1. 1 Diabetes-Where to from here ? Prepared by [Lynne Gilks] [CNC Diabetes Education] [Diabetes Centre, Tamworth] [November 2009]

2. Diabetes-Where to from here?  Diabetes is a relatively common condition affecting about 7.8% Australian population (AusDiab study)  In some Aboriginal communities prevalence rates can be as high as 31%. (DA NSW)  Impaired Glucose Tolerance or Impaired Fasting Glycaemia affects 16.3% of the population (AusDiab)  1 in 4 Australians 25 yrs & over has Diabetes or IGT/IFG (AusDiab)  Diabetes has increased by 300% over the last 10 years. (DA NSW)

3. Diabetes-Where to from here?  Currently in Australia 275 people are being diagnosed with diabetes each day i.e. 100,000 new cases per year  The rate of Diabetes in the lowest socioeconomic group is almost twice that compared with the highest socioeconomic group

4. Diabetes-Where to from here?  The number of people with Diabetes is expected to double by 2010  Type 2 Diabetes is predicted to have the largest increase of the chronic diseases by 2020  Associated costs are predicted to increase by 679% by 2031.

5. Diabetes-where to from here? Cost of diabetes in Australia in 2005 was $10.3 billion of which: * Health system costs $1.1 billion *Productivity lost $4.1 billion *Carer costs $4.4 billion As well *Lost wellbeing $11.6 billion Total cost of diabetes in 2005 $21.3 billion (NSW Diabetes Action Plan)

8. Diabetes-Where to from here? Despite this epidemic of diabetes there has been little corresponding increase in staffing. In 2008 in NSW there are * 920 Dietitians * 800 Podiatrists * 250 Diabetes Educators * 130 Endocrinologists

9. Diabetes-Where to from here? In NSW according to Diabetes Australia NSW figures there are more than 271,000 people diagnosed with DM therefore  For every 1 Dietitian there are 295 PWD  For every 1 Podiatrist there are 339 PWD  For every Diabetes Educator there are 1,084 PWD  For every Endocrinologist there are 2,085 PWD

10. Diabetes-Where to from here?

11. Implications  Increase in waiting times to see specialist services  Lack of resources to run preventative programs  Prioritorising which clients to see first  Less time for individual consultations  Discharging clients from specialist Diabetes services to GP’s when well managed  Possible burnout of overworked staff

12. Diabetes-Where to from here? How do we use existing resources to maximise accessibility? Training of existing Health Professionals (such as Practice Nurses & GP’s ) to handle people with non complicated type 2 diabetes. Referral to specialist services for more complicated patients Collaborative programs with GP’s & Allied Health More group programs Encourage patients to more self management.

13. Diabetes-Where to from here? Courses for Practice Nurses  National Association of Diabetes Centres’ Training program  Australian Diabetes Educators’ Association online training program  Diabetes Australia, NSW & virtualMedicalCentre.com- www.virtualnursingeducation.com www.virtualnursingeducation.com  Australian Practice Nurse Association online module

14. Diabetes-Where to from here? Practice Nurses are not Diabetes Educators however-  They can provide basic education, support & encouragement at diagnosis  Explain benefits of exercise and advise of available local programs  Give basic advice on healthy eating  Explain benefits of weight loss & control  Advise on locally available healthy lifestyle programs  Identify those patients who require referral to group education &/or more specialist service  Review with patients their annual cycle of care & clinical targets

15. Diabetes-Where to from here? Development of greater links between GP’s, Diabetes Educators (DE) & Allied Health. From May 1 st 2007 Medicare allowed GP’s to refer patients to group sessions conducted by Credentialed Diabetes Educator, an Accredited Practicing Dietitian or an Accredited Exercise Physiologist (who are registered providers with Medicare) using normal GP plan rather than a team care plan.

16. Diabetes-Where to from here? Thus people with Type 2 DM referred by their GP are entitled to an initial individual assessment, followed by up to eight group sessions in a calendar year provided by eligible Health Professionals.

17. Diabetes-Where to from here? Chronic Disease management (CDM) Medicare Items (Enhanced Primary Care):  Preparation of a GP management Plan (Item 721)  Review of a GP Management Plan (Item 725)  Coordination of Team Care arrangement (TCA- Item 723)  Coordination of Review of TCA (Item 727)  Practice Nurse support & management

18. Diabetes-Where to from here? Team Care arrangement which involves GP & at least 2 other care providers. 5 individual Allied Health Visits available to eligible patients per calendar year with Team care arrangement.

19. Diabetes-Where to from here? Eligible Allied Health Professionals:  Aboriginal Health Worker  Audiologist  Chiropractor  Diabetes Educator  Dietitian  Exercise Physiologist

20. Diabetes-Where to from here?  Mental Health worker  Occupational therapist  Osteopath  Physiotherapist  Podiatrist  Psychologist  Speech Pathologist

21. Diabetes-Where to from here? Also incentive payments to GP’s to complete annual cycle of care including BP, BMI, HbA1C, lipids, smoking, nutrition, alcohol, & physical activity as well as complications screening-eyes, feet & kidneys.

22. Diabetes-Where to from here?  Some local GP’s run diabetes clinics within their practice for non complicated Diabetes  360 Health clinic group program  TCA in conjunction with Diabetes services  Medical student from UNE attending Diabetes Centre as part of their training  Practice Nurses attending NADC course  Tamworth Diabetes Centre provides advice & support to GP’s & Practice Nurses  Discharge guideline

23. Diabetes-Where to from here? Discharge Guideline:  Objectives  Service Description  Service Priorities  Intake System  Discharge procedure for Type 2 DM  Discharge criteria for Type 2 DM  Discharge criteria for women with Gestational Diabetes

24. Diabetes-Where to from here? Objectives  Intake of clients for DNE & Dietitian  Priority clients  Timely & appropriate discharge

25. Diabetes-Where to from here? Priority Clients  Children  Pregnant women with DM  Type 1 DM  People with DM related complications  Type 2 commencing insulin  Aboriginal & TSI  Unstable DM

26. Diabetes-Where to from here? Discharge  Well controlled or when education is complete Type 2 DM to be discharged back to LMO with letter  Chime closed

27. Diabetes-Where to from here? Discharge Criteria for Type 2 DM:  Well controlled DM with HbA1C <7% and/or BG 4 to 8 mmol/l  If there has been an improvement in glycaemic control & client shows evidence of maximum capacity for improvement has been reached

28. Diabetes-Where to from here? Type 2 Insulin commencement  Client taught how to adjust insulin  Client aware of target for blood glucose  Review appointment to monitor progress  When stable refer back to LMO

29. Diabetes-Where to from here?