Some GPs see patient after patient and may not talk to another doctor or health care professional throughout the day. But the team approach at Dr Kean-Seng Lim’s Mount Druitt, Sydney, clinic is tackling diabetes with a new team approach.

When Dr Kean-Seng Lim started working at his Mt Druitt, Sydney, general practice twenty years ago, the scales he weighed patients on went up to just 130kg. He and his team had to upgrade several times over the years: for scales that went up to 160kg, 200kg and, most recently, 250kg.

The problem Dr Lim is dealing with is type 2 diabetes – a disease dubbed the Silent Pandemic for the fact that so many already have it but don’t realise it. Currently, type 2 diabetes costs taxpayers $6 billion per year, with three million Australians over the age of 25 projected to develop the condition by 2025, according to Diabetes Australia. That it is largely preventable remains a thorn in the side of many health care professionals, including Dr Lim, who works in one of Australia’s most worrying diabetes hot spots.

“The Blacktown and Penrith areas experience a significantly higher rate of patients developing type 2 diabetes – and when we analysed our clinical data in 2012, it became clear that we were way ahead in national averages, in terms of weight and prevalence of diabetes,” he explains.

“We knew it was likely to be an ongoing and increasing problem in years to come.”

The knowledge motivated Dr Lim’s decision to restructure his practice significantly according to patient needs. It was a move which, along with his commitment to student training, helped see him recognised and awarded the RACGP 2015 Doctor of the Year award.

Rethinking the GP model

Although a team approach to treating disease is something hospital clinics have done for some time, it’s not common in general practice in Australia, says Dr Lim.

“If you look at countries like the UK, the US and even New Zealand, there are whole regions where there has been a much greater degree of top-down leadership from governments which has led to that innovation – but here in Australia, there hasn’t been that same support for planning for true, preventative, comprehensive care.”

Dr Lim found a way. His first step was to tap into his Primary Health Network, a government initiative which provided data auditing tools and staff training. Similar resources are available to GPs around Australia, he says.

“These tools enabled us to develop a much greater insight into the health needs of our patients as well as track the changes and measure improvements,” Dr Lim explains. “We then evaluated the profile of the practice, mapped out the future direction it was likely to take and made decisions on restructuring – which meant bringing in an integrated, multi-disciplinary team.”

This team – comprised of a dietitian, exercise physiologist, psychologist and clinical pharmacist – often see patients together or consecutively, and work together to establish a staged approach to treatment.

The results have been impressive, with 82 per cent of Dr Lim’s diabetic patient population now experiencing good or reasonable control of their condition; a 30 per cent improvement since 2012, he says. “We’ve seen similar results with blood pressure and cholesterol control and the optimal use of medication. These improvements are very hard to do on your own, but are much more manageable with a whole team approach.”

While shifting to a new business model can impact your bottom line, Dr Lim says his practice is doing well financially.

“It was something we had concerns about, but our primary aim was to produce a model of service which would produce better outcomes. We also work to engage the allied health members of our team to ensure they are also financially sustainable – so we look at how we can use the team to manage not just chronic disease but everything from work related injuries to, say, motor vehicle accidents.”

The clinic’s next challenge is to effectively leverage advances in wearable technology so they can offer better services to patients. “We’re looking at fitness devices that sync to a person’s mobile phone, and the capacity for us to link data between our systems and patients’ smartphones,” Dr Lim explains. “We’d very much like to link all this in with video consultations, remote monitoring and improving access to care.”

Hope for the future

For clinics thinking of tweaking their practice and adopting a similar team approach, Dr Lim admits it has been a learning curve. “In the beginning we tried to do too much, which led to burn-out, but now we’re working much better as a team and the systems within our practice have continued to improve.”

His advice would be to work out where you want to take your practice, make changes in manageable chunks and make use of the tools to help – including those from your Primary Health Network and the local branch of your Australian Medical Association [AMA]. Dr Lim, who is vice president of the NSW AMA, says it is very active in this space.

“For example, the NSW AMA has launched a program called the Future Practice program which is about trying to improve the quality of care we deliver in a sustainable manner offering a variety of resources to help practices plan and transform.”

Ultimately, Dr Lim believes the practice he has developed is a model that works and one he hopes will be more widely adopted among general practitioners around the country.

“We’ve seen some very clear and measurable improvements in diabetes care and weight loss, and we’ve extended the same methodology to how we would deal with lung disease and heart disease,” he says.

“While we are still at the early stages of collecting data on that, we believe we’re making a good impact for those patients as well. One of my hopes is that I can encourage more health professionals – not just doctors – but all health professionals to come together and work as a team to produce best results for patients.”

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