CVD and diabetes assessments a top priority for Settlers Health Centre

Great teamwork has been translating into high assessment rates for cardiovascular disease and diabetes at Settlers Health Centre in Christchurch.

Practice manager Ruth Baker (left) with administrator Krissy Colvin.

In mid-2015, the Settlers team had reached an impressive 91.34% of their eligible population.

Practice manager Ruth Baker says the development of a formal protocol for assessments in February 2012 and the proactive approach of the practice’s nursing and administration staff have been the main reasons for their success.

‘We have always done CVD and diabetes assessments but now we have proper systems to capture all of our new patients, those that need to be recalled and others that are coming of age,’ she says.

Settlers Health Centre also made a deliberate effort to increase its overall number of CVD and diabetes assessments after it started working on a project with recently released prisoners and others thought to be at risk of major health issues.

Ruth says, ‘Some of these new patients, many of whom are still with the practice, had rarely seen a doctor and had undiagnosed chronic health conditions such as diabetes.’

The CVD and diabetes assessments worked so well for this new group that the practice decided to better target all of its eligible patients.

Administrator Krissy Colvin’s skills in using Medtech query builder have been particularly important in identifying patients that need to be assessed. She also sends appointments and, each day, checks to see who will be coming into the surgery to see if anyone can be opportunistically assessed.

‘Some people, particularly European men in the 30 to 50 age bracket, would rather not think about their risk and will avoid it (an assessment) like the plague,’ says practice nurse Laura Baigent.

‘We place a big emphasis on relationship building and discuss any lifestyle changes rather than tell people what to do. People can get very defensive if they think we are telling them they are doing something wrong.’

Laura says opportunistic assessments have been made much easier by the fact that fasting is no longer needed before a blood glucose test. Settlers Health Centre also charges only $5 for an assessment and $12 for a follow-up appointment to make assessments as accessible as possible.

All patients are phoned when their results come back. If the assessment has identified the person has diabetes or is at high risk of cardiovascular disease they will be offered an appointment with Settlers general practitioner Jeremy Baker.  

‘Sometimes we will call them back to discuss possible lifestyle changes and we might suggest that they join a programme like Appetite for Life or receive some other type of support to help manage their health,’ Laura says.

Other patients such as Nigel Clephane, who had a heart attack in January 2014, are on Settlers watch list and are seen more regularly for checks related to their cardiovascular disease or diabetes.

Pegasus Health PHO General Practice & Community Service Operations Manager Lisa Brennan says Settlers Health Centre should be congratulated for its increased assessment rates.

‘They have really run with this initiative, embracing the concept and using it as an opportunity to engage with patients. They also saw the clear need to record their activities,’ she says. ‘As a practice, they know exactly who their smokers are and who is at most risk of CVD.’

Pegasus Health has been making a concerted effort to encourage all of their Canterbury practices to improve their CVD and diabetes assessment rates. To support them they have been providing electronic tools to make recording easier, offering education sessions and employing liaison staff to work with practices.


This story is part of Canterbury finds better ways to care for diabetes patients.

Read the next story in this series: Regular checks pay off.

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