Diabetes Care Collaborative

What is a Breakthrough Collaborative?

Breakthrough Collaborative is a short-term (9- to 15-month) learning system that brings together a large number of teams from General Practices, hospitals and clinics to seek improvement on a common goal. Participants learn from each other and from recognised experts in topic areas with a view to closing the gap between what we know and what we do.

What are we trying to achieve?

To improve the outcomes of diabetes care we seek to minimise variation in type 2 diabetes management, improve or increase collaborative multidisciplinary care and care planning and enhance sharing of key information (namely the HbA1c marker).

Whilst there will be several measures tracked, our overall aim is:

  • By December 2016, 70% of registered patients with Type 2 Diabetes will have a recorded HbA1c as part of their diabetes management.

Other projects goals are to:

  • Improve data input for patients with T2DM
  • Improve the linkage and collaboration with Hospital based services
  • Enhance collaboration and communication between service providers
  • Reduce variation from best practice in the management of patients with T2DM
  • Increase capacity of patient/carers to self-manage
  • Increase completion rates of GP Management Plans (GPMPs), Team Care Arrangements (TCAs) and Annual Cycles of Care
  • Increase rates of review of GPMP and TCAs
  • Decreased potentially preventable hospital admissions for type 2 diabetes

Diabetes Care Collaborative Expectations

By committing to the Diabetes Care Collaborative participating organisations are signing up to a twelve-month partnership. This includes attending three face to face learning sessions that will be held in November 2015, March 2016 and July 2016. Additionally, there will be monthly teleconference held to support participants during the action periods. Extensive support will be provided to complete monthly reports that describe the outcomes of tests of change undertaken.

The Expert Faculty will:

  • Provide evidence based information on subject matter
  • Develop a collaborative charter, change package and measurement strategies
  • Provide education and guidance on improvement methodology
  • Provide support around measurement strategies and data collection
  • Provide regular feedback reports and support participants to complete PDSA’s
  • Provide coaching for participants

Participating organisations will:

  • Commit to participate in a collaborative for twelve months
  • Complete pre-work activities to prepare for learning session
  • Participate in all three learning sessions
  • Participate in conference calls
  • Take measurements and report them monthly
  • Submit monthly progress reports
  • Perform test of changes in the organisation that lead to widespread implementation of improvements in the organisation and their practices
  • Share information with the collaborative including details of changes made and data to support these changes, both during and between learning sessions