Improving Service Delivery to Primary Care Diabetic Patients in the Multidisciplinary Risk Assessment and Management Programme – Diabetes Mellitus (RAMP–DM)

Abstract Description

Authors (including presenting author) :

Ng KM(1), Chu TK(1), Lo CW(1), Chan ML(1), Liang J(1)

Affiliation :

Department of Family Medicine and Primary Health Care, New Territories West Cluster

Introduction :

The Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) was introduced into the public primary care general out-patient clinics (GOPCs) of Hong Kong for more than a decade. This multidisciplinary model of care has been proven to reduce diabetic-related complications and mortality, and is cost-effective.

Objectives :

To evaluate if this evidence-based practice has been arranged biannually and delivered to diabetic patients followed up in GOPCs in the New Territories West Cluster (NTWC), and to implement changes for improving service coverage to target patients.

Methodology :

Monthly review of electronic medical records of diabetic patients followed up in eight GOPCs in NTWC in the period from 1 Nov 2015 to 30 Nov 2018 was done. Service coverage for RAMP-DM was defined as attendance for the service in prior 30 months divided by total diabetic patients attending for follow up of diabetes in the last 12 months. Regular feedback to clinical staff on service coverage, promotion among staff and patients, patient education, reminder system to frontline doctors were implemented.

Result & Outcome :

The service coverage for RAMP-DM in NTWC GOPCs has improved from 80.38% to 90.36% over the past 3 years. The service has been put in place and delivered to target patients in the community.