1. To establish a diabetes referral system between community health facilities and higher-level hospitals.
2. To establish an integrated care pathway for targeted health facilities.
3. To improve capacity for diabetes management in community health facilities.
4. To disseminate and promote project learnings on a policy level.
An assessment of best practices for diabetes care will be done through an analysis of the current system for care and referral of diabetes patients between community (primary), county (secondary) and provincial/municipal (tertiary) level. County and provincial health authorities will be mobilised and take co-ownership at all stages of this process.
Following the initial assessment of best practices the project will develop and implement an integrated two-way referral system for diabetes clinics. The model will include integration of electronic health records at rural primary and secondary level hospitals.
The project will work to strengthen decentralised capacity for diabetes care at primary and secondary level through training of health care professionals from the targeted rural county hospitals and community health facilities. Trainings will focus on general diabetes care and be closely linked to implementation of the new referral system developed by the project.
In order to raise awareness on outcomes and learnings of the initiative, at the end of the project the care/referral model will be presented to policy-makers in to explore the possibility of scaling up of the approach. As the project partner China National Health Development Research Centre is located within the National Commission for Health and Family Planning it is possible that the project can have some influence in this regard.
• 86 diabetes clinics (two at provincial level, four at county level, 80 at grassroots/community level) strengthened and connected to joint EMR system.
• 120 doctors trained in DM care and referral.
• 100 nurses trained in DM care and referral.
• 50 administrators trained in DM care and referral.
• At least 4,000 people screened for diabetes.
• At least 8,000 known diabetes patients registered at hospitals (EMR) and trained in diabetes self-care.
• 2 dissemination meetings and 4 presentations convened for national policy-makers.