IDETECKD: Transforming Diabetes-Kidney Care

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

The project purpose was to create and evaluate an innovative care pathway for people living with diabetes and kidney disease to improve timely access to care.

Dates: 1 November 2023 -

Implementation sites: Logan Hospital

Partnerships: University of Queensland

Aim

To understand the needs and preferences for health care delivery for consumers living with diabetes and kidney disease to co-design, implement and evaluate a consumer-focused service.

Outcomes

Consumer insights revealed key healthcare needs: "regular communication, easy-to-understand information, speak laymen terms, people and trusted relationships, If I don't feel valued, I won't turn up."

These principles shaped the co-designed IDETECKD service, with high consumer satisfaction: "they seem to care more about you as an individual instead of just a number on the form, and "my blood glucose levels have dropped for the first time in years."

Consumers valued the DDE workforce: "You're getting all the information from one person"  alongside NPs providing alternative care pathways to ease pressure on specialist services.

Background

In Logan, diabetes and chronic kidney disease (CKD) pose a disproportionately high burden. With a diabetes prevalence of 6,31%, Logan exceeds both the state average of 5.27% and the national average of 5.47% (NDSS, 2024). Additionally, same-day renal dialysis admissions in Logan surpass state and national averages (PHIDU, 2021). This high diabetes prevalence has strained specialist diabetes services, contributing to lengthy delays to care. Such delays heighten risks of health deterioration and lower consumer satisfaction, especially for individuals with co-morbid diabetes and CKD. Effective management of these conditions demands holistic, multifaceted approaches to reduce disease progression and vascular complications (Zimbudzi E, 2022; Hahr AJ, 2015).

Alarmingly, CKD is commonly underdiagnosed, with >90% of those living with CKD unaware that they have the condition despite the benefit of early intervention which can curb kidney function decline by up to 50% (Kwok, R, MacIsaac, R, and Ekinci, E., 2023, Johnson DW. 2004). Traditionally, multidisciplinary team care for diabetes and early-stage CKD is coordinated by an Endocrinologist, focusing on lifestyle changes, self-management, and medications targeting risk factors (Kwok, R, MacIsaac, R, and Ekinci, E., 2023). The nature of care presents an opportunity for an alternative care model delivered by a dual qualified Dietitian Diabetes Educator and Nurse Practitioner to help relieve demand on medical services. Despite the clear role alignment, there is currently no evidence demonstrating the effectiveness of dual qualified DDE and NP in optimising diabetes and CKD whilst patients await Endocrinologist care.

Patient-centred models of care are proven to enhance health outcomes for CKD, diabetes, and other chronic conditions. Yet, these models vary significantly, and few are co-designed with consumers and stakeholders (Zimbudzi E, 2022; Clemens KK, 2019). While Australian researchers Lo et al. evaluated a medical-led, multidisciplinary model of care for co-morbid diabetes and CKD, which improved mortality, glycaemic control, and self-care behaviours, no evidence supports co-designed, workforce-driven models offering timely care access (Lo C. &., 2018). This gap limits investment in value-focused, multi-morbidity solutions designed to optimise consumer engagement.

Methods

The IDETECKD project followed a structured multiphase approach to co-design and evaluated a consumer-focused service model, improving healthcare delivery for individuals with Type 2 Diabetes Mellitus (T2DM) and CKD. Each phase contributed to creating a service model based on consumer insights and collaboration.

Phase 1: Consumer needs assessment

This phase focused on understanding consumer perspectives to shape co-design efforts and healthcare design principles. Data was collected through focus groups, interviews, and surveys involving adults with T2DM and CKD and their carers, recruited from Logan Hospital's outpatient clinics and waiting lists (March - May 2024). Patient journey mapping was conducted to document care interactions, touchpoints, emotions, challenges, and needs across the care continuum. Insights gathered informed key design principles, which were shared with stakeholders - including Logan Hospital staff, project steering committee members, and external consultants like the Patient Experience Agency. These collaborations led to the creation of a prototype care model.

Phase 2: Co-Design development of IDETECKD model

Co-design workshops engaged consumers in refining and improving the prototype care model created after completion of phase 1. Consumers played a key role in reviewing and shaping all major elements of the care pathway, from initial contact to discharge. These workshops ensured the model aligned with patient preferences and strengthened the project's focus on patient-centred care.

Phase 3: Implementation and evaluation of consumer experiences

Drawing upon existing locally available resources, the IDETECKD model was implemented to support patients on category 2 and 3 waiting lists living with T2DM and early-stage CKD. The dual-qualified DDE and a Nurse Practitioner-led service model delivers comprehensive diabetes and dietary assessments and chronic disease management optimisation. Clinical oversight provided through multidisciplinary case conferences involving an Endocrinologist, Nephrologist, DDE, and Nurse Practitioner enabling collaborative care planning and escalation as indicated. The model is also supported by a HP1 cadet who provides waiting list care options and undertakes pre-service assessments for those who consent to the IDETECKD service.

The implemented model was evaluated to assess its impact on consumer experiences. Feedback was collected through focus groups and interviews to identify successes and areas for improvement. Qualitative analysis was guided by the framework method, ensuring a thorough examination of consumer insights.

Phase 4: Continuous improvement and evaluation of health outcomes

Currently underway, the final phase focuses on assessing clinical health outcomes, healthcare utilization, and patient-reported health outcomes to further evaluate the service's effectiveness.

The IDETECKD project's multiphase approach highlights the value of a consumer-focused, iterative methodology that fosters collaboration and addresses real-world challenges. By integrating consumer feedback at every stage, the service model effectively aids in tackling local disease burden, waiting list issues while enhancing consumer engagement. This process illustrates the importance of co-design in creating impactful, patient-centred healthcare solutions.

Discussion

The success of the IDETECKD project was contingent upon several contextual factors. Firstly, the project was made possible through an Allied Health Model of Care funding grant through the Office of the Chief Allied Health Officer. This funding enabled the recruitment of a project officer to lead comprehensive project management and coordination, consultation with an external patient experience agency and importantly the remuneration of consumers.

Broad collaboration which brought together consumers, specialist departments and external healthcare providers was critical to address an identified needs and collaboratively develop a responsive solution.

Strengths, Weaknesses and Opportunities

The project's main strength lay in its collaborative and phased approach, which allowed for iterative refinement and integration of consumer feedback at every stage. Additionally, the use of patient journey mapping and co-design workshops fostered a holistic understanding of the care continuum, from a consumer lens. A key strength for the local implementation was the consideration of local workforce and resource availability in the development of the service model. This however poses some limitations when considering broader adoption of the service model in its current form, given the reliance upon a dual qualified Dietitian and Diabetes Educator and Nurse Practitioner workforce which are not currently broadly available across the state. The evaluation of this model however provides evidence demonstrating the value of this innovative workforce.

A key learning from this project  

Pleasingly, the consumer insights obtained showcase the high acceptability and satisfaction with the DDE and NP workforce. These consumer experiences, coupled with an ongoing evaluation of health outcomes will provide evidence to support future workforce innovations which may provide cost-effective care options. The adoption of a HP1 cadet to support pre-assessments has enabled appropriate task delegation and support patient preparedness aiming to optimise value-based clinical encounters.

The service model and components thereof present a range of translation opportunities including;
•

  • application of the DDE workforce within rural and remote regions experiencing workforce restraints.
  • multi-morbidity approach to care, overcoming traditional siloed approaches, taking a holistic approach particularly for diseases which share common treatment and management approaches.
  • service pre-assessment conducted by a cadet lends itself to a health worker first contact model to facilitate trust and engagement with First Nations people.
  • actively waiting principles whilst patients await specialist medical care.

Evaluation of health outcomes including patient reported outcome measures, clinical health outcomes and cost effectiveness will continue to demonstrate clinical outcomes alongside patient experience. The project team will continue to share and collaborate with Queensland colleagues to support the adoption of a locally adapted version of the service model. This project will also serve the foundations for continued innovations which extend to broader patient cohorts and contexts.

References

Clemens KK, K. V. (2019). Nonconventional diabetes-related care strategies for patients with chronic kidney disease: A scoping review of the literature. J Comorb.

Kowk, R, Maclsaac, R, and Ekinci, E. (2023). Change the Future: Saving Lives by Better Detecking Diabetes-related kidney disease. Canberra: Diabetes Australia. Retrieved from https://www.diabetesaustralia.com.au/wp-content/uploads/2023-Diabetes-Related-Kidney-Disease-Report-1.4-DIGITAL.pdf

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology 2013;13(1):117.

Hahr AJ, M. M. (2015). Management of diabetes mellitus in patients with. Clin Diabetes Endocrinol.

Johnson DW. (2004). Evidence-based guide to slowing the progression of early renal insufficiency. Intern Med J, 34.

NDSS. (2025, Feb). The NDSS Geospatial Map. Retrieved from https://map.ndss.com.au/ 

PHIDU. (2021). Dialysis hospitalisations . Retrieved from Social Health Atlas of Australia [data set]: phidu.torrens.edu.au

Zimbudzi E, L. C. (2022). A co-designed integrated kidney and diabetes model of care improves mortality, glycaemic control and self-care. Nephrol Dial Transplant, 1472-1481.

Key contact

Jacqueline Cotugno

A/Advanced Dietitian Diabetes Educator, Project Lead iDETECKD

Logan Hospital

Email: jacqueline.cotugno@health.qld.gov.au

Last updated: June 2025

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