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Figure 1
Evolution and implementation of diabetes care programmes in Hong Kong

• Annual or bi-annual nurse-coordinated structured assessment for all patients with diabetes referred to
the Prince of Wales Hospital (PWH), the CUHK teaching hospital
• Provided nurse-coordinated post-assessment classes for patient education and empowerment, nurse
review clinics, and care triage
• Documentation of risk factors, comorbidities, family history, medication use, and self-management
1995: • Data were used to establish the HKDR while PhD/MPhil health care students run disease management
HKDR, programmes
CUHK-PWH • Launching of the rst Diploma Course in Diabetes Management and Education and Master Course in
Endocrinology, Diabetes and Metabolism

• HA adopted and incorporated the HKDR structured data collection form into the EMR
• Created career paths for diabetes nurses with provision of training
• Set up 18 hospital-based diabetes centres that provided nurse review clinics, insulin initiation
classes, and patient support groups
2000: • Data were used by administrators to benchmark performance with regular feedback to frontline
HA diabetes operators to improve care
risk assessment
programme

• HKDR protocol was digitalised to establish a web-based platform for structured data collection
• Automated risk categorisation using validated risk engine
• Triage of patient care based on risk levels
• Issuance of personalised reports with individualised decision support to both doctors and patients
2007:
JADE

• Used public-private partnerships (PPP) to make community-based integrated diabetes care more
accessible and affordable
• Used university-af liated, self-funded, nurse-coordinated diabetes centre to provide assessment and
education with yearly telephone reminders to ensure car continuation
• Provided alternative option to reduce service demand in the public care setting aimed at enhancing
2007: diabetes care in the private sector
PPP

• Peer support, Empowerment, And Remote Communication Linked by information technology
Programme
• Trained patients with type 2 diabetes and stable glycaemic control to be peer supporters
• Four 8-h workshops of tutorials, case sharing, re ections, role-playing, and games, focusing on
diabetes self-management
2009: • Patients participating in both JADE and PEARL Programmes showed reduced hospitalisation rates
PEARL

• HA adopted the JADE model for structured assessment in all publicly funded primary care clinics
• Earlier screening of risk factors and complications with enhanced use of organ-protective
medications
• Increased attainment of ABC treatment goals, reduced micro-/macrovascular complications and
2009: health services utilisation
RAMP-DM
(primary care)

• Complement the RAMP-DM Programme to improve self-management
• Six sessions delivered by trained nurses and social workers, coordinated by nongovernmental
organisations
• Generic components: diet and exercise, behaviour modi cation, psychosocial support
• Diabetes-speci c components: education on medications, self-management of
2010: hypo-/hyperglycaemia
PEP • Improved treatment adherence, reduced micro-/macrovascular complications and death rates
(primary care)

Source: Chan et al., 2019

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