to 1,000 persons with diabetes a Competeny Level 2 attributes: ore diabetes management The estimated total ontat hours imply just over 22 FTE linial positions for 1,000 persons with diabetes or 1 liniian/46 people with diabetes. What this might mean for the omposition of the primary are team is reported in Table 3, based on mapping of ompetenies onto oupations, refleting the highest ompeteny level implied by the eduational objetives of urrent undergraduate training in Australia. The results, in terms of primary are team omposition, are reported in Table 3 and the budget impliations in Table 4. It was found that half of the multidisiplinary primary are team positions would be taken up by just two oupations: nursing at 7.9 FTE (3.15 FTE for distrit nursing, 2.75 FTE for diabetes eduation, and 2.03 FTE for pratie nursing) and dietetis at 3.4 FTE (see Table 3). For distrit nurses, most of the workload was attributed to the management of impaired ognitive ability Level 3 attributes: ompliations Level 4 attributes: threats to self-are Total hours per year by ompeteny b Dietary advie and management 2, ,070 5,000 Home nursing 1,500 3,320 4,820 Diabetes eduation 2, ,210 Preventative are and surveillane 2, ,110 Psyhologial are ,190 3,030 Exerise presription and management ,280 2,890 Soial support ,660 2,390 Lower-limb are ,900 Clinial medial are ,470 Case management/are oordination 1,220 d 10 1,230 Speialist pharmaeutial management 940 d 80 1,020 Ethni/migrant ultural ompetene Eye are Dental are Enabling funtional independene Orthoti support Indigenous ultural ompetene Perinatal are 35 0,5 40 TOTAL 13,380 7,790 12,610 33,780 Data are n. a With attributes similar to those of the Australian population with diabetes. b To derive mean ontat hours per person by ompeteny, simply divide by 1,000. For level 4 attributes, hours will support basi diabetes are or management of ompliations but have not been not alloated there, as they apply only to persons with speifi threats to self-are. d Hours alloated to Level 1 but is also to support management of ompliations, i.e., level 2. (primarily for mediation management) and diabeti foot disorder (for wound management). The workload of diabetes eduators was largely taken up in the management of established type 1 and type 2 diabetes but was also taken up in addressing diabetes self-are issues that arise in the ontext of major soial insults (suh as death of a partner) and in advie on sexual dysfuntion (the most ommon ompliation of diabetes). Muh of the workload of pratie nurses was attributed to the preventive are and surveillane role. Medial are provided by the general pratitioner (GP) (or primary are physiian) was estimated to aount for 1.75 FTE positions, whih for 1,000 persons represents a aseload of 570 persons with diabetes per GP. The GP was identified as ontributing 8% of the total time of the are team but a higher perentage of onsultations and ost. Psyhosoial are, in this example assumed to be delivered by a psyhologist or soial worker (but might also be delivered by other professionals with relevant ompetenies), was identified with 3.5 FTE positions, making up ~15% of the are team. The ost of delivering diabetes are by the multidisiplinary primary and ommunity are team identifiedin Table 3 was estimated at million Australian dollars (AUD) per annum (2012). This equatesto2,052aud(;2,145 USD) per person with diabetes (Table 4). Over half of the salary ost was attributed to four oupations: GPs, nurses (i.e., distrit nurses, diabetes eduation, and pratie nurses), and dietitians. GPs aounted for 18.6% of the estimated salary ost, though making up just 8% of the diabetes primary health are workfore owing to onsiderably higher salaries. Psyhosoial are was estimated to aount for 14.5% of the primary are team ost. The annual primary are ost at just over 2,000 AUD per person seems modest relative to the mean ost of 1 day in hospital at 1,625 AUD (30) (adjusted to 2012 values using the health omponent of the onsumer prie index) or ;15 months supply of two ommon mediations for people with diabetes (a holesterol-lowering drug plus an antidiabetes agent) (31). CONCLUSIONS Overview of key findings 1. The appliation of an original health workfore planning model to diabetes has demonstrated the feasibility of implementing an evidene-informed needs-basedhealthworkforemodel, drawing predominantly on existing datasets. This represents a major advane over ommonly used liniianto-population ratios for health workfore and health servies planning. 2. The omposition of the multidisiplinary are team required to support bestpratie are derived by the model is ;50% linial diabetes are (medial/ nursing, pharmay, podiatry, and dental), ;25% to support more healthy lifestyle behaviors (predominantly dietetis and exerise physiology), and 25% to deliver psyhosoial are. 3. The model estimates a required primary are team of 22 FTE for 1,000 persons with diabetes at a mean estimated ost per person for 12 months of ;2,000 AUD (2,090 USD), whih is equivalent to the ost of 1.25 days in hospital or ;15 months supply of two are.diabetesjournals.org DIABETES CARE 5

6 Ideal regional diabetes primary are team Table 3dNumber of FTE positions by oupation a to deliver best-pratie diabetes are in the primary and ommunity are setting to 1,000 persons with diabetes Oupation a FTE positions Main areas of management: linial role and patient attribute (% of linial workload) Dietitian 3.25 Dietary advie and management for persons with established type 1 and type 2 diabetes (44%), review of dietary advie in response to soial insults (13%) Distrit nurse 3.15 Mediation ompliane support for persons with impaired ognitive ability (68%), ommunity nursing for diabeti foot disorder (31%) Diabetes eduator 2.75 Diabetes eduation for persons with established type 1 and type 2 diabetes (54%), soial insults (11%), sexual dysfuntion (10%) Pratie nurse 2.03 Preventive are and surveillane in persons with established diabetes (64%) Exerise physiologist 1.9 Exerise presription and management in persons with established type 1 and type 2 diabetes (21%), impaired physial ability (13%), morbid obesity (13%), eating disorder (10%) Psyhologist 1.98 Psyhologial support related to sexual dysfuntion (45%), eating disorder (22.3%), diagnosed mental health disorder (18.3%), morbid obesity (8.5%) General pratitioner 1.75 Medial are (58%) and ase management and are oordination (42%) Soial worker 1.56 Soial support in response to soial insults (54%), poor mental wellbeing (15%) Podiatrist 1.25 Foot are for persons with established type 1 and type 2 diabetes (34%), diabeti foot disorder (22%), neuropathy (17%) Pharmaist 0.67 Speialist mediations advie for established type 1 and type 2 diabetes (92%) Ethni/migrant health 0.45 Care of persons of an ethni/migrant bakground (100%) worker Optometrist 0.42 Eye hek/eye are for established type 1 and type 2 diabetes (85%), eye ompliation (13%) Dentist 0.36 Dental are for established type 1 and type 2 diabetes (99%) Oupational therapist 0.3 Enabling funtional independene for persons with vision impairment (eye ompliation [35%], neuropathy [31%]) Orthotist 0.15 Preparing orthoses for persons with impaired physial ability (100%) Aboriginal health worker 0.07 Care of persons with an indigenous bakground (100%) Community midwife 0.02 Type 2 diabetes in pregnany (68%), gestational diabetes mellitus (25%) Total Data are n. a Oupation listed reflets the profession most likely to hold the highest level of ompeteny for that ativity, based on eduational objetives of urrent undergraduate training in Australia. This does not take into aount possibility for role substitution, diversity of staff experiene and speifi training, or workfore supply. FTE would hange if another oupation group delivered the ompeteny with a different level of produtivity. ommon mediations for this population (an antidiabetes agent and a holesterol-lowering drug). 4. The breadth of the proposed skill base of the primary are team and espeially the inlusion of psyhosoial apability should better address the diversity of lini populations and improve outomes, partiularly in more disadvantaged populations. Limitations A number of simplifiations with model implementation need to be noted. First, it is a stati model (or potentially steady state). It reflets a population and its health status and other attributes at a partiular point of time (most inputs were from 2006) and best-pratie are as desribed in 2011 by our linial experts, also drawing on earlier published guidelines. However, we note that a hange in linial best pratie does not neessarily mean a hange in the desirable ompetenies of the primary are team. While we have used a rolling linial panel with a diverse membership and a Delphi tehnique to eliit onsensus and informed the deliberations with the best published guideline evidene, it is possible that another expert group would have arrived at a somewhat different set of are protools. In publishing the model, we would invite other onstituenies to repliate the appliation to reflet the harateristis of their own populations and perhaps a different understanding about the translation of bestpratie are objetives into number and length of onsultations for eah ompeteny. The linial panel did not inlude formal patient representatives. However, a number of members of the linial panel did have diabetes and brought their experiene as patients to the disussion. Multidisiplinary are team This researh supports the need for a multidisiplinary team that overs a wide range of ompetenies for the delivery of diabetes are. The proposed team is not dissimilar to that whih an be inferred from published linial pratie guidelines for diabetes, whih suggests a ore primary are team of 3-10 members aross the disiplines of diabetes eduation, dietetis, exerise therapy, mediine, nursing, dentistry, optometry, pharmay, podiatry, and mental health (25 27). Guidelines also mention the need for indigenous or ethniity-speifi health workers, depending on the lini population. The major professional areas left out relate to ompetenies for addressing threats to aspets of self-are apaity, notably soial work. While it might be argued that the ompetenies we have inluded in the primary are team ould be overed through referral, this is not onsistent with a quality multidisiplinary team model, whih ideally inludes all those involved in patient are (at the primary 6 DIABETES CARE are.diabetesjournals.org

7 Segal and Assoiates Table 4dSalary ost of primary and ommunity are team for delivery of best-pratie diabetes are to 1,000 persons with diabetes (AUD in 2012) Oupation a Full-time annual salary are level). This should inlude soial work, oupational therapy, and all other allied disiplinesdnot just the ore medial/nursing teamdboth to develop a speial understanding of the partiular issues faing people with diabetes (or related hroni onditions) and to provide for a lose working relationship between all members of the are team. Further, as this analysis suggests, the required input from the psyhosoial disiplines is onsiderable; their membership as part of the ore team simply makes sense. Multidisiplinary team and disadvantage A fous on the medial are team would undoubtedly leave the quality of are for ertain subpopulations with diabetes, partiularly those experiening hallenging soial issues, poor mental health and well-being, and physial or intelletual FTE positions required (n) Total annual salary ost Total wages ost (plus 15% of wage on osts) GP 209,546 d , ,710 Distrit nurse 73, , ,440 Diabetes eduator 79, , ,840 Dietitian 70,443 b , ,280 Pratie nurse 73, , ,420 Exerise physiologist 70,443 b , ,910 Psyhologist 70,443 b , ,400 Soial worker 70,443 b , ,370 Podiatrist 70,443 b , ,260 Pharmaist 70,443 b ,200 54,300 Dentist 91,074 b ,790 37,700 Optometrist 70,443 b ,590 34,020 Ethni/migrant health worker 51, ,175 26,650 Oupational therapist 70,443 b ,130 24,300 Orthotist 70,443 b ,570 12,150 Aboriginal health worker 51, ,610 4,160 Community midwife 73, ,460 1,680 Subtotal ,051,590 Total (ost per person with diabetes) 2,052/person a Oupations reflet the professions most likely to hold the highest level of ompeteny in the area based on eduational objetives of undergraduate training. It does not take into aount possibility for role substitution, possible differenes in produtivity, diversity of staff experiene and training, or supply. b South Australian Government wages parity (salaried) enterprise agreement Allied Health Professionals lassified as Allied Health Professional, level 2, year 2; dentists lassified as dental servies offier, level 1, year 7 (Department of Premier and Cabinet, Adelaide [ pdf ]. Nursing/midwifery (South Australian publi setor) enterprise agreement Distrit/pratie nurse lassified as registered nurse, level 1, year 10; diabetes eduator lassified as linial nurse, level 2, year 10; ommunity midwife lassified as registered midwife, level 1, year 10; aboriginal and ethni/migrant health workers lassified as enrolled nurse (ertifiate), year 7 (Department of Premier and Cabinet. Nursing/ Midwifery (South Australian publi setor) enterprise agreement 2010 (Department of Premier and Cabinet, Adelaide [ d Average gross personal earnings of GPs aross Australia in 2008 (ref. 42). disabilities, with inadequate quality are and poorer outomes than neessary. These fators impat on glyemi ontrol (16,17,19), the effetiveness of linial are, and disease progression, as well as health-related quality of life (32). Inorporating into the diabetes team health professionals with demonstrable ompeteny in delivering psyhosoial are is fundamental if optimal outomes are to be ahieved, espeially in people with diabetes with multiple disadvantages that onstitute threats to self-are. For example, 42% of adult Australians with diabetes report medium, high, or very high levels of psyhologial distress (33). If the onsiderable disparity in health outomes observed between persons from higher and lower soioeonomi status is to be redressed, ensuring that the primary are team has the ompetenies to deal with threats to self-are will be ritial. Regional variation in workfore/team requirements The struture of the model makes it possible to inorporate loal data that apture the health status and other attributes of a loal ommunity. In Australia, the widespread use of information tehnology based linial are systems results in a high apaity to populate the model with loal data. In translating ompetenies into oupations, knowledge of the regional workfore would be a valuable input. However, in identifying the ore ompetenies and broad skill areas that need to be overed within the are team, the model may also highlight speifi training needs. The model parameters ould also be modified to take into aount different delivery modes, suh as the use of internet-based are options or group delivery of are. Comparison with urrent are team A omparison between our estimate of need with workfore supply for the management of diabetes in Australia ould not be ompleted beause of limitations with published workfore data (11). Given the strong medial fous of primary are in Australia, modified in reent years to fund greater aess to allied health and psyhology servies and pratie nursing, it is almost ertain that there will be a onsiderable gap in aess to other members of the are team, espeially soial work, dietetis, diabetes eduation, dental, and pharmay. These servies are predominantly funded by state governments, with funded plaes and thus aess, limited by presribed budget aps, ontrasting with open-ended funding by the Australian Government of GPs through the Mediare Benefits Shedule plus extensive funding for pratie nursing and psyhology. However, the funding model being largely fee for servie for individual pratitioners does not enourage genuine multidisiplinary team are. Training of health professionals The ompetenies identified through this researh math many of those seen in the hroni disease self-management literature (34,35). These models enourage health professionals to beome oahes and failitators of self-management rather than treatment providers. A hallenge in preparing the future workfore of health professionals is to ensure that priniples of interdisiplinary team are and hroni disease self-management are inorporated are.diabetesjournals.org DIABETES CARE 7

8 Ideal regional diabetes primary are team into health professional eduation and embedded within ontemporary urriula. But support through appropriate models of primary are funding is also ritial if the primary are is to be allowed to ahieve the right balane. The ideal funding model is through a needs-adjusted apitation formula with servies purhased/delivered through a fundholder with ommunity and patient input to priorities (36,37). This researh ould be used to inform the eduational objetives of possible new ross-disiplinary health professionals for working with lients with hroni disease to reflet ompetenies identified in the WEB model. For example, Rosenthal et al. (38) disuss the ommunity health worker as an emerging onept to onsider in redefining and redesigning primary are servies. The ompetenies desribedinthewebmodelouldinform the set of ompetenies and skills for a ommunity health worker to work more effetively with people with hroni disease, espeially those with multiple disadvantage. Training workers who an ompetently over more than one ompeteny would enable a redution in the number of members of the multidisiplinary team required to deliver best-pratie are. This would be an advantage in terms of level of oordination required and would be more onvenient for the patient. Many pratitioners from different oupations may have the knowledge, skills, and experiene to support lients with diabetes. The WEB model, with its desription of patient attributes and assoiated ompeteny requirement, opens the way for workfore development to address these attributes through appropriate skills and ompetenes rather than simply onsidering professional labels. The onus is on the pratitioner to demonstrate skill and apaity to manage seleted patient attributes rather than presumed by virtue of professional designation. For example, a soial worker, psyhologist, nurse, or oupational therapist may have the skills to support lients with issues related to psyhosoial insults, and so, rather than identifying the profession in reruitment materials, the area of management of psyhosoial issues beomes the fous. It is then up to the pratitioner to provide evidene of skills and knowledge in that area, rather than relying on assumptions that the professional label provides that evidene. The WEB model s artiulation of ompetenies required for hroni disease are refleting partiularly on self-are apaity is timely, given the shift in fous of health are poliy from a disease and oupational servie model to a patiententered are approah (39). This allows the development of are teams around the patient s needs rather than the professions need to speialize. Flexibility of team onstrution is also useful to reflet hanging workfore and population omposition over time (40,41). The WEB model supports examination of the ompetenies required from a patient-entered approah that better reflets the extreme diversity in lini populations. It also demonstrates the advantage of using ompetenies to define the team, rather than starting with professions or oupations. If family members or others have the ompetenies and preparedness to deliver needed are (suh as mediation support), this ould potentially substitute for a liniian in the primary are team. Need for feedbak loop In implementing the model in a speifi loal area, the primary are team mix defined by the model would need to be arefully monitored against atual demand. Demand for servies will reflet, for instane, the extent to whih the target population hooses to aess servies and mode of servie delivery. Patients may find the estimated shedule of onsultations too onerous or simply onsider the suggested level of onsultations unneessary. If this is the ase, understanding why will be important. Mode of delivery ould potentially have a large impat on workfore needs. For example, the provision of group onsultations or extensive use of internet/phone-based are would hange the optimal team onfiguration. In applying the model in a partiular servie delivery ontext, where mode of delivery an be desribed, adjustment to reflet this is of ourse desirable. However, it is important to distinguish when an alternate servie model reflets best-pratie are and when it represents a ompromise imposed by limited funding. Summary The delivery of best-pratie diabetes are requires a broad multidisiplinary health are team, with the neessary skills and ompetenies to effetively address the biopsyhosoial needs of the population with diabetes. These inlude not just medial are requirements but also the ompetenies to address the many fators that impat on self-are apaity. We argue that one reason quality of diabetes are is often observed to be poor with failure to ahieve linial targets, espeially in more disadvantaged groups, is the narrowness of the multidisiplinary team. While the omposition of the primary are team does not guarantee the delivery of best-pratie are, whih in addition requires a sound linial quality-assurane system, appropriate funding, and well-trained liniians, the ahievement of good hroni disease outomes for patients will remain elusive in the absene of a primary are team with the appropriate mix of ompetenies. The WEB model helps define those ompetenies. Appliation of the WEB model to other onditions is a possible extension of this researh and ould be used to define global primary and ommunity are workfore needs. Disussions with health workfore planning agenies have onfirmed the value and originality of the model for those seeking an evidenebased approah to health workfore and health servies planning. AknowledgmentsdThis researh was funded by an Australian Researh Counil Linkage Grant (LP ). Funding from the Australian Researh Counil and the Department of Health, South Australia, as the partner organization is aknowledged. No potential onflits of interest relevant to this artile were reported. L.S. oneived the original plan for the study and the artile, devised the researh design, supervised implementation of the researh, and had major arriage of manusript preparation and finalization. M.J.L. jointly developed the WEB model, jointly planned the researh, had responsibility for day-to-day management, undertook the analyses, reported the results, and ontributed to manusript preparation and finalization. E.M. and C.T. ontributed to the overall researh design, the refinement of the WEB model, and manusript preparation. L.S. is the guarantor of this work and, as suh, had full aess to all the data in the study and takes responsibility for the integrity of the data and the auray of the data analysis. The authors sinerely thank all members of the expert linial panels for their valuable ontribution to the projet, in partiular, Dr. P. Phillips for the ongoing support (endorinologist, Queen Elizabeth Hospital), J. Giles (redentialed diabetes eduator, Queen Elizabeth Hospital), C. Stanton (aredited pratiing dietiian, Queen Elizabeth Hospital), D. MKenzie (pratie nurse, Adelaide Western Division of General Pratie), J. Badenoh (president, 8 DIABETES CARE are.diabetesjournals.org

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