We are involved in a number of initiatives with our partner, Melbourne Primary Care Network.

HARP Diabetes Co-Management Service

The Diabetes Co-Management Service operates as part of the our Hospital Admission Risk Program (HARP). The service is administered by the Melbourne Primary Care Network.

HARP provides specialist treatment, care planning, education and support to help people with chronic and complex health issues to manage independently and reduce the risk of a hospital admission.

The service is available to individuals with unstable diabetes who have been admitted to hospital or presented to the emergency department (ED) during the last 12 months.

The RMH HARP Liaison, who works closely with the RMH Diabetes Education Team, is involved in patient assessment as well as discharge planning with hospital staff, GPs, patients and family members. The HARP community based diabetes educators and dietitians work together with the patients’ GP, RMH Endocrinologists and other specialist and community services involved in the patients’ care.

If you wish to refer your patients for an assessment, please contact the RMH HARP Liaison Team.

HealthPathways Melbourne Collaboration

The Royal Melbourne Hospital specialist services have been working collaboratively with St Vincent’s Hospital Melbourne, Eastern Health, Melbourne Primary Care Network and Inner East Melbourne Medicare Local (IEMML) to implement HealthPathways Melbourne.

HealthPathways provides a manual for general practice teams to assess, manage and refer patients to secondary, tertiary, and community services. The pathways have been designed for use during consultation and are jointly developed through collaboration between hospital clinicians and community clinicians

Access HealthPathways (login required)

Inner North West Diabetes Services Review Collaborative

Increasing prevalence of Diabetes and related health complications, combined with growing service demands and inappropriate referrals, were the impetus for Inner North West Primary Care Partnership (INW PCP) member agencies to agree to work together on developing a more coordinated approach to service delivery. The Inner North West Primary Care Partnership, together with its member agencies seeks to improve current pathways of care for populations with Diabetes whereby clients are seen by the right service, in the right setting, at the right time.

Diabetes Services Review Collaborative purpose

  • work together to improve service coordination, including local diabetes referral patterns, levels of care and inter-agency communication
  • review implementation of the Adult Diabetes Referral Guide and Inter-Agency Agreement
  • build a strong professional network between local diabetes service providers and together identify common ground for future service improvements
  • to advocate for quality improvement with diabetes service provision amongst and between local diabetes services

Collaborative members

  • Inner North West Primary Care Partnership
  • Royal Melbourne Hospital HARP Diabetes Co-Management Service
  • Royal Melbourne Hospital Diabetes Education Service
  • Melbourne Primary Care Network
  • Inner East Community Health Service
  • cohealth (Niddrie site)
  • St. Vincent’s Hospital HARP Restoring Health Diabetes Stream
  • St. Vincent’s Hospital Diabetes Education Unit
  • Merri Community Health Service
  • North Yarra Community Health Service
  • North Richmond Community Health Service

Tools developed by the Inner North West Diabetes Services Review Collaborative include the Adult Diabetes Referral Guide.

Diabetes Demonstration Project

The Diabetes Demonstration Project is an initiative of health services in the Inner North West Melbourne, working together to provide a seamless diabetes care experience for its community. The projects are led by the Melbourne Primary Care Network with support of collaborative partners.

Collaborative partners

  • The Royal Melbourne Hospital
  • Melbourne EpiCentre
  • Melbourne Primary Care Network
  • Merri Community Health
  • cohealth
  • Diabetes Australia Victoria
  • Inner North West Melbourne General Practices

Snapshot of diabetes in the Inner North West Melbourne catchment

  • Fourth highest cause of avoidable mortality.
  • One of the most prevalent chronic conditions for people living in the Inner North West Melbourne catchment
  • Estimated that 3.6/100 people in the catchment (13,160 total) have Type 2 diabetes
  • Leading cause of avoidable hospital admissions across the catchment
  • Patients residing in the INWMML catchment make up 49% of RMH diabetes outpatient activity (2011-2012)
  • Up to 60% of cases of Type 2 diabetes can be prevented

Diabetes Demonstration Projects

  • Insulin initiation in General practice: ‘Stepping-up study’ Promoting Insulin Initiation in General Practice
    Partnership project with University of Melbourne to increase insulin initiation in eight INWMML General Practices.
  • CCC4D (‘Triple C for D’): Coordinated Community Care for Diabetes
    To develop and implement innovative diabetes care models across the acute primary interface in Moonee Valley and Moreland