Diabetes and Pre-Diabetes

“Diabetes is a complex disorder and requires a systematic approach to care. There is evidence that this approach in the general practice setting results in better outcomes.

A systematic approach to care is facilitated by the use of:
  • Disease register: This is a list of all patients in the practice with diabetes and basic demographic data. The register can also include clinical information. This allows tracking of patients’ clinical status and their need for ongoing care
  • Recall system: This facilitates timely recall of patients when certain aspects of their care require review eg: recall for annual review, ophthalmologist review, etc
  • Flow charts: Included in the patients’ notes these allow following of clinical parameters and flag when interventions or investigations are necessary
  • Review charts: Included in the patients’ notes, these are checklists for annual and three monthly reviews to facilitate thorough coverage of all issues at these milestone consultations

Diabetes Management in General Practice 

DIABETES CYCLE OF CARE
In November 2001 the Federal Government introduced the Diabetes Annual Cycle of Care incentive to encourage GPs who take a coordinated approach for patients who have been diagnosed with diabetes. The annual cycle of care involves providing patients with a diabetes program of care with specific minimum requirements over a 12 month period.  

Practice Incentive Payments (PIP)
One-off payment only. Practices must be accredited and registered for Practice Incentive Payment. This step must be taken before you can access the Annual Cycle of Care. PIP practices will receive payment if they use a recall and reminder system for their patients with diabetes. $1.00 per Standardised Whole Patient Equivalent (SWPE), or approximately $1000 per full time GP.
 
The Recall system must include:
  • A list of all known patients who have diabetes attending the practice, by name, contact number and file number
  • An active patient recall/reminder system either electronic or paper based

Service Incentive Payments (SIP)
To be eligible to receive the SIP, the Diabetes Annual Cycle of Care must be completed for patients with diabetes. $40.00 per patient will be paid for each completed annual cycle of care. Use the usual attendance item numbers for the care you provide during the cycle of care. Use the item numbers below in place of the usual attendance item for the consultation that completes the minimum annual requirements of care to trigger the SIP.

Outcomes Payment
Payment is made to practices that complete annual programs of care for a target proportion of their patients with diabetes (for whom an HBA1c test has been conducted in the previous two years). Target 20% of total number of diabetic patients must have completed the annual cycle of care. Payments ($20 per patient) will only be made to practices where 20% of diabetes patients have completed an annual cycle of care. (SCDGP 2007).
                                                                                                                                               
DIABETES AND EPC
A GP Management Plan (GPMP) and a Diabetes Service Incentive Payment (SIP) are complementary. The Diabetes Annual Cycle of Care is a check on best practice management and care for a patient with diabetes over the last 12 months where as the GP Management Plan is used to set up the management of the patient for the forthcoming two years.
 
A Diabetes SIP and a GPMP review item however should not be claimed within three months of each other as the work for both involves reviewing the GPMP and recalling for the Diabetes Annual Cycle of Care.
 
A patient may be referred for a Home Medicine Review (HMR) if clinically necessary. The HMR would meet the medication review requirement of the Diabetes Annual Cycle of Care.
PRE DIABETES
40-49 Year Old Risk Assessment - MBS Item 713
The purpose of this item is to support general practitioners (GPs) to address the health needs of patients 40 to 49 years of age who are at 'high risk' of developing type 2 diabetes.  The 'high risk' score will be determined following the patient's completion of the Australian Type 2 Diabetes Risk Assessment Tool. The aim of this item is to review the factors underlying the 'high risk' score identified by the Australian Type 2 Diabetes Risk Assessment Tool to instigate early interventions, such as lifestyle modification programs, to assist with the prevention of type 2 diabetes. 
Eligibility
Eligible patients must be aged 40 to 49 years (inclusive) and at high risk of developing type 2 diabetes as determined by the Australian type 2 diabetes risk assessment tool. Patients with newly diagnosed or existing diabetes are not eligible for this item.
Assessing a 'high risk' score and conducting a type 2 Diabetes Risk Evaluation
The type 2 Diabetes Risk Evaluation is a review of the factors underlying the 'high risk' score identified by the Australian Type 2 Diabetes Risk Assessment Tool. 
Patients at risk can also be identified using the Clinical Audit Tool click for instructions.
Clinical factors that the GP should consider include:
  • lifestyle, such as smoking, physical inactivity and poor nutrition
  • biomedical risk factors, such as high blood pressure, impaired glucose metabolism and excess weight
  • any relevant recent diagnostic test results
  • family history.
The Role of Other Health Professionals
Practice Nurses, Aboriginal Health Workers and other health professionals may assist GPs in performing the type 2 Diabetes Risk Evaluation, in accordance with accepted medical practice and under the supervision of the GP.
 
The Role of the GP
The GP is expected to take a primary role in the following activities:
  • Reviewing and analysing the information collected
  • Making an overall assessment of the risk factors that contributed to the ‘high’ risk score of the patient and their readiness to make lifestyle changes to address the identified factors
  • Undertaking and arranging relevant investigations
  • Making relevant referrals and identifying appropriate follow-up
  • Providing information and advice to the patient, for example, to undertake lifestyle modifications, and/or the use of Lifescript resources

SETTING UP THE DIABETES CLINIC
As per the Royal College of General Practitioners Standards for general practices, Criterion 5.2.1 there are minimum requirements for comprehensive primary care and resuscitation equipment. 

In terms of what the Practice Nurse may use in the Diabetes Clinic the following is recommended:

  • blood glucose monitoring equipment
  • disposable syringes and needles
  • gloves (sterile and non-sterile)
  • height measurement device
  • measuring tape
  • monofilament for sensation testing
  • scales
  • specimen collection equipment
  • sphygmomanometer (with small, medium and large cuffs)
  • stethoscope
  • tourniquet
  • urine testing strips
  • visual acuity charts
 In some practices the Practice Nurse also performs the following tests:
  • Doppler Ultrasound
  • Electrocardiograph

NURSE LED DIABETES CLINICS 
 “Diabetic Clinics” conducted by a suitably qualified Practice Nurse can benefit the practice by assisting to:

  • Improve the structure of consultations
  • Reduce the need for adhoc consultations
  • Increase patient satisfaction
  • Reduce GP workload
  • Increase income from MBS items
  • Provide further opportunities to research patient care
The Practice Nurse will need dedicated time to work on patient data and ensuring the data base is accurate, this is often known as data cleansing and requires a whole of practice approach. 
 
Cleaning the patient data base involves:
  • Checking for deceased patients
  • Checking patients that have not been to the practice for some time (determine the time frame with the Practice Manager) and Inactivate those that fallout of the timeframe
  • Use clinical software Action Lists to alert GPs to record data
The Practice Nurse needs to ensure the Diabetes Register is current date and that all patients with diabetes are entered into the system. See the Information Management section of this resource for more information. 
 
The nurse can assist in identifying which patients with diabetes would benefit from a Care Plan (e.g. HbA1c over 7%) and assist in preparing Care Plans for the GP and assist the patient in setting goals of care. 
 
The role of the Practice Nurse in the Diabetes Clinic includes:
  • Identifying patients with diabetes on the patient data base
  • Operating the Register and Recall system
  • Recalling patients to the clinic

Coordinating the Chronic Disease Management Items (Care Plans)

  • Prompting the MBS billing
  • Informing the Practice Manager, GPs and Practice staff of the processes and progress

RELATED RESOURCES

Pre-Diabetes Risk Assessment Tool 

Clinical Goals for Diabetes Management

Diabetes Foot Assessment Sample

Basic Foot Check Template (Non-Podiatrist) for MD/BP

Nurse Prompts During Diabetes Clinics

Diabetes Cycle of Care Requirements

Diabetes Model of Care Flow Chart