“Courageous conversations” bring disengaged patients with diabetes back to GP clinics

Amidst New Zealand’s ever-increasing diabetes epidemic, unique support to re-engage patients with diabetes back to primary care is proving successful in the Waikato. 

An estimated 277,000 people are currently diagnosed with diabetes in Aotearoa New Zealand, and prevalence of the disease is three times higher in Māori and Pacific populations.   

Poorly controlled diabetes and the complications arising from it comes at a high cost to individuals and their whānau, as well as the New Zealand health system. Diabetes New Zealand estimates there are around 600 preventable diabetes-related amputations each year.  

General practices throughout the Waikato routinely offer ongoing support to help manage diabetes, and preventative care to reduce complications, but this doesn’t help patients who are disengaged from services.  

“We know patients with diabetes who are not connected with primary care often don’t present to their GP until they are really unwell.” says Sally Newell, Pinnacle clinical services manager – regional services. 

To help address the issue, Pinnacle and Diabetes New Zealand created a new jointly funded role in 2021, aimed at supporting patients to re-engage with primary care and receive the support they need on their diabetes journey.  

The full-time job is a combination of two part-time roles: diabetes kaiawhina for Pinnacle, and kaimahi for Diabetes NZ.   

“It’s a different model from what’s been used before,” says Sally. “The kaiawhina is a non-clinical role that practices can use to get in touch with their disengaged patients with diabetes and support them to come back in.  

“The goal is to help patients re-form that bond and connection with their general practice, so they see the practice as a place of support for them.” 

She says the development of the new model has been organic, driven partly by a necessary response to COVID-19 that required a more community-based approach, and partly by the work of the current kaiawhina – Lee Page-Deane.  

Lee is a woman of many hats and many colours. Five minutes talking to her brings a sense that she has many stories from a life that so far includes having been a truck driver, private investigator, MSD employment consultant, jazz singer, comedian, advocate for the Deaf community, mental health and disability support worker, and rainbow community advocate.   

Currently wearing the two hats of kaiawhina for Pinnacle and kaimahi for Diabetes NZ, Lee says it’s other people’s stories that drive her mahi.   

“It’s all about people and engagement,” she says. “My job is to listen, to awhi people to tell their stories. People feel better for that kōrero.  

“It is about having courageous conversations, being respectful and understanding other things like mental health come into it. I help them release that stuff holding them back.” 

Recently a patient Lee spoke to was adamant they were not going into a medical centre, so Lee listened and during their kōrero the patient brought up their experience of mental illness. As a non-clinician, Lee doesn’t give advice, but hearing about it prompted her to talk about the support available from nurses at the clinic. The patient agreed to have one of them call. It was the first step in a successful return to their local practice. 

Response rates from patients contacted by Lee have been consistently high across the region, and feedback from practices she has supported is overwhelmingly positive.   

In just three weeks, a practice Lee recently supported saw 20 people who hadn’t been to the clinic for years return for support with their diabetes journey. That’s 20 people now getting support from their practice to better manage their diabetes, along with preventative care to help avoid serious complications.  

For Lee, it’s a common result of the mahi she does in the Waikato. “It’s about giving the patients our whaiora time and walking the journey with them.” 

Having lost whānau to diabetes, Lee knows how much of a difference things like supported management of HbA1c and glucose levels, and early prevention care for circulation and foot care, can make.  

“The diabetes epidemic is one that many people don’t understand. If people understood about their diabetes, the implications of not managing it – loss of limbs and loss of life, outcomes could be much better.” 

She says communication is the most important thing. “Breaking it down and simplifying the language, but also engaging with them in a way that recognises they are scared, and often a bit whakamā. They feel stink, like what did I do wrong? I see a lot of that with Type 2 diabetes.”  

Along with contacting patients the practices have asked her to reach out to, Lee also attends community hauora events and is planning self-management workshops for people with Type 1 and Type 2 diabetes. She says she talks to or engages with around 90 people per week.  

“I want to get the message out that there are good people here to support you with diabetes, who will listen to you and support you.”  

She says there are people everywhere, every day. “I went to the bank the other day and the teller asked me if they could talk to me after the transaction,” says Lee.   

“I was wearing my diabetes t-shirt and lanyard. The teller had Type 2 diabetes and wanted some information, so I listened and talked and pointed them where to go.”  

“I never say no, I go wherever the need is. I believe there’s no throwaway people, no-one we can’t look after or take care of.”