A feasibility study to determine the efficacy of using an actively managed discharge care plan for promoting enhanced communication for patients with diabetes.

The study will be a multi-centre, feasibility study conducted in Sydney, Australia for a period of 6 months. We will recruit 100 patients through the Diabetes centres at the following public hospitals in the Sydney, South Eastern Sydney Local Health District and St Vincent’s Hospital Network: namely Royal Prince Alfred Hospital, Prince of Wales Hospital and St Vincent’s Hospital. Eligible patients will be screened and explained the study in their regular visit of outpatient clinics. Interested patients will be provided with an information sheet containing details on the study (Participant Information Statement). The potential participant will give written consent before any activities are performed. All participants will be educated on the project procedures and commitments that are involved with participation in the project. Participants enrolled in the study will be registered in the National Diabetes Services Scheme (NDSS). The NDSS provides support services for practical help and guidance, diabetes and health information and resources and enables access to diabetes supplies at subsidised costs. Subsidised products include: blood glucose testing strips, urine testing strips, insulin pump consumables (for approved people with type 1 diabetes and gestational diabetes), continuous and flash glucose monitoring products (for eligible and approved people with type 1 diabetes and ‘other’ eligible conditions) and insulin syringes and pen needles. An actively managed discharge care plan with calling criteria for PCP will be developed for every patient enrolled to ensure continuity of care and shared care planning. The calling criteria allow trends in observations such as blood glucose levels and HbA1c’s to be tracked to trigger a response by the health professional to refer to the Staff specialist at the Diabetes Centre. The frequency and duration of participant clinic visits will be a maximum of 30 minutes depending on the severity of the patient’s condition and/or further diabetes education is required. Diabetes educators and Pharmacists from each diabetes centre will be utilised to support the effective self-management of diabetes. Face-to-face, telephone or videoconference will be the modes of administration for clinic visits/communication between participants and health care professionals. The total duration of the care plan will depend on the patient’s condition and how they respond to the treatment plan. Staff involved in the project will also be required to complete satisfaction surveys on months 3 and 6 of the study period for project assessment. Staff satisfaction survey questionnaires specifically designed for this study, with seven questions, will be sent through email with a specified REDCap link and will take around 10 minutes to complete. All the information collected from the study will be treated confidentially, and only the researchers named will have access to it. Results from this study may be used in future research studies, for which ethical approval will be sought from the relevant Ethics Committees. A summary of de-identified project results will be available five months after the completion of the last patient visit. Individual results will be provided via email indicated in the consent form, if possible/applicable.