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Our Integrated Care Collaborative Alliance initiatives aim to make hospital and community health services more joined up and better for patients.

Our goal is for people with diabetes to have most of their care managed through their Primary Care General Practice team, with input from the Specialist Service as required, through an integrated collaborative approach to service delivery. Over time the Specialist Service will develop into a high end consultation service that is able to deliver targeted care closer to people with diabetes. There is a focus on the delivery of services according to peoples’ needs, in particular for Māori and Pacific populations. Diabetes management and outcomes are not the same for Māori and Pacific people as the rest of the population.

The CCDHB diabetes model’s key components will include:

  • Collaborative case service in priority practices – The specialist team will visit the selected priority practices on a regular basis and work with the Primary Health Care team to participate in case discussions, combined clinics, practice education, collegial support and peer review. Priority practices will be selected based on those with the highest number of Māori and Pacific populations
  • Nurse practice partnership – A diabetes clinical nurse specialist has been partnered with each primary care practice to provide the first point of contact for specialist advice, upskill practitioners, support the development of practice diabetes plans, support insulin starts and reduce barriers to care
  • Practice population management – Each primary care practice receives diabetes population based funding to provide effective diabetes care tailored to their population. The funding is weighted further based on the practices number of Maori and Pacific populations.
  • Specialist service focused on complex, Type 1, paediatric, gestational and renal diabetes – The Specialist Service will deliver a high quality specialist service and consultation service that is able to deliver targeted care closer to people with diabetes. The service will provide expert consultation service that actively returns peoples care back to primary care.
  • Self-Management Groups - Community based structured group self- management programmes, based on the CCDHB model “Your life, Your Journey” is being delivered across geographical locations.
  • Workforce development – Each primary health care team has team members identified as Diabetes Champions in their practices and completed the education programme aligned with the National Diabetes Knowledge & Skills
  • Combined Primary and Secondary Diabetes Clinical Network – Includes clinical leads from across the sector across a range of disciplines. As part of the ICC, they lead the ongoing support for the collaborative and integrated approach to effective diabetes care across the primary and secondary sectors of CCDHB.

Find out more about the Integrated Care Collaborative Alliance

Last updated 12 September 2019.