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Diabetes Model of Care Project

Key Project Resources

Project Summary 

Project Outline

Newsletter - DDHHS Diabetes Model of Care Project - October 2017

How did this project come about?

Queensland Health has established an Integrated Care Innovation Fund (ICIF) with a primary aim to invest in initiatives that generate new ideas for better integration of care, address fragmentation in services and achieves greater efficiency and value from health delivery systems.

Hospital and Health Services (HHS) were asked to work in collaboration with their local Primary Healthcare Network (PHN) and other community health providers to develop and progress new models of care and approaches to integrated care for funding consideration by the Department.

What is the project hoping to achieve?

This innovation is based on a stepped-up approach for diabetes care. There are two main aims:

  • Reduce the demand on specialist and emergency services by up-skilling primary health care to manage their patients within the community.
  • Improve patient health literacy and self-management to "close the gap" and improve health outcomes.

The primary program outcomes are to:

  • Reduce ED presentations by 25%;
  • Reduce the number of diabetic “frequent flyers” to ED;
  • Reduce hospital admissions for diabetes related complications;
  • Empower patients to self-care leading to improved medication compliance/titration and diabetic control
  • Improve health outcomes for indigenous people ("Closing the Gap" in health status and a reduction in the number of people discharged against medical advice); and
  • Reduce chronic potentially preventable hospitalisations (PPH).

What is the project about?

This innovation is based on a stepped-up approach providing innovative care solutions for low through to high need diabetics. The project has four key components:

  1. Aboriginal and Torres Strait Islander (ATSI) Care Coordination Virtual Team
  2. GP-Led Diabetes Care
  3. QAS Referral Pathway
  4. Home Monitoring


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