Authors: (including presenting author): :
LI LL(3), CHOW SY(1), Lau SF(1), LO W(1), Wong YFB(2), Hui SS(2), HO KL(1), Chan YL(3), LI SN(1), Lee KK(1)
Affiliation: :
(1)North Lantau Family Medicine Integrated Centre, North Lantau Hospital, (2) Medical & Geriatric, North Lantau Hospital, (3) Specialist Out-Patient Clinic, North Lantau Hospital
Keyword 1: :
glycemic control
Keyword 2: :
quota utilization
Keyword 3: :
staff engagement
Keyword 4: :
communication
Keyword 5: :
multidisciplinary approach
Keyword 6: :
Self-care management
Introduction: :
Effective communication and collaboration between doctors and nurses are essential for delivering high-quality and sustainable patient care, leading to improved patient safety, better chronic disease management, higher patient satisfaction, and more efficient use of resources. Patient’s glycemic control outcomes (HbA1c) in North Lantau Family Medicine Integrated Center (FMIC) were found to be less than ideal in comparison with other family medicine clinics in Kowloon West Cluster. From early 2025, a systemic review was conducted at NLFMIC to look into quota management, current DM service operations by senior nursing team, also staff interviews and doctor small group discussion. A serious of enhancement actions through multidisciplinary approach were implemented in NLFMIC with significant improvement.
Objectives: :
To improve glycemic control outcomes (HbA1c) for patients with Diabetes Mellitus. To optimize service quota utilization and reduce patient waiting times. To enhance continuity of care by strengthening staff engagement, clinical competency, and communication between the medical and nursing teams.
Methodology: :
1.Service quota profiles were reviewed and prioritized to patients most likely to develop DM complications due to poor control. The time need to start insulin therapy which were shortened to those patients. 2.Patient education was enhanced by the prescription of tailored made contents which easily accessible via HA Go. Group education and counselling sessions were established which led by doctors to empower patients for self – care management and motivating them for treatment adherence. Through setting achievable goals per each visit, patients gain confidence in managing their own health. 3.Communication between medical and nursing teams was enhanced through the use of standardized documentation and clinical reminders, in addition the establishment of regular case conferences. 4.Workflow was streamlined which including making phone calls prior to assessment date to remind patients to bring necessary blood glucose monitor equipment and attend sessions with caregivers when appropriate; and dietary assessment performed by supporting staff. The measures helped to reduce quota wastage, saving nursing times and allow more time focus on patient interventions. 5.Staff training and engagement were promoted which training delivered by Associate Nurse Consultant (Diabetes) to provide updated DM knowledge and insulin injection therapy to FM nursing staff.
Result & Outcome: :
As of March 2025, the North Lantau Family Medicine Integrated Center (NLFMIC) provided care for 10,857 patients with Diabetes Mellitus (DM), with over 97% receiving regular HbA1c monitoring. The multidisciplinary enhancement program was implemented from March to December 2025. Glycemic control among the DM cohort showed steady and significant improvement during this period: The proportion of patients achieving good glycemic control (HbA1c < 7.0%) increased from 44% to 57%. The proportion of patients with suboptimal control(HbA1c7.0% –8.4%) decreased from 44% to 30%. The proportion of patients with poor control(HbA1c≥8.4%)remained stable at 10–13%. These results demonstrate a positive shift in the patient population toward better glycemic control following the interventions. Furthermore, service efficiency was maintained for high-risk patients. From October to December 2025, all urgent DM cases continued to receive timely counseling within three to four weeks, ensuring early intervention for those most at risk and supporting overall outcome improvement. This improvement was driven by a structured service review and the targeted enhancement of interprofessional communication, clinical workflows, and staff competency. Sustainable progress in DM care at the NLFMIC will depend on the ongoing monitoring of these outcomes and the continuous engagement of the multidisciplinary team.
