Download Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006

Guidelines for Care and Referral of Adults
with Type 2 Diabetes 2006
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Guidelines for Care and Referral of Adults
with Type 2 Diabetes 2006
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Foreword
Diabetes is a national and state health priority. The AusDiab study indicated that approximately 940 000 people in Australia
have diabetes.1 Every day 275 Australians develop diabetes2. The prevalence is increasing in Australia with the number of
people with diabetes expected to double by 2010.3 The prevalence in Aboriginal and Torres Strait Island peoples is reported to
be two-four times higher than the non-indigenous population.3 Obesity, overweight, dyslipidaemia, hypertension, metabolic
syndrome and physical inactivity all increase the risk of diabetes2. Diabetes impacts financially and socially upon the
individual with diabetes, their families and carers and the community. The Diabco$t Australia study estimated the cost of
diagnosed Type 2 diabetes as $3 billion per year.4 AusDiab 2005 reported that over a five year period those with previously
diagnosed diabetes were twice as likely to die compared with those with normal glucose tolerance.2
Complications of diabetes can be significantly reduced by a combination of good glucose control and improved blood
pressure levels. A 1% decrease in HbA1c has been associated with a 21% reduction in risk for all end points related to
diabetes, including a 21% reduction in deaths related to diabetes, 14% reduction in myocardial infarction and a 37%
reduction in microvasclar complications . Each 10 mmHg decrease in systolic blood pressure has been associated with
reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial
infarction and 13 % for microvasculr complications.5 Therefore any interventions that improve blood glucose and blood
pressure control are likely to have a significant positive impact. Lipid abnormalities are common in people with Type 2
diabetes and a major contributor to the increased incidence of cardiovascular disease that occurs in people with Type 2
diabetes. Treatment of cardiovascular risk factors, including dyslipidaemia is effective in reducing morbidity and mortality
from macrovascular disease.6
In 1999 the Allied Health Diabetes Task Group developed Best Practice Guidelines for Type 2 Diabetes. Three sets of
guidelines were developed and implemented; one set each for Dietitians, Diabetes Educators and Podiatrists. These
guidelines were produced to address difficulties the Divisions of General Practice had with accessing public allied health
services. As there have been a number of significant publications, strategies and reports that impact on the management of
Type 2 diabetes, it was appropriate to review and revise the guidelines.
The aim of the revised guidelines is to improve the management and care of individuals with Type 2 diabetes and to help
health professionals and the individual with diabetes to work as a team by providing a framework of the services that need to
be provided from diagnosis through the continuum of care. The guidelines provide:
•assessment, management and education criteria that need to be addressed to achieve best practice through the
continuum of care of diabetes
•links to existing clinical guidelines/evidence based guidelines and resources to promote evidence based best practice
•criteria other professionals should use when referring
•information regarding the services that can be provided by a range of service providers-flexible competencies.
•descriptions of the roles and responsibilities of each member of the multidisciplinary team
These guidelines are not clinical practice guidelines. The revised guidelines have been entitled “Guidelines for Care and
Referral of Adults with Type 2 Diabetes” to better reflect the content. The three sets of documents have been combined into
one document to reflect a multidisciplinary team approach and self-management is promoted. The revision aims to better
address the psychological issues associated with diabetes and the needs of Aboriginal and Torres Strait Island peoples.
An increasing prevalence of Type 2 diabetes in young people, particularly in Aboriginal and Torres Strait communities is
acknowledged. There are limited guidelines available for the management of Type 2 diabetes in children and adolescence and
this is beyond the scope of these guidelines. It is recommended that when the Best Practice Guidelines for the Management
of Type 1 Diabetes in Children and Adolescence are reviewed that Type 2 diabetes be included.
These guidelines are designed to be consistent with and to be used in conjunction with the Queensland Health Standard Care
Pathway for the Management of Diabetes Mellitus in Adults and Diabetes Management in General Practice. The Queensland
Health Standard Care Pathway has been revised at the same time as these guidelines to ensure consistency.
This document and the Queensland Health Standard Care Pathway help to support the implementation of the National Chronic
Disease Strategy, the National Service Improvement Framework for Diabetes 2006 and the Queensland Strategy for Chronic
Disease 2005-2015.
I recognise the significant work done by professionals and professional associations involved in developing these guidelines
and wish to thank every one involved. I am pleased to endorse these guidelines and encourage health professionals
involved in the care of people with diabetes to strive for best practice by implementing the recommendations outlined in this
document.
Uschi Schreiber
Director-General
November 2006
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Acknowledgements
Facilitator:
Jane Musial
Senior Project Officer Queensland Health
Name
Position
Paula Bowman
Principal Allied Health Advisor, Queensland Health
Christine Kardash
CEO South East Alliance of General Practice
Dianne Bond
A/CNC Diabetes
Nurse Educator Cairns Base Hospital
Peter Lazzarini
Podiatrist, Community Health
Pine Rivers, TPCH
Helen Elliot
Dietitian,
Diabetes Australia- Queensland
Michelle Robins
Nurse Educator, Team Leader, Diabetes Allied Health, Logan Hospital,
Chair- Qld Branch Australian Diabetes Educators Association
Jan Parr
Director Psychology,
Cairns Health Service District
Susan Ash
Associate Professor, School of Public Health- Nutrition and Dietetics
Claire Jackson
Professor of General Practice and Primary Health Care and Head of Discipline,
Discipline of General Practice
School of Medicine
Irene McCarthy
Principal Project Officer
Clinical Practice Improvement Centre, Diabetes Collaborative
Jacquie Nankervis
Principal Project Officer
Clinical Practice Improvement Centre
Dr Michael D’Emden
Endocrinologist, Royal Brisbane and Women’s Hospital
Gerry Cleary
Manager National Policy, Policy and Legislation Branch, Queensland Health
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Contents
Chapter 1 Background......................................................................................................................................................................... 7
1.1. Introduction .............................................................................................................................................................................................. 7
• Aim ................................................................................................................................................................................................................ 7
• Management Goals . ................................................................................................................................................................................. 7
• Table 1: Targets . ......................................................................................................................................................................................... 7
• Principles .....................................................................................................................................................................................................8
1.2. Models of Care/Service Delivery ................................................................................................................................................8
• Aboriginal and Torres Strait Islander Peoples ...................................................................................................................................9
• Examples of Models of Care . .................................................................................................................................................................9
1.3. Annual Cycle of Care . ........................................................................................................................................................................10
1.4. Management of Diabetes Mellitus in Adults
Queensland Health Standard Care Pathway 2006 .......................................................................................................10
1.5. Education ..................................................................................................................................................................................................10
• Diabetes Self Management Education (DSME) .............................................................................................................................. 10
• Group Education . .................................................................................................................................................................................... 10
1.6. Incentives Supporting Diabetes Care ....................................................................................................................................10
• Practice Incentive Program (PIP) ......................................................................................................................................................... 10
• Patient Register and Recall/Reminder System ............................................................................................................................... 11
• Service Incentive Payment (SIP) ......................................................................................................................................................... 11
• Outcomes .................................................................................................................................................................................................. 11
• Practice Nurse Incentive . ...................................................................................................................................................................... 11
• Chronic Disease Management (CDM) Medicare Items ............................................................................................................... 11
− GP Management Plan (GPMP, Item 721) ....................................................................................................................................... 11
− Review of a GP Management Plan (GPMP, Item 725) ................................................................................................................ 11
− Coordination of Team Care Arrangements (TCA- Item 723) ..................................................................................................... 11
− Coordination of a Review of a Team Care Arrangement (Item 727) ....................................................................................... 11
− Contribution to a Multidisciplinary Care Plan Being Prepared by
Another Health or Care Provider (Item 729) ................................................................................................................................ 11
− Contribution to a Multidisciplinary Care Plan Being Prepared by
Another Health or Care Provider for a Resident of an Aged Care Facility (Item 731) ........................................................ 12
• Allied Health and Dental Care Item Numbers ................................................................................................................................. 12
• Home Medicines Review (HMR) .......................................................................................................................................................... 12
1.7. Services/Resources to Assist the Management Of Type 2 Diabetes ................................................................ 12
• Diabetes Australia .................................................................................................................................................................................. 12
• National Diabetes Services Scheme (NDSS) ................................................................................................................................... 12
• Diabetes Management in General Practice ..................................................................................................................................... 12
• Diabetes Patient Record Forms ........................................................................................................................................................... 13
• Diabetes Network .................................................................................................................................................................................... 13
• Resources to Assist with the Management of Aboriginal and Torres Strait Island Peoples . ............................................. 13
• Smoking, Nutrition, Alcohol and Physical Activity (SNAP) ............................................................................................................ 3
• Lifestyle Prescriptions . .......................................................................................................................................................................... 13
• Chronic Disease Self Management Programs ................................................................................................................................. 14
• QUIT . ........................................................................................................................................................................................................... 14
• Healthy Weight Program . ...................................................................................................................................................................... 14
• Lighten UP ................................................................................................................................................................................................. 14
• Local Councils .......................................................................................................................................................................................... 14
• Heart Foundation .................................................................................................................................................................................... 14
1.8 Government Strategies ................................................................................................................................................................... 14
• National Service Improvement Framework for Diabetes . ............................................................................................................ 14
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
• Queensland Strategy for Chronic Disease ....................................................................................................................................... 14
• Aboriginal and Torres Strait Islander Health ................................................................................................................................... 15
1.9 Guidelines ................................................................................................................................................................................................ 15
• Australian National Evidence Based Guidelines (NHMRC) ......................................................................................................... 15
• Other Guidelines ..................................................................................................................................................................................... 15
Chapter 2 Guidelines for Care and Referral of Adults
with Type 2 Diabetes ...........................................................................................................................................................................16
2.1 Table 2 Assessment ...........................................................................................................................................................................16
2.2 Table 3 Management . ...................................................................................................................................................................... 20
2.3 Table 4 General Education and Counselling ..................................................................................................................... 24
2.4 Prevention And Management of Complications .............................................................................................................27
2.4.1 Table 5 Risk Factors .........................................................................................................................................................................27
• Blood glucose ..........................................................................................................................................................................................27
• Weight ........................................................................................................................................................................................................27
• Lipids ..........................................................................................................................................................................................................27
• Blood pressure . ...................................................................................................................................................................................... 28
• Smoking .................................................................................................................................................................................................... 28
• Alcohol ...................................................................................................................................................................................................... 28
2.4.2 Table 6 Complications . ................................................................................................................................................................. 28
• Feet ............................................................................................................................................................................................................. 28
• Eyes ............................................................................................................................................................................................................ 29
• Cardiovascular Disease ........................................................................................................................................................................ 30
• Kidneys . .................................................................................................................................................................................................... 30
2.5 Table 7 Specific Issues..................................................................................................................................................................... 30
• Medications ............................................................................................................................................................................................. 30
• Diet/eating habits .................................................................................................................................................................................. 32
• Exercise ..................................................................................................................................................................................................... 32
• Psychological Issues ............................................................................................................................................................................. 32
• Sick Days . ..................................................................................................................................................................................................33
• Nausea/ Vomiting ...................................................................................................................................................................................33
• Pregnancy ..................................................................................................................................................................................................33
• Driving ....................................................................................................................................................................................................... 34
• Travel . ........................................................................................................................................................................................................ 34
• Sexual Issues .......................................................................................................................................................................................... 34
Chapter 3 The Multidisciplinary Team . ...........................................................................................................................35
3.1 Educator .......................................................................................................................................................................................................35
• Goals and objectives . ............................................................................................................................................................................35
• Definition ...................................................................................................................................................................................................35
• Qualifications ...........................................................................................................................................................................................35
• Competencies ..........................................................................................................................................................................................35
• Role ...................................................................................................................................................................................... 35
• Referrals .....................................................................................................................................................................................................37
• Flexible Competencies . .........................................................................................................................................................................37
• Diabetes Resource Health Professional .......................................................................................................................................... 38
• Nurse Practitioner .................................................................................................................................................................................. 38
3.2 Dietitian . .................................................................................................................................................................................................... 38
• Rationale . ................................................................................................................................................................................................. 38
• Goals and objectives . ........................................................................................................................................................................... 38
• Role ............................................................................................................................................................................................................ 38
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
• General Nutrition Therapy . .................................................................................................................................................................. 39
• Medical Nutrition Therapy ................................................................................................................................................................... 39
• Qualifications .......................................................................................................................................................................................... 40
• Standards of Professional Practice ................................................................................................................................................... 40
• Referrals .................................................................................................................................................................................................... 40
• Flexible Competencies . ........................................................................................................................................................................ 40
3.3 Indigenous Health Worker . ............................................................................................................................................................. 41
• Rationale . .................................................................................................................................................................................................. 41
• Goals and Objectives ............................................................................................................................................................................. 41
• Role ............................................................................................................................................................................................................. 41
• Diabetes Health Workers ..................................................................................................................................................................... 42
• Nutrition Health Care ............................................................................................................................................................................ 42
• Referrals .....................................................................................................................................................................................................43
3.4 Podiatrist ....................................................................................................................................................................................................43
• Rationale . ..................................................................................................................................................................................................43
• Goals and Objectives ............................................................................................................................................................................ 44
• Role ............................................................................................................................................................................................................ 44
− “Low Risk Foot” Management .........................................................................................................................................................45
− “At risk Foot” Management ..............................................................................................................................................................45
− “High risk Foot” Management ........................................................................................................................................................ 46
− “Acute Complication” Management ............................................................................................................................................. 46
• Qualifications ...........................................................................................................................................................................................47
• Standards of Professional Practice ....................................................................................................................................................47
• Referrals .....................................................................................................................................................................................................47
• Flexible Competencies . .........................................................................................................................................................................47
3.5 Psychologist ............................................................................................................................................................................................ 48
• Rationale . ................................................................................................................................................................................................. 48
• Goals and Objectives ............................................................................................................................................................................ 48
• Qualifications .......................................................................................................................................................................................... 49
• Standards of Professional Practice ................................................................................................................................................... 49
• Referrals .................................................................................................................................................................................................... 49
• Flexible Competencies . ........................................................................................................................................................................ 50
3.6 General Practitioner ........................................................................................................................................................................... 50
3.7 Other Members of the Team . ........................................................................................................................................................ 50
• Endocrinologist . ..................................................................................................................................................................................... 50
• Exercise Professional/ Physiotherapist ........................................................................................................................................... 50
• Pharmacist ............................................................................................................................................................................................... 50
• Social Worker
• Ophthalmologist/Optometrist ............................................................................................................................................................ 51
• Nephrologist ............................................................................................................................................................................................. 51
• Vascular Surgeon . ................................................................................................................................................................................... 51
• Oral Health/Dentist ................................................................................................................................................................................ 51
Appendix .........................................................................................................................................................................................................52
1 Basic Foot Screening Checklist ...........................................................................................................................................................52
2 Integrated Diabetic Foot Continuum of Care Clinical Pathway . ................................................................................................ 55
3 Wraight et al’s Clinical Assessment and Investigations and Management
of Acute Diabetic Foot Complications .............................................................................................................................................. 57
References .................................................................................................................................................................................................... 58
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Chapter 1 Background
1.1 Introduction
Aim
The aim of the revised guidelines is to improve the management and care of individuals with Type 2 diabetes and to help
health professionals and the individual with diabetes to work as a team by providing a framework of the services that
need to be provided from diagnosis through the continuum of care. The guidelines provide:
•assessment, management and education criteria that need to be addressed to achieve best practice through the
continuum of care of diabetes
•links to existing clinical guidelines/evidence based guidelines and resources to promote evidence based best
practice
•criteria other professionals should use when referring
•information regarding the services that can be provided by a range of service providers-flexible competencies.
•descriptions of the roles and responsibilities of each member of the multidisciplinary team
Management Goals
The goals of management are to:
•limit the progression of diabetes
•improve self management of diabetes
•decrease risk of complications
•manage existing complications
•decrease hospital admissions
•improve quality of life and
•maintain functional capacity and independence
Table 1 Targets 7
Fasting BGL
4-6 mmol/L
HbA1c
<7 %
LDL
<2.5 mmol/L
Cholesterol
<4.0 mmol/L
HDL Cholesterol
> 1.0 mmol/L
Triglycerides
<2 mmol/L
Blood Pressure
<130/80
BMI
<25kg/m2
Waist circumference
<94 cm-men
<80 cm-females
Urinary Albumin Excretion
<20 µg/min timed overnight collection
<20mg/L spot collection
<3.5 mg/mmol women
<2.5 mg/mmol men albumin creatinine ratio
eGFR
>60 ml/min/1.73m2
Cigarette Consumption
Zero
Alcohol Intake
<4 standard drinks (40g)/day (men)
<2 standard drink (20g)/day (women)
Physical Activity
At least 30 minutes of moderate intensity physical
activity on most, preferably all days. Plus, if able, some regular
vigorous activity.28
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Principles
The principles underlying these guidelines are consistent with the Queensland Strategy for Chronic Disease8 and are
listed below.
•People with diabetes should be provided with information, education and skills to enable self-management.
•Support should be provided to encourage healthy lifestyle choices.
•Services should be based upon best practice and available evidence.
•Services need to be flexible to meet varying needs and provided through the continuum of care.
•Treatment and management should be patient focused taking into consideration the individual’s needs, wants and
expectations.
•Services should be equitable across metropolitan, rural and remote areas.
•Specific needs of people from diverse cultural backgrounds including Aboriginal and Torres Strait Islanders should
be addressed and catered for.
•An integrated, coordinated and multidisciplinary team approach should be adopted.
•A coordinator of care should be nominated.
1.2 Models of Care/Service delivery
The delivery of health services has to change to accommodate the increasing impact of chronic diseases. The
Queensland Strategy for Chronic Disease 2005-2015 suggests that there needs to be greater emphasis upon primary
prevention, an increased focus on community or home based services and the strengthening of partnerships between
the community, primary health care providers and the acute sector.8
Communication between the individual with diabetes and service providers across sectors is essential to ensure
effective transition between acute, primary care and community services. Services should be evidence based where
evidence exists and span the continuum of care. A multidisciplinary team approach that involves the individual in
decision making and promotes self-management is recommended. The appointment of a care coordinator to assist
the individual in all aspects of management and to coordinate support services is recommended. The care coordinator
maybe the patient, the General Practitioner, Nurse, Diabetes Educator, Indigenous Health Worker, Remote Area Health
Nurse or another appropriate member of the team. Providers of service should aim for best practice and implement
evidence based clinical management diabetes guidelines where they exist. Systems should be in place to detect and
manage complications early. The implementation of a diabetes register and recall system is recommended. Effective care
for people with diabetes must address psychological and social issues as part of ongoing care.8 Models of care need
to be responsive to cultural, geographical and literacy needs. Particular attention needs to be given to addressing the
needs of older Australians, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse
backgrounds and rural and remote areas.
Models of care should be practical, sustainable and cost effective. To ensure quality and safety, data should be collected,
analysed and compared with benchmarks to monitor performance.3, 8
The American Diabetes Association suggests that the optimal management of diabetes requires an organised, systematic
approach and a coordinated team of health care professionals. According to the American Diabetes Association the
features of successful programs reported in the literature include:9
•Improving education of health care professionals regarding standards of care through formal and informal
education programs.
•Delivery of Diabetes Self Management Education (DSME) which has shown to increase adherence to standards of
care.
•Adoption of practice guidelines. Guidelines should be readily accessible at the point of service.
•Use of checklists that mirror guidelines.
•Use of automated reminders that report process and outcome data to service providers and identify at risk patients.
•Quality improvement programs.
•Practice changes such as clustering of diabetes visits into specific times and /or organising access to multiple
health professionals on a single day.
•Tracking systems with either an electronic medical record or patient registry.
•Non-automated reminders such as chart stickers, flow sheets and mail outs.
•Availability of case management services.
•Availability and involvement of expert consultants.
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Aboriginal and Torres Strait Islander Peoples
The National Improvement Framework for Diabetes suggests that the best practice model for the delivery of primary
health care to Aboriginal and Torres Strait Islander communities is the provision of Aboriginal Community Controlled
Health Services as well as mainstream services. 3
The National Strategic Framework for Aboriginal and Torres Strait Islander Health: Framework for Action by Governments
2003 recommends that the following principles be applied when designing health services for Aboriginal and Torres
Strait Islander Peoples: 8, 10
•cultural respect
•holistic approach to health including physical, spiritual, cultural, emotional and social wellbeing, community
capacity and governance
•whole of health sector responsibility
•community control of the primary health services
•government and non-government and private organisations within and outside the health sector working in
partnership with the Aboriginal and Torres Strait Islander health sector
•decision making capacity devolved to the local Aboriginal and Torres Strait Islander communities
•health promotion and illness prevention activities
•building the capacity of the health services and communities to respond to health needs and take responsibility for
health outcomes
•accountability for health outcomes and effective use of funds by community and mainstream services.
The document can be accessed through the webpage below.
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubs-healthstrategy.htm/$FILE/
nsfatsihfinal.pdf
Examples of Models of Care 3
Person/Patient Centred Care
The Queensland Strategy for Chronic Disease 2005-2015 defines Person Centred Care as care that respects the people
at the centre of care. The individual performs an integral role in their care and is considered an expert on his/her
condition.8 Patient centred education involves the patient and the carer in planning the education. The patient’s
opinions, ideas and feelings are sought and considered and the patient is involved in the decision making process.3 It
promotes respect, dignity, autonomy and informed decision making. Self management and empowerment is essential
in person centred care.8 The benefits include, increased satisfaction with care, reduced levels of anxiety, improved
adherence to treatment, symptom resolution and improved physiological and functional status.3
Diabetes Shared Care 3
Shared care is the joint management of a patient by the general practitioner and a hospital specialist. Effective
communication strategies are critical to ensure information is exchanged between both providers. This model helps to
facilitate the integration of care across primary and secondary health care sectors.
Positive outcomes have been achieved with the shared care model provided there is adequate support and
communication from the hospital specialists.3
Overland et el suggest that while diabetes management can occur largely in the primary care setting, there are some
patients such as those with macrovascualr complications that require referral to a specialist. Systems should be
implemented that support the general practitioners to care for their patients in the primary care setting while also
facilitating access to specialists for those patients that require them.11
Care in General Practice 3
Quality diabetes care can be achieved in general practice provided care is structured. This can be facilitated by the
implementation of a diabetes register, a recall system, flow charts, review charts, goal setting and care planning.3 Access
to specialists and practice nurse involvement in education and clinical checks results in better quality care.12
General Practitioner Mini Clinics and Educational Outreach 3
The National Service Improvement Framework for Diabetes states that “mini clinics” based in general practice
are effective in improving processes of care and glycaemic control. These mini clinics are special clinics possibly
coordinated by practice nurses and outside routine consultations.
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
1.3 Annual Cycle of Care
Medicare Australia provides a Service Incentive Payment (see below for details) to general practitioners (GPs) who as a
minimum complete the prescribed annual cycle of care for their patients with diabetes. The Annual Cycle of Care dictates
the minimum levels of care that need to be provided. Individuals with complications, risk factors or co-morbid conditions
will require care beyond that outlined in the annual cycle of care. The annual cycle of care is described in Diabetes
Management in General Practice.7
1.4 Management of Diabetes Mellitus in Adults - Queensland Health Standard Care
Pathway 2006
The Standard Care Pathway is an integrated diabetes management guideline based upon available evidence or
consensus where evidence does not exist. It provides best practice guidelines and criteria for screening, diagnosis,
stabilisation, ongoing review and referral. After initial stabilisation, quarterly reviews are recommended with the six
and twelve month reviews being more comprehensive. The provision of care that is consistent with the Standard Care
Pathway will exceed the minimum levels of care required by the Annual Cycle of Care to enable the GP to claim a Service
Incentive Payment. While the Annual Cycle of Care dictates minimum levels of care, the Standard Care Pathway promotes
best practice. Therefore implementation of the Standard Care Pathway is recommended where practical.
A patient brochure has been developed to complement the pathway. The patient brochure provides checklists to inform
patients of the level of care they should expect. The brochure also provides patients with recommendations regarding
referral to other members of the multidisciplinary team.
1.5 Education
Diabetes Self Management Education (DSME)
The Australian Diabetes Educators Association defines diabetes self management education as, “the process of
facilitating the development of knowledge, skills, attitudes and behaviours that enable the person with diabetes to
perform self care on a day to day basis.”13 DSME is an integral component of diabetes care.
It aims to achieve self care behaviours such as appropriate lifestyle choices, compliance with medications and blood
glucose monitoring. Lifestyle issues targeted include smoking, nutrition, alcohol and physical activity. The individual
is encouraged to identify problems and possible solutions and to take appropriate actions to reduce the risk of
complications. DSME needs to be planned, structured and focused upon the individual with diabetes. It involves
assessment of the patient’s needs and goal setting. The process should be documented, evaluated, revised as required
and communicated to other members of the multidisciplinary team.14,15 Demographic background including culture,
literacy, and education level should be considered when planning and implementing DSME.
The involvement of a multidisciplinary team with an identified coordinator of care is recommended.14,15 The team will
include as a minimum, a Credentialed Diabetes Educator, a dietitian and a podiatrist. 14 The providers of DSME should
have received training specific to diabetes and participate in continuing education in the areas of diabetes management,
behavioural interventions , and teaching, learning and counselling skills. 14,15
For further information refer to the Australian Diabetes Educators Association’s National Standards for Diabetes
Education Programs. 14
Group Education
Deakin et el.’s systematic review of group based, patient centred educational programs for people with Type 2 diabetes
found that group based training is an effective way of providing self management education and skills. Outcomes
include significant improvements in knowledge, fasting blood glucose, glycated haemoglobin, systolic blood pressure
and decreased diabetes medication requirements. Group based programs delivered annually may result in longer-term
improvements in clinical outcomes. Programs can be delivered by any health professional provided they are trained to
deliver diabetes education programs. Size of groups does not appear to alter the effectiveness of education. 5 Rickheim
compared group education with intensive individual consultations and found that individual consultations were less
effective than the group programs. 16 Issues such as culture, ethnic background, literacy, disability and geography may
make group education inappropriate for some individuals in which case individual consultations are recommended.
1.6 Incentives Supporting Diabetes Care
Australian Government, Department of Health and Ageing
Practice Incentives Program (PIP)
The aim of the Practice Incentives Program, Diabetes Incentive is to enhance prevention, promote earlier detection and
diagnosis and improve the management of diabetes. The diabetes incentive consists of three components, patient
register and recall system, service incentive payment-diabetes (SIP-diabetes) and an outcomes component.
10
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Patient Register and Recall/Reminder System
Practices receive a one off payment if they use a patient register and a recall/reminder system for their patients with
diabetes.
Service Incentive Payment (SIP)
GPs that have a patient register and recall system will receive a payment once a year per patient that has had the Annual
Cycle of Care implemented. Doctors need to use a diabetes specific Medicare item number to inform Medicare Australia
that the annual cycle of care has been completed for each patient.
Outcomes
A diabetes outcome payment is made to practices that reach target levels of care for their patients with diabetes.
Practices will receive a payment per patient with diabetes if an Annual Cycle of Care for a target proportion of their
patients with diabetes has been completed.
Practice Nurses Incentive
Funding is available to employ practice nurses in eligible general practices. The practice must be located in a rural area
or an area of need. The aim of the incentive is increase the employment of practice nurses to support the management of
chronic diseases, to provide clinical support and to undertake population health activities. This enables the GP to spend
more time on diagnosis and clinical care. The practice must be participating in the PIP and employ a practice nurse for
equivalent to two sessions per week per full time GP equivalent. The funding is capped at one full time equivalent nurse
per practice.
Chronic Disease Management (CDM) Medicare Items
Chronic Disease Management Items provide a Medicare rebate for health assessments, care planning and case
conferencing services for patients with a chronic condition and multidisciplinary care needs. These items have replaced
the Enhanced Primary Care Items. The new CDM items have increased patient eligibility and increased the flexibility
in who can provide the services. The CDM items apply to patients living in the community, private inpatients being
discharged from hospital and residents of aged care facilities. GPs can be assisted by practice nurses, aboriginal
health workers and other health professionals in providing the CDM items. The GP must see the patient and confirm all
assessments and arrangements but the practice nurse can assist with the assessment, identify patient needs, facilitate
communication and discuss costs with the patient.
The CDM Items:
GP Management Plan (GPMP- Item 721)
GPs have access to a Medicare rebate per patient for preparing and reviewing GP Management Plans for patients with
one or more chronic or terminal medical conditions. The GPMP is developed between the GP and the patient with a
chronic condition. The GP maybe assisted by a practice nurse or other health worker in the development of a GPMP. A
GPMP should be prepared once every two years and supported by regular review services.
Review of a GP Management Plan (GP MP- Item 725)
A Medicare rebate can be claimed for the review of a GPMP. The GPMP needs to be reviewed and any changes need to
be documented. A date for the next review needs to be determined. Reviews should occur every six months or earlier if
clinically indicated. The practice nurse or other health workers can assist in the review.
Coordination of Team Care Arrangements (TCA- Item 723)
A rebate is available for a GP to coordinate a Team Care Arrangement for an eligible patient. Patients are eligible for a
TCA involving care from a multidisciplinary team if they have a chronic or terminal medical condition and require ongoing
care from a multidisciplinary team including at least three health care providers. A TCA involves the GP and at least two
other health or community care providers. The recommended frequency for a TCA is once every two years supported by
regular review services.
Coordination of a Review of Team Care Arrangements (Item 727)
A rebate is payable for coordination of a review of the TCA. This should occur every six months or more frequently if
clinically indicated. The GP collaborates with other members of the team to review progress. A practice nurse or other
health worker may help the GP with this process. Any changes need to be documented.
Contribution to a Multidisciplinary Care Plan Being Prepared by Another Health or Care Provider (Item 729)
A rebate is payable to GPs for contribution to a multidisciplinary care plan prepared or reviewed by another provider. The
recommended frequency is once every six months or more frequently if clinically indicated.
11
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Contribution to a Multidisciplinary Care Plan Being Prepared by Another Health or Care Provider for a Resident of an
Aged Care Facility (Item 731)
As above for patients that are residents of an aged care facility.
A GPMP and a diabetes SIP can be claimed for the same patient as these services are complimentary. A review of a
GPMP and the SIP should not be claimed within three months of each other as the services required overlap. A GPMP and
TCA and a SIP can be claimed as patients with a TCA will have complex needs that can not be met by the SIP alone.
Allied Health and Dental Care Item Numbers
Patients who have both a GPMP and TCA or who previously had an Enhanced Primary Care plan can access allied health
and dental items on the Medicare Benefits Schedule. Residents of aged care homes whose GP has contributed to a
care plan prepared by the aged care facility also have access to allied health and dental items. Patients can claim for
five allied health rebates and three dental care services per year. These services can be provided either individually
or in a group. The need for services should be documented in the patient’s care plan. Health professionals eligible for
patient rebates include- Credentialled Diabetes Educators employed in private practice, dietitians, podiatrists, Aboriginal
and Torres Strait Islander health workers, psychologists, speech pathologists, occupational therapists, audiologists,
chiropractors, exercise physiologists, mental health workers, osteopaths and physiotherapists. Allied health
professionals need to be registered with Medicare Australia and provide a written report regarding the service provided
to the referring GP.
Home Medicines Review (HMR)
A medication review is a review of the patient’s prescribed, over the counter and complimentary medicines that occurs
for patients living at home in the community. The review is conducted by a general practitioner, community pharmacist
and an accredited pharmacist. The review includes the development of a management plan and may occur in the
surgery, home or health care setting. Both the general practitioner and the accredited pharmacist are remunerated for
this service.
For further information regarding the above refer to the Australian Government Department of Health and Ageing website.
www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-epc-index.htm
1.7 Services/Resources to Assist the Management of Type 2 Diabetes
Diabetes Australia - Queensland
Diabetes Australia, which is a member of the International Diabetes Federation, is a consumer organisation consisting of
medical, scientific, health and research professionals. The organisation works to increase public awareness of diabetes,
actively contributes to research and is an advocate for people with diabetes in Australia. Diabetes Australia-Queensland
Branch (DAQ) is part of Diabetes Australia, which operates in all States and Territories of Australia. A data base of
Queensland diabetes services can be accessed through the DAQ web site. http://www.daq.org.au/diabeteslink/ It
provides members with discounts on Diabetes Australia products, support, education, resources and services to manage
diabetes. A comprehensive series of fact sheets, books, and other educational resources are available from Diabetes
Australia. A multilingual web site including multilingual resources can also be accessed through Diabetes Australia.
Diabetes Australia
GPO BOX 9824
In your capital city
PH: 1300 136 588
www.diabetesaustralia.com.au
National Diabetes Services Scheme (NDSS)
Diabetes Australia coordinates the NDSS on behalf of the Commonwealth Government. The scheme provides
information, free syringes and pen needles for people with diabetes. NDSS registrants receive a resource pack containing
basic information on diabetes, diabetes self management and where to go for help. Individuals who have registered with
the NDSS will also receive subsides for the cost of testing strips and insulin pump consumables. A data base of those
who have registered with the NDSS is also maintained.
Diabetes Management in General Practice 7
This booklet produced by the Royal Australian College of General Practitioners and Diabetes Australia provides
guidelines for the management of Type 2 Diabetes in general practice. This easy to read booklet provides guidelines and
recommendations for screening, diagnosis, assessment, management and review. Specific issues such as medications,
complications, sick days, pregnancy, travel and driving are all addressed. The following guidelines for care and referral
aim to complement the Diabetes Management in General Practice booklet and refer to it often as a valuable resource.
The use of both resources is recommended.
12
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Diabetes Patient Record Forms 7
The RACGP have developed diabetes patient record forms including clinical management targets and incorporating
the NDOQRIN minimum data set. These forms provide a continuous clinical record and facilitate the implementation
of best practice guidelines, care planning, referral and communication. A copy of the form is exhibited in the Diabetes
Management in General Practice Booklet. Forms can be ordered through RACGP and Diabetes Australia. Work is being
conducted to produce an electronic version of the form.
Diabetes Network
The Queensland Health Clinical Practice Improvement Centre (CPIC) Diabetes Network was initiated in 2005. A
network is a state-wide collaboration of clinicians who share a common goal, and work together to identify gaps
between evidence and practice, in order to improve aspects of patient care and achieve change at a local level. In
contrast to a collaborative, the network also advises budget holders on spending to address inequities of services. It
achieves this through hosting 6-monthly statewide workshops for multidisciplinary groups of Queensland Health staff
currently working with patients with diabetes throughout Queensland and across a range of health settings including
acute, community and administration. The Diabetes Network has identified five key areas in which to target service
improvement efforts. These include:
•Intensive management of Type 1 diabetes
•Management of Type 2 diabetes and the community interface
•Diabetes in pregnancy
•Paediatric diabetes
•Aboriginal and Torres Strait Islander issues and regional/rural issues in diabetes
Further information is available at www.health.qld.gov.au/cpic
Queensland Health staff can also access CPIC resources through http://qheps.health.qld.gov.au/cpic/
Resources to Assist with the Management of Aboriginal and Torres Strait Island Peoples
•Communication Australian Indigenous HealthInfoNet
http://www.healthinfonet.ecu.edu.au/frames.htm
•Office for Aboriginal and Torres Strait Islander Health, Aust Govt Dept Health and Ageing
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Office%20for%20Aboriginal%20and%20Torres
%20Strait%20Islander%20Health%20(OATSIH)-1
•Warnock’s Indigenous Diabetic Foot Resources and Workshops
http://www.sarrah.org.au/IDF=121
Smoking, Nutrition, Alcohol and Physical Activity (SNAP) 17,18
SNAP is an integrated framework to support the management of behavioural risk factors in general practice. The
framework provides a system wide approach to the identification and management of behavioural risk factors. It
provides evidence based information and patient information resources covering smoking, nutrition, alcohol and
physical activity. The Royal Australian College of General Practitioners have published SNAP- A population health
guide to behavioural risk factors in general practice.18 This guide provides information covering why behavioural
risk factors need to be addressed and guidelines to assess the patient’s readiness to change. A five step model for
detection, assessment and management of risk factors is also provided. Clinical strategies, business strategies and
resources to address SNAP risk factors are provided. Copies can be accessed from http://www.health.gov.au.pubhlth/
about/gp/
Lifestyle Prescriptions 19
A lifestyle prescription consists of written recommendations that are provided to the patient to help the implementation
of healthy lifestyle behaviours. Lifestyle prescriptions are recommended to address SNAP behavioural risk factors.
A Lifescript Resource Kit has been developed to assist GPs and their practices to manage lifestyle risk factors. The
kit consists of consumer resources, practitioner resources, an educational CD-ROM and an implementation manual.
Lifestyle script pads are available to write individualised lifestyle recommendations. The pads can also be used to refer
patients to other services. Assessment tools and guidelines for each risk factor are available.
More details are available at the Australian Government Department of Health and Ageing Websitehttp://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-lifescripts-index.htm
13
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Chronic Disease Self Management Programs:
•Kate Lorig Self Management Program
•Flinders Self Management Program
•Queensland Arthritis Foundation: The Chronic Disease Self Management Program
The Queensland Arthritis Foundation provides chronic disease self management programs in the community. The
courses which involve client participation are facilitated by two trained leaders, one or both of whom have a chronic
disease themselves. Subjects covered include: techniques to deal with problems such as frustration, fatigue, pain and
isolation, appropriate exercise, medications, communication with family, friends and health professionals, nutrition and
use of community resources.
Arthritis Queensland
1800 011 041.
http://www.arthritis.org.au/content/view/28/47/
QUIT
Quitline is a 24 hour counselling service for people who want to give up smoking.
Quitline: 131 848
The QUIT web site provides statistics, resources and information for health professionals and the public regarding
smoking and giving up.
http://www.quitnow.info.au/
Healthy Weight Programs
The healthy weight program is a weight control program designed for Indigenous people. Contact your local Community
Health Centre to find out if this program is available in your local area.
Lighten Up
Lighten up is a weight control program delivered through Community Health Centres. Contact your local Community
Health Centre to find out if this program is available in your local area.
Local Councils
Some local councils run physical activity programs and manage community physical activity facilities. Contact your local
council to find out what is available in your local area.
Heart Foundation
The Heart Foundation offers a comprehensive series of publications, resources and programs to assist with the
prevention and management of heart disease. It also conducts and supports research into heart, stroke and blood
vessel disease.
‘Just Walk It’ which is organised through the Heart Foundation, Queensland is a group walking program. It is a free
program which aims to help people become more physically active by walking regularly as part of a group. ‘Just Walk It’
groups are located throughout Brisbane and regional Queensland. For more details phone: 3872 2500 or log onto the
following web site http://www.heartfoundation.com.au/index.cfm?page=210
Heart Foundation
http://www.heartfoundation.com.au/
Queensland Division
Ph: (07) 3854 1696
1.8 Government Strategies
National Service Improvement Framework for Diabetes3
This framework complements the National Chronic Disease Strategy and is a national approach to improving the
prevention and management of diabetes. The framework identifies where critical improvements can be made to health
services at state, territory and national levels. The framework recognises that services for diabetes need to be provided
through the continuum of care, from prevention through to the advanced stages of the disease.3
Queensland Strategy for Chronic Disease8
“This statewide strategy aims to engage all stakeholders involved in the prevention, intervention and management of
chronic disease at a system, service and individual level across the continuum of care. It identifies evidence based
14
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
approaches to prevent or reduce behavioural and lifestyle risk factors and supports better care for people with chronic
disease and their carers/families.” 8
Aboriginal and Torres Strait Islander Health
• National Strategic Framework for Aboriginal and Torres Strait Islander Health 200310
• Productivity Commission’s Strategic Framework for Overcoming Indigenous Diseases20
• Cultural Respect Framework for Aboriginal and Torres Islander Health 2004-200921
• National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-201022
1.9 Guidelines
Australian- National Evidence Based Guidelines23
National evidence based guidelines are being prepared for the prevention, detection and management of Type 2
Diabetes. The guidelines are being prepared by a consortium led by Diabetes Australia and in accordance with the
National Health and Medical Research Council (NHMRC) standards.
When completed, there will be nine guidelines:
1*Primary Prevention45
2*Case Detection and Diagnosis 44
3*Diagnosis and Management of Hypertension 38
4*Prevention and Detection of Macro vascular Disease6
5*Identification and Management of Diabetic Foot Disease40
6Blood Glucose Control
7*Lipids 39
8Renal Disease
9Education.
*Guidelines have been completed and are available on the Diabetes Australia Website and the NHMRC website.
http://www.diabetesaustralia.com.au/education_info/nebg.html
http://www.nhmrc.gov.au/publications/subjects/diabetes.htm
Other Guidelines
•Guidelines-Management and Care of Diabetes in the Elderly, Australian Diabetes Educators Association (ADEA) ,
2003 24
•Best Practice Guidelines for the Management of Type 1 Diabetes in Children and Adolescents, Queensland Health,
200225
•National Standards for Diabetes Education Programs, ADEA 200114
•Dietetic Practice Guidelines for the Management of Adults with Type 2 Diabetes Mellitus, endorsed by the Dietitians
Association of Australia, 200626
•Australian Dietary Guidelines, Australian Government, Department of Health and Ageing, NHMRC, 200327
•National Physical Activity Guidelines for Australians, Australian Government, Department of Health and Ageing,
NHMRC, 199928
•NHMRC Guidelines- Clinical Practice Guidelines For the Management of Overweight and Obesity in Adults, 200329
•National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines on the Management of Diabetic
Retinopathy, Australian Diabetes Society (ADS), 200530
•Australian Podiatric Guidelines for Diabetes, Australian Podiatric Councils and Diabetes Australia, 1997 31
•Gestational Diabetes Mellitus- Management Guidelines, The Australasian Diabetes in Pregnancy Society, 1998 32
•The Australasian Diabetes in Pregnancy Society Consensus Guidelines for the Management of Type 1 and Type 2
Diabetes in Relation to Pregnancy, The Australasian Diabetes in Pregnancy Society, 200533
•Smoking Cessation Guidelines for Australian General Practice, Department of Health and Ageing, 200434
•Australian Alcohol Guidelines: Health Risks and Benefits, NHMRC, 2001 35
•American Psychiatric Association Practice Guidelines for the Treatment and Management of Psychiatric Disorders36
•American Diabetes Association, Standards of Medical Care in Diabetes 2006 9
•Global Guideline for Type 2 Diabetes, International Diabetes Federation (IDF), 200537
15
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Chapter 2 Guidelines for Care and Referral of Adults with Type 2 Diabetes
The following tables provide health professionals with a framework for initial and ongoing assessment, management
and education of adults with Type 2 Diabetes. The tables are not intended to be prescriptive but rather outline the
parameters that need to be addressed, by whom and how often. Care that is consistent with the Management of
Diabetes Mellitus in Adults- Queensland Health Standard Care Pathway 2006 is promoted. Referral and flexible
competency criteria are provided. Resources including national evidence based clinical guidelines are listed to assist the
implementation of best practice through the continuum of care.
The Primary Care Coordinator referred to throughout the following guidelines is the designated individual who assists
the client in all aspects of management and coordinates support services. The care coordinator maybe the patient,
the General Practitioner, Nurse, Diabetes Educator, Indigenous Health Worker, Remote Area Health Nurse or another
appropriate member of the team.
At diagnosis it is recommended that all patients register with the NDSS to enable the patient to access resources and
information about diabetes and to ensure their details are added to the National Data Base.
Documentation of services provided and communication between the service providers and the patient and/or carer are
essential throughout the continuum of care to ensure coordinated care is provided.
2.1 Table 2 Assessment
What
Frequency
Who
Referrals
Resources
Knowledge
Diagnosis
Every three months
(3 mths)
Primary Care
Coordinator (e.g. GP/
Diabetes Educator/
Indigenous Health
Worker/Remote Area
Health Nurse)
Consider referral to:
Diabetes Educator
Indigenous Health
Worker
Diabetes
Management in
General Practice7
(RACGP)
http://www.racgp.
org.au/folder.
asp?id=1168
NDSS ph: 1300 136
588
http://www.
diabetesaustralia.
com.au/ndss/index.
html
Diabetes Australia
- Queensland
http://www.daq.org.
au
ph: 1300 136 588
Symptoms7
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Nocturia
• Malaise
• Altered vision
• Recurrent infections
• Neuropathic foot
symptoms
• Sexual issues
DiagnosisPrimary Care
comprehensive review Coordinator
of symptoms
3 mths-check current
and new symptoms
Every 12 Months (12
mths)- comprehensive
review
Consider referral to:
Diabetes Educator
Dietitian
Indigenous Health
Worker
Podiatrist
Ophthalmologist
Optometrist
Psychologist
Diabetes
Management in
General Practice7
(RACGP)
Standard Care
Pathway
Annual Cycle of Care
(RACGP)
Complications
• Macrovascular
disease
• Renal disease
• Eye damage
• Neuropathy
(Sensory, motor,
autonomic nerves)
• Foot disease
Diagnosis and 12
mths
Consider referral to:
Endocrinologist
Nephrologists
Ophthalmologist
Optometrist
Neurologist
Cardiologist
Diabetes
Management in
General Practice7
(RACGP)
Standard Care
Pathway
Annual Cycle of Care
Primary Care
Coordinator
16
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
ECG6
Risk Factors for
Complications &
Investigations
• Blood glucose
• HbA1c
• Blood pressure
• Lipids
- LDL
- HDL
- Triglycerides
• Renal function
- Urea
- Creatinine
- eGFR
Frequency
Diagnosis and every
2 yrs if > 50 yrs & > 1
risk factor
Who
Referrals
Resources
Vascular Specialist
Podiatrist
Psychologist
Diabetes Educator
Dietitian
NHMRC Clinical
Practice Guidelines on
the Management of
Diabetic Retinopathy 30
http://www.nhmrc.
gov.au/publications/
synopses/cp56 covr.
htm
Evidenced based
Guidelines for
the Prevention
and Detection of
Macrovascular
Disease in Type 2
Diabetes 6
http://www.
diabetesaustralia.com.
au/education_info/
nebg.htmlcovr.htm
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
See Section
2.4.2: Table 6
Complications-Feet
and Section 3.4:
Podiatry
GP/Medical Officer
Consider referral to:
Cardiologist
Primary Care
Coordinator
Consider referral to:
Diabetes Educator
Dietitian
Indigenous Health
Worker
Exercise Professional
Psychologist
Endocrinologist
Nephrologists
Cardiologist
Podiatrist
Diagnosis, Every Visit
Diagnosis, 3-6 mths
3mths if Aboriginal,
Torres Strait Islander/
on insulin or poor
control
Diagnosis, Every visit
Diagnosis, 6 mths
Diagnosis, 12 mths
Diagnosis, 12 mths
• Urine
- Microalbuminuria
- albumin
- nitrates
- leucocytes
• Liver Function Tests Diagnosis, 12 mths
• Height
Diagnosis/as
appropriate
Standard Care
Pathway
Annual Cycle of Care
Evidenced Based
Guideline For the
Diagnosis and
Management of
Hypertension in Type
2 Diabetes38
National Evidenced
Based Guidelines
for the Management
of Type 2 Diabetes
Mellitus Lipid
Control39
http://www.
diabetesaustralia.
com.au/education_
info/nebg.html
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
17
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
Who
Referrals
Resources
• Weight, BMI
Diagnosis, 3 mths
• Waist
circumference
Diagnosis, 3 mths
• Personal history
Diagnosis
• Family history
Diagnosis
• Life- SNAP
- Smoking
- Nutrition
- Alcohol
- Physical Activity
Diagnosis, 3 mths
Self Care
Home blood glucose
monitoring
Foot checks and care
Lifestyle (SNAP)
Diagnosis, 3 mths
Primary Care
Coordinator
Consider referral to :
Diabetes Educator
Feet Risk Assessment
and Examination40
• Peripheral
neuropathy
• Peripheral vascular
disease
• Foot deformity
• Ulceration
(See Section
2.4.2: Table 6
Complications-Feet
and Section 3.4:
Podiatry)
Foot risk assessmentDiagnosis and 12
mths
Foot inspecection-3
mths
Primary Care
Coordinator
Consider referral to :
Podiatrist
See Section
2.4.2: Table 6
Complications-Feet
and Section 3.4:
Podiatry section
Appendix 1- Basic
Foot Screening
Checklist47
National Evidence
Based Guidelines
for the Management
of Type 2
Diabetes Mellitus
– Identification
& Management
of Diabetic
Foot Disease40
http://www.
diabetesaustralia.
com.au/education_
info/nebg.html
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
Eyes30
• Visual acuity
• Fundal abnormality
• Retinal abnormality
(see section
2.4.2 Table 6
Complications- eyes
for details)
Diagnosis, 2yrs if no
retinal abnormality
If retinopathy
detected- 3-12 mths
depending on level of
diabetic retinopathy
Appropriately trained
GP/Medical Officer
Consider referral to:
Ophthalmologist
Optometrist
NHMRC Clinical
Practice Guidelines on
the Management of
Diabetic Retinopathy 30
http://www.nhmrc.
gov.au/publications/
synopses/cp56 covr.
htm
Psychological Status9
• Adjustment
• Depression
• Anxiety
• Stress
• Anger
• Cognition
Diagnosis,
3 mths
Primary Care
Coordinator
Consider referral to:
Psychologist
ADA Standards
of Medical Care
in Diabetes,
Psychological
Assessment and Care,
20069
SNAP 17,18
http://www.racgp.
org.au/guidelines/
snap/
18
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
Who
Referrals
Resources
http://care.
diabetesjournals.org/
cgi/content/full/29/
suppl_1/s4#SEC9
• Behaviour
• Social
(see section 2.5 Table
7: Specific IssuesPsychological Issues
for details)
Canadian Diabetes
Association Clinical
Practice GuidelinesPsychological Aspects
of Diabetes41
http://www.diabetes.
ca/cpg2003/
chapters.aspx?psycho
logicalaspectsofdiabe
tes.htm
Depression Anxiety
Stress Scales 21 and
4242
The Kessler
Psychological Distress
Scale (K10)92
Culture
Diagnosis, 3 mths
Primary Care
Coordinator
Consider referral to:
Indigenous Health
Worker
Telephone Interpreter
services
Diabetes Australia,
Multicultural
Internet Resource
and Cross Cultural
Communication
Program
http://www.
diabetesaustralia.
com.au/
multilingualdiabetes/
index.htm
QH Multicultural
Health web site
http://www.
health.qld.gov.au/
multicultural/default.
asp
Cultural DiversityA Guide for Health
Professionals
http://www.
health.qld.gov.au/
multicultural/cultdiv/
default.asp
Disability
Medications
Diagnosis,
As required
Primary Care
Coordinator
Diagnosis, 3 mths
GP/Medical Officer
Disability Services Qld
http://www.disability.
qld.gov.au/
Consider referral to:
• Symptoms
Endocrinologist
• Blood glucose
Pharmacist
• Complications
• Risk factors for
complications
19
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
Who
Immunisations
Diagnosis, 12 mths
Primary Care
Coordinator
Thyroid Function Test7
Diagnosis if family
history/clinical
suspicion
GP/Medical Officer
Referrals
Initial, 3 mths
Primary Care
Coordinator
Document
assessment results
and communicate
with other providers
of care
Diagnosis, 3 mths
Primary Care
Coordinator
7
Referrals
Resources
Patient record
Diabetes Patient
Record Forms7
(RACGP)
2.2 Table 3 Management
What
Frequency
Who
Referrals
Determine Primary
Care Coordinator
Diagnosis, 12 mths
Patient and General
Practitioner/ Medical
Officer
Consider referral to:
Resources
Diabetes Educator
Indigenous Health
Worker
Remote Area Health
Nurse
Register with NDSS
Goals
Diagnosis
Diagnosis, 12 mths
Negotiate goals and
objectives with the
patient
Review achievement
of goals
Patient and
Credentialed Diabetes
Educator/ GP/Medical
Officer
National Diabetes
Services Scheme
(NDSS)
http://www.
diabetesaustralia.
com.au/ndss/index.
html
ph: 1300 136 588
Primary Care
Coordinator and
Patient
Consider referral to:
Psychologist
Primary Care
Coordinator and
patient
Consider referral to:
3 mths
Management Plan
• Develop
management
strategies to meet
goals
Diagnosis, 3 mths
• Consider
development/
review of “GP
Management Plan”
Diagnosis, 6mths
• Consider
establishment/
review “ Team Care
Arrangement”
Diagnosis, 6 mths
• Manage acute
symptoms
Diagnosis, 3 mths
• Optimise blood
glucose
Diagnosis, 3 mths
Indigenous Health
Worker
Diabetes Educator
Dietitian
Endocrinologist
Exercise Professional
Podiatrist
Psychologist
Pharmacist
Nephrologists
GP/Medical Officer
Ophthalmologist
Optometrist
20
GP Management Plan
(MBS Item:721)
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/pcdprograms-epcchronicdiseaseforms/$FILE/
sform721gpmp.pdf
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
• Optimise
blood pressure
Diagnosis, 3 mths
• Optimise lipids
Diagnosis, 6mths
• Treat complications
Diagnosis, As
required
• Optimise risk
factors
Who
Referrals
Resources
Neurologist
Team Care
Arrangement (MBS
Item: 727 )
Cardiologist
Vascular Specialist
Diagnosis, 3mths
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/pcdprograms-epcchronicdisease-forms/
$FILE/sform723tca.pdf
Standard Care
Pathway
Annual Cycle of Care
Self Management/
Care/DSME13
Diagnosis, 3mths/as
required
Diabetes Educator
ADEA National
Standards for
Diabetes Education
Programs 200114
Encourage
• Home blood
glucose monitoring
ADA National
Standards for
Diabetes Self
Management
Education15
• Self foot
examinations and
care
• Lifestyle (see
below)
Lifestyle
Encourage required
lifestyle changes
Diagnosis, 3mths
Primary Care
Coordinator
Dietitian
Exercise Professional
• Smoking
• Nutrition
Refer for Medical
Nutrition Therapy
Consider referral to:
Physiotherapist
Psychologist
Dietitian
Indigenous Health
Worker
• Alcohol
Group programs
• Physical Activity
Support Groups e.g.
Diabetes Australia
Healthy Lifestyle
Workshops
For more details see
section 2.4.1 Table 5
Risk factors- Smoking
and Alcohol and
2.5 Table 7 Specific
Issues-, Diet, and
Exercise
Lifestyle
Prescriptions 19
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/healthpubhlth-strateglifescripts-index.
htm#kit
Australian Dietary
Guidelines 27
http://www.nhmrc.
gov.au/publications/
synopses/dietsyn.
Flexible Competencies htm
Diabetes Resource
Lighten Up to a
Health Professional/
Healthy Lifestyle
RN
The Healthy Weight
Program
Australian Physical
Activity Guidelines28
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/phdphysical-activityadults-pdf-cnt.htm
QUIT
http://www.quitnow.
info.au/
21
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
Who
Referrals
Resources
Smoking Cessation
Guidelines for
Australian General
Practice 34
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/healthpubhlth-publicattobacco.htm/$FILE/
smoking_flip.pdf
NHMRC Australian
Alcohol Guidelines:
Health Risks and
Benefits35
http://www.nhmrc.
gov.au/publications/_
files/ds9.pdf
Chronic Disease
Self-Management
Programs eg. Kate
Lorig
Flinders, Arthritis
Foundation
Diabetes Australia
- Queensland
Diabetes
Management in
General Practice7
Medications
• Prescribe/adjust
medications to
treat symptoms,
complications and
risk factors for
complications
• Consider
prophylactic
aspirin6
• Provide education
re medication and
side effects.
• Emphasize
importance of
compliance
Diagnosis,
Three months
GP/Medical Officer
Consider referral to:
Endocrinologist
Pharmacist
Diabetes Educator
Diabetes
Management in
General Practice7
Evidenced Based
Guideline for the
Diagnosis and
Management of
Hypertension in Type
2 Diabetes38
Evidenced based
Guideline for the
Prevention and
Management of
Macrovascular
Disease in Type 2
Diabetes 6
http://www.
diabetesaustralia.
com.au/education_
info/nebg.html
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
Diabetes Education
See Table 4- General
Education and
Counselling
Diagnosis
3 mths/as required
Primary Care
Coordinator
Consider referral to:
Diabetes Educator
Dietitian
Podiatrist
Exercise Professional
Table 4: General
Education and
Counselling
22
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Frequency
Who
Referrals
Resources
Physiotherapist
Psychologist
Indigenous Health
Worker
Group programs
Support Groups e.g.
Diabetes Australia
Healthy Lifestyle
Workshops
Flexible Competencies
Diabetes Resource
Health Professional/
RN
Immunisations
Diagnosis, 12 Months
GP/Medical officer
Emotional Support
and Counselling
Diagnosis, 3 mths
Primary Care
Coordinator
Consider referral to:
Psychologist
Address Impact of
Cultural Issues
Diagnosis,
As required
Primary Care
Coordinator
Consider referral to:
Indigenous Health
Worker
Address disability
issues
Diagnosis,
As required
Primary Care
Coordinator
Disability Services Qld
Primary Care
Coordinator
Austroads Assessing
Fitness to Drive43
Diabetes
Management in
General Practice7
Administer required
immunisations
Notify Driver Licensing Diagnosis
Authority
See resources listed
for assessment
of cultural issuesSection 2.1 Table 2
Assessment
http://www.disability.
qld.gov.au/
http://www.
austroads.com.au/
aftd/index.html
Add details to Patient
Register +/- Recall
system
Diagnosis
• Document goals,
treatment and
management in
patient record/ GP
Management Plan
Diagnosis, 3 mths
Update as required
Primary Care
Coordinator
Primary Care
Coordinator
Flexible
Competencies:
Practice Nurse
• Communicate
management plan
to patient and other
providers of patient
care
• Consider
establishment of
patient held record
Organise Required
Referrals
Diabetes Register/
Recall System
Diagnosis, 3 mths
Primary Care
Coordinator
23
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
2.3 Table 4 General Education and Counselling
The following table include questions patients may ask. These are designed to promote patient focused education.
What
Content
Who
Referrals
Resources
Definition
• Define diabetes
Consider referral to:
NDSS
What is diabetes?
• Differentiate between
Type 1 and Type 2
Primary Care
Coordinator
Diabetes Educator
Diabetes Australia Queensland
Dietitian
Indigenous Health
Worker
Flexible
CompetenciesDiabetes Resource
Person, Practice
Nurse, RN,
Podiatrist,
Pharmacist,
Psychologist,
Exercise professional
Blood Glucose
Control
What is glucose?
What affects blood
glucose levels?
How do I check blood
glucose levels?
• Discuss the link between
glucose, insulin, food,
exercise and illness
• Define and explain cause
of hyperglycaemia and
hypoglycaemia
• Self monitoring-measuring
blood glucose
Symptoms
• No symptoms/signs
(stress importance of
I feel fine-are you sure
treating diabetes even if
I have diabetes and
no symptoms are present)
do I really have to
treat it?
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Nocturia
• Malaise
• Altered Vision
• Recurrent infections
• Poor wound healing
• Neuropathy
• Claudication
• Sexual Issues
Complications
• Macrovascular disease
What are the effects
of diabetes?
• Renal Disease
• Eye damage
• Neuropathy (Sensory,
motor, autonomic nerves)
• Foot Disease
• Sexual issues
• Infections
24
Diabetes Australia
Qld: Diabetes link
(diabetes service
directory)
http://www.daq.org.
au
Diabetes Management
in General Practice7
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
Primary Care
Coordinator
Consider referral to:
Psychologist ,
Counsellor
Flexible Competencies
Diabetes Resource
Health Professional,
Practice Nurse, RN
Dietitian
Podiatrist
Pharmacist
Exercise professional
NDSS
Diabetes Australia
- Queensland (Don’t
Ignore Diabetes
campaign)
Diabetes Management
in General Practice7
National Evidenced
Based Guidelines for
Case Detection and
Diagnosis44
National Evidenced
Based Guidelines for
the Primary Prevention
of Type 2 Diabetes45
http://www.
diabetesaustralia.com.
au/education_info/
nebg.html
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
General Treatment of
Primary Care
Diabetes
Coordinator
Can you cure Diabetes? • Explain no cure
• Treatment Goals
- Blood Glucose Control
- Manage acute symptoms
- Minimise complications
and the risk of
complications.
- Targets
How will my diabetes
• Explain the role of
be treated?
- Diet/healthy eating
How can I manage my
- Exercise/activity
diabetes?
- Weight control
- Medication
- Self management
- Complication screening
- Regular review
consistent with the
Standard Care Pathway
or the Annual Cycle of
Care
Consider referral to:
Diabetes Educator
Dietitian
Indigenous Health
Worker
Flexible Competencies
Diabetes Resource
Health Professional,
RN
Exercise Professional
Podiatrist
Psychologist
Pharmacist
Practice Nurse
Diabetes Management
in General Practice7
NDSS
Diabetes Australia Queensland
Standard Care Pathway
Annual Cycle of Care
Risk Factors for
• Family history
Diabetes44
• Ethnic background
Why did I get diabetes? • Weight
• Gestational diabetes
• Age
• Lifestyle
• Depression
• Other eg hypertension,
hyperlipidaemia
Progression of
diabetes
Will I end up on
Insulin?
Explain the progression of
diabetes and the possibility
of progression from diet/
lifestyle control to tablets to
insulin
Hypoglycaemia
Will I have a hypo?
What do I do if I have
a hypo?
How can I prevent
hypos?
• Causes
• Treatment
• Prevention
25
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
Home Blood Glucose
Monitoring
• Discuss the role of the
Blood Glucose Meter
Primary Care
Coordinator
Refer to Diabetes
Educator
NDSS
How do I know if
my glucose is well
controlled?
• Organise a Blood Glucose
Meter if appropriate
• Complete NDSS form
How do I test my
blood glucose at
home?
• Provide education
regarding the use of a
Blood Glucose Meter
Patient Resources
Provide list of resources with Primary Care
contacts details
Coordinator
Diabetes Australia Queensland
Refer as required
NDSS
Where can I get more
information?
Diabetes Australia Flexible competencies Queensland
Pharmacist
NDSS subagent
Diabetes Management
in General Practice7
Frequency of Review
Discuss
How often do I need
to have a check up
and by whom?
• Frequency of review
Primary Care
Coordinator
Consider referral to:
Diabetes Educator,
• Referrals
Dietitian,
• Team approach
Indigenous Health
Worker,
• Self monitoring and
management
Podiatrist,
• Model of Care/Clinics/ GP
Psychologist,
• Ensure patient details
registered on recall
system/register
Exercise Professional
Endocrinologist,
Ophthalmologist
Standard Care
Pathway
Managing your
diabetes - What you
should know (patient
brochure) Queensland
Health and Diabetes
Australia - Queensland
Annual Cycle of Care
Diabetes Management
in General Practice7
Optometrist
Neurologist
Cardiologist
Vascular specialist
Support groups
associations
Presenting to the
Doctor
When else do I need
to go to the doctor?
Discuss when to present
to the doctor in addition
to scheduled review
appointments
Primary Care
Coordinator
Consider referral to:
Diabetes Educator,
Dietitian,
Indigenous Health
Worker,
• Complications
• Lifestyle difficulties
Podiatrist,
• Poor blood glucose
control
Psychologist,
• Medication issues
Exercise Professional
• Foot disease especially
infections
Endocrinologist,
• Change in vision
Optometrist
• Chest pain
Neurologist
• Unwell/ vomiting/
infection/poor intake
Cardiologist
• Emotional Issues
Support groups
associations
Ophthalmologist
Vascular specialist
26
Diabetes Australia Queensland
Diabetes Management
in General Practice 1
Standard Care
Pathway
Managing your
diabetes - What you
should know (patient
brochure) Queensland
Health
Annual Cycle of Care
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
2.4 Prevention and Management of Complications
2.4.1 Table 5 Risk Factors
What
Content
Who
Referrals
Resources
Blood Glucose
Control
• Review, manage and
provide education
including;
Primary Care
Coordinator
Consider referral to:
NDSS
Diabetes Educator
SNAP 17,18
Dietitian
Lifestyle
Prescriptions19
q Self monitoring
Endocrinologist
q Lifestyle
q Medication
Psychologist
Diabetes Australia
- Queensland
Refer to Dietitian
SNAP17,18
Consider referral to:
Weight Watchers
Exercise Professional
http://www.
weightwatchers.com.
au/
q Other contributing
factors eg illness, other
medications
Weight
• Negotiate with the patient Primary Care
to set realistic weight loss Coordinator
and patient
goals
• Review and provide
education/counselling
q Diet
Weight Control Group
Dietitian
Psychologist
Surgeon
q Medical Nutrition
Therapy
q Exercise
Dietitian/
Primary Care
Coordinator
q Medication
GP/Medical
Officer
q Surgery
Lighten Up19
NHMRC GuidelinesOverweight and
Obesity in Adults- A
Guide for General
Practitioners29
http://www.health.
gov.au/internet/
wcms/publishing.
nsf/Content/
obesityguidelinesguidelines-adults.htm
• Provide Lifestyle
Prescription
Lifestyle
Prescriptions19
Chronic Disease
Self Management
Programs
Lipids39
• Review and encourage
lifestyle changes
especially diet and
exercise
Primary Care
Coordinator
SNAP17,18
Dietitian
National Evidenced
Based Guidelines
for the Management
of Type 2 Diabetes
Mellitus Lipid
Control39
Exercise Professional
Endocrinologist
• Emphasise importance of
weight loss if required
• Review and improve blood
glucose control if possible
• Review medication
requirements
Consider referral to:
GP/Medical
Officer
• Monitor lipids
http://www.
diabetesaustralia.
com.au/education_
info/nebg.html
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
Chronic Disease
Self Management
Programs
Diabetes
Management in
General Practice7
27
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Blood Pressure
38
Content
Who
Referrals
Resources
• Review lifestyle (SNAP)
and recommend
appropriate changes
Primary Care
Coordinator
Consider referral to:
SNAP17,18
Dietitian
National Evidenced
Based Guidelines
for the Management
of Type 2 Diabetes
Mellitus-Diagnosis
and Management of
Hypertension38
Diabetes Educator
• Emphasize importance of
weight loss if required
• Review medications and
compliance
Exercise Professional
GP/Medical
Officer/
Endocrinologist
• Consider ACE Inhibitor
initially and combination
therapy if required
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
Chronic Disease
Self Management
Programs
• Emphasize importance
of compliance with
medications
• Monitor at every visit
Smoking
• Emphasize benefits of
stopping
Diabetes
Management in
General Practice7
Primary Care
Coordinator
QUIT
Psychologist
• Counsel
Diabetes Educator
• Consider lifestyle
prescription
RN
Smoking Cessation
Guidelines for
Australian General
Practice34
Practice Nurse
Smoke Check
Diabetes Resource
Person
Lifestyle Script19
Consider referral to:
Lifestyle Scripts 19
ATODS
Psychologist
NHMRC Australian
Alcohol Guidelines:
Health Risks and
Benefits35
Who
Referrals
Resources
Primary care
Coordinator/
Podiatrist
Consider a referral
to a Podiatrist via
Integrated Diabetic
Foot Continuum of
Care Pathway48
(See Appendix 2)
See Section 3.4: Podiatry
Diabetic Foot Evidence
and ‘Low’, ‘At’, ‘High’ Risk
& “Acute Complications”
Management
Appendix 1: Basic Foot
Screening Checklist
(screening tool) 47
Appendix 2 :
Integrated Diabetic
Foot Continuum of Care
Pathway48
National Evidence
Based Guidelines for
the Management of
Type 2 Diabetes Mellitus
– Identification &
Management of Diabetic
Foot Disease 40
http://www.
diabetesaustralia.com.
au/education_info/
nebg.html
• Refer to QUIT
• Consider nicotine
adjunctive therapy or
Bupropion34
Alcohol
Consider referral to:
• Assess intake
• Educate re recommended
intake
Primary Care
Coordinator
Counsellor
• Provide counselling to
reduce intake if required
Chronic Disease
Self Management
Programs
2.4.2 Table 6 Complications
What
Content
Feet
• Ensure annual screen for
Foot Risk Status, i.e. assess
Low Risk Foot
for:
(i.e. without
q Peripheral Neuropathy
Neuropathy, PVD, Foot
q Peripheral vascular
Deformity, Ulceration
disease (PVD)
or Amputation)
q Foot deformity
q Ulceration & Amputation
40
Refer to Basic Foot Screening
Checklist 47
(See Appendix 1)
• Inspect for Foot
Complications
• Educate :
q Effects of hyperglycaemia
on feet
q Self foot care
q Footwear choices
q Services available to
assist
28
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
At Risk Foot
• Consider further
assessment and
management of:
Podiatrist,
GP, Diabetes
Educator
Consider referral to:
Australian Podiatric
Councils & Diabetes
Australia Australian
Podiatric Guidelines
for Diabetes 31
(i.e. Neuropathy,
PVD or
Foot Deformity)
q Neurological status,
q Vascular (i.e. Doppler,
IHW trained in
foot care
PPG, Duplex),
Deformity,
q Dermatology (eg callus),
q Footwear.
• Reinforce above diabetic
foot care education
• Ensure appropriate
pressure off-loading,
(i.e. Foot Deformity
pathological skincare,
with Neuropathy &/or
foot care & footwear.
PVD, Previous Ulcer or
Amputation)
• Reinforce above diabetic
foot care education.
Podiatrist,
GP, Wound
Care Nurse,
Diabetes
Educator
Acute Diabetic Foot
(i.e. Foot Ulcer,
Foot Infection,
Ischaemic Pain,
Charcot Foot)
• Use ‘Clinical Assessment,
Investigations &
Management of
Acute Diabetic Foot
Complications’ tool46
(See Appendix 3) to
assess and manage.
Consider where
appropriate:
q Debridement
q Dressing Regime
q Pressure Off-Loading
q Antibiotics
q Specialist Referral
Eyes30
• Ensure regular eye
examinations
q Assess visual acuity
q Check for fundal or
retinal abnormality
q Check Cataracts
If > 2cm
cellulitis and/
or can probe
wound to
bone include
urgently:
Orthopaedic Surgeon
or Surgical Podiatrist
http://www.apodc.
com.au/apodc/
diabetes.
Refer < 0.5 Ankle
Brachial Index
or < 40mmHg
Toe Pressures for
further vascular
investigations &/or
Vascular Specialist
Warnock’s Indigenous
Foot Project
Consider referral to:
Appendix 3: Wraight
et al’s Clinical
Assessment and
Investigations and
Management of
Acute Diabetic Foot
Complications46
Endocrinologist,
Vascular or
Orthopaedic Surgeon
or Surgical Podiatrist,
Infectious Diseases
Specialist, Plaster
Technician & Orthotist QH Podiarty resources
http://qheps.health.
qld.gov.au/odb/
hau/allied/html/
disciplines/podiatry.
htm
Endocrinologist
Vascular
Surgeon
Infectious
Disease
Specialist
Orthopaedic
Surgeon or
Surgical
Podiatrist
Appropriately
Trained
GP/Medical
Officer
Outreach Eye
Team
q Check for Retinopathy/
Diabetic Macular
Oedema
• Optimise control of
blood glucose and blood
pressure
Vascular Surgeon
Neurologist or
Orthotist
q Biomechanical & Foot
High Risk Foot
Endocrinologist
Primary Care
Coordinator
• Inform patient of
the indications for
urgent presentation to
Ophthalmologist
29
Refer to
Ophthalmologist/
Optometrist within
1 year of diagnosis,
then every 2 years if
no retinopathy, yearly
once retinopathy
identified
Urgent referral if:
• Diabetic
retinopathy greater
than the presence
of occasional
microaneurysms
detected
• Diabetic macular
oedema
• Declining visual
acuity
Standard Care
Pathway
NHMRC Clinical
Practice Guidelines on
the Management of
Diabetic Retinopathy 30
http://www.nhmrc.
gov.au/publications/
synopses/cp56 covr.
htm
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
Cardiovascular
Disease6
• Assess and treat risk
factors aggressively
Primary Care
Coordinator
Consider referral to
National Evidence
Based Guidelines
for the Management
of Type 2 Diabetes
Mellitus-Prevention
and Detection of
Macrovascular
Disease 6
q Smoking
Cardiologist
Endocrinologist
q Weight
Diabetes Educator
q Blood pressure
Dietitian
q Activity
Exercise Professional
q Lipids
q Depression
Psychologist
http://www.nhmrc.
gov.au/publications/
subjects/diabetes.htm
Lifestyle
Prescriptions19
Refer to Nephrologist
and Dietitian if
renal impairment is
detected (eGFR < 60)
ADA Standards of
Medical Care in
Diabetes 20069
http://care.
diabetesjournals.org/
cgi/content/full/29/
suppl_1/s4#SEC14
Diabetes
Management in
General Practice7
Evidenced Based
Practice Guidelines
for the Nutritional
Management of
Chronic Kidney
Disease49
http://hi.bns.health.
qld.gov.au/rbh/
dietetics/Clinical_
Information/Chronic_
kidney_disease_
guidelines.pdf
• Lifestyle
Reemphasize importance
of lifestyle changes
(consider lifestyle scripts)
GP/Medical
• Assess for atrial
Officer
fibrillation
6
• Resting ECG
Perform every 2 years in
people aged over 50 years
who have one or more risk
factors
• Consider aspirin6
Kidneys7,9
• Provide education and
treatment for:
GP/Medical
Officer
q Blood glucose control
q Blood pressure control
• Monitor
q Microalbuminuria
q Urinary tract infections
q GFR
• Review Medication
q Metformin
q ACE inhibitors
• Check cardiovascular risk
• Avoid NSAS and radiocontrast media
• Provide Medical Nutrition
Therapy
Dietitian
2.5 Table 7: Specific Issues
What
Content
Who
Referrals
Resources
Medications
• Review medications
q Side Effects
q Actions
q Dose
q Timing
q Contraindications
q Effectiveness
q Combinations
q Change in health status
GP/ Medical
Officer
Consider referral to
Diabetes
Management in
General Practice7
Endocrinologist
Accredited Pharmacist
ADEA (02) 6287 4822
for Home Medicines
Review
www.adea.com.au
30
Pharmacist
MIMS
Diabetes Educator
http://www.mims.
com.au/
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
Consider referral to :
Endocrinologist
Diabetes Australia
- Queensland
Diabetes Educator
MIMS
• Alter medications as
required
• Educate
q Side effects
Diabetes
Educator
q Importance of
Pharmacist
compliance
Oral Hypoglycaemic
agents (OHAs)
• Review blood glucose
control, HbA1c
GP/Medical
Officer
• Commence tablets as
required
• Educate and counsel
q Reasons
q Actions
Diabetes
Educator
Pharmacist
Pharmacist
q Side Effects
q Dose
q Timing
q Importance of
compliance
q Implications for
commercial driver’s
licence
Insulin
• Review blood glucose
control, HbA1c
Primary Care
Coordinator
Consider referral to :
Diabetes Educator
Diabetes Australia
- Queensland
• Commence insulin as
required
GP/Medical
Officer
Dietitian
MIMS
Primary Care
Coordinator
Endocrinologist
NDSS
• Educate and counsel
Pharmacist
NDSS Subagents
RN
Community
Pharmacists
q Actions
q Complications/side
Diabetes Resource
Health Professional
effects (insulin sites)
q Hypoglycaemia
q Dose
q Frequency
q Storage
q Needles-supply and
disposal
q How to administer
q Food
q Physical Activity
q Alcohol
q Sick days
q Travel
q Implications for
commercial driver’s
licence
31
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
Resources
Diet
• Provide General Nutrition
Education.
• Provide Medical Nutrition
Therapy
q Nutrition assessment
q Goals
q Individualised nutrition
prescription
q Counselling/education
q Evaluation
Primary Care
Coordinator
Dietitian
Refer to Dietitian
See section 3.2:
Dietitian
Australian Dietary
Guidelines27
Diabetes Australia Queensland
Healthy Eating
Workshops
Dietetic Practice
Guidelines for the
Management of Adults
with Type 2 Diabetes
Mellitus 26(endorsed by
DAA)
American Diabetes
Association, Position
Statement, Nutrition
Principles and
Recommendations 50
http://care.
diabetesjournals.
org/cgi/content/full/
diacare;27/suppl_1/s36
ADA Standards of
Medical Care in
Diabetes, 2006, 9
http://care.
diabetesjournals.org/
cgi/content/full/29/
suppl_1/s4#SEC7
Exercise
Primary Care
• Assess contraindications/
cardiac risk/ensure medical Coordinator
clearance for exercise
• Assess current/past
exercise patterns
• Explain the benefits of
exercise/motivate
• Provide exercise
prescription (consider
using a Lifestyle
Prescription)
• Educate and counsel
q Precautions
q Blood glucose
q Medication/insulin
q Food
q Foot wear
Refer to Cardiologist if
cardiac risk
Consider referral to
Exercise Professional
Group
Psychologist
Flexible Competencies:
RN
Diabetes Resource
Health Professional
Practice Nurse
Podiatrist
Dietitian
National Physical
Activity Guidelines for
Australians28
Lifestyle Prescriptions19
Standards of Medical
Care in Diabetes 20069
ADA Physical Activity/
Exercise and Diabetes 51
Psychological Issues
• Examine and address poor
adherence/poor control
• Consider psychological
issues
q Adjustment
q Depression
q Anxiety
q Stress
q Anger
q Cognition
q Behaviour
q Relationships
Consider referral to:
Psychologist
Support Group
Social Worker
Global Guideline
for Type 2 DiabetesPsychological Care,
IDF, 2005 37
http://www.idf.
org/webdata/docs/
IDF%20GGT2D.pdf
Primary Care
Coordinator/
Psychologist
32
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
• Address factors impacting
upon management
ADA Standards
of Medical Care
in Diabetes,
Psychological
Assessment and
Care,20069
http://care.
diabetesjournals.org/
cgi/content/full/29/
suppl_1/s4#SEC9
Canadian Diabetes
Association Clinical
Practice GuidelinesPsychological Aspects
of Diabetes41
http://www.diabetes.
ca/cpg2003/chapters.
aspx?psychologicalasp
ectsofdiabetes.htm
Australian Psychological
Society
Depression Anxiety
Stress Scales 21 and 4242
The Kessler
Psychological Distrress
Scale (K10)92
APA Practice
Guidelines for
the Treatment of
Psychiatric Disorders36
(American Psychiatric
Association)
q Family issues
q Work
q Adherence
q Adjustment
q Financial Impact
q Sexual implications
• Provide treatment/
counselling as required
• Monitor regularly
Sick Days
Provide management
strategies including;
• Blood glucose testing
• Medications
• Meals and fluids
• When to notify the Doctor
Primary Care
Coordinator
Consider referral to:
Diabetes Educator
Dietitian
Diabetes Resource
Health Professional
Practice Nurse
Nausea/Vomiting
• Consider medication
causes
• Assess, educate and
treat for gastroparesis if
appropriate
• Consider prokinetics
• Investigate cause further
GP/Medical
Officer
Consider referral to
Dietitian
• Preconception issues
q Blood Glucose control
q Medications
q Folate
q Educate re complications
of pregnancy, congenital
abnormalities and
complications of
diabetes (retinopathy,
hypertension,
nephropathy)
Primary Care
Coordinator
Pregnancy
Resources
Diabetes Australia
- Queensland
Guidelines for Sick
Day Management
Diabetes
Management in
General Practice7
Gastroenterologist
• Pregnancy
q Team care arrangement
33
Refer to:
Obstetrician,
Endocrinologist
Ophthalmologist
Diabetes Educator,
Dietitian
Paediatrician
Consider referral to:
Midwife
Position StatementThe Australasian
Diabetes in Pregnancy
Society (ADIPS)
Consensus Guidelines
for the Management
of Type 1 and Type 2
Diabetes in Relation
to Pregnancy,200533
ADIPS Gestational
Diabetes MellitusManagement
Guidelines32
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
What
Content
Who
Referrals
q Blood glucose control
Resources
http://www.adips.
org/
q Medications
q Eye review
q Monitoring
q Screen for and address
complications of
pregnancy, congenital
abnormalities
q Screen for and manage
complications of
diabetes (retinopathy,
hypertension,
nephropathy)
q Delivery
• Post partum follow up
q Blood glucose control
q Contraception
q Ongoing assessment
and management as per
Standard Care Pathway/
as required
Driving
• Discuss and assess
effects of:
GP/Medical
Officer
Diabetes
Management in
General Practice
q Treatment
Assessing Fitness to
Drive 200343
q Medications
q Complications
www.austroads.com.
au/aftd/index.htm
q Hypoglycaemia
q Eyes
Diabetes Australia
- Queensland
• Assess fitness to drive
according to Driving
Licensing Authority
Standards
• Complete and provide
patient with Medical
Certificate. Retain a copy
in patient record. Inform
and counsel patient of
outcome
Travel
Provide advise re
• Planning
Primary Care
Coordinator
• Insurance
Diabetes Educator
• Food
Diabetes Resource
Health Professional
• Medications
RN
• Monitoring
• Medical letter
Sexual Issues
I am having sexual
problems
Consider referral to:
• Optimise blood glucose
control
GP/Medical
Officer
Practice Nurse
Primary Care
Coordinator
Consider referral to:
• Consider micro vascular
and macrovascular causes
• Review medications
• Offer treatment as
appropriate and provide
counselling
34
Endocrinologist
Diabetes Australia
- Queensland
Diabetes
Management in
General Practice7
Relationships
Australia
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Chapter 3 The Multidisciplinary Team
3.1 Diabetes Educator
Goals:
The goal of diabetes education is to provide the individual with the necessary knowledge, skills and attitudes to carry out
the daily medical and lifestyle recommendations for effective self management of Type 2 diabetes.
The Objectives of Diabetes Education are
1 To improve metabolic control (blood glucose, lipids, blood pressure)
2To help decrease the risk of complications
3To improve quality of life
4To develop the knowledge and skills required to make appropriate choices to maintain or improve health
5 To ensure care is coordinated
6To increase community awareness of diabetes and help to reduce the risk of diabetes
7 To manage and develop diabetes services
Definition of a Diabetes Educator:
A Diabetes Educator is a full member of the Australian Diabetes Educators Association (ADEA) who is qualified to practice
in nursing, dietetics, podiatry, psychology, medicine or Aboriginal Health. A Diabetes Educator has an acquired core
body of knowledge and skills in biology and social sciences, the principles underpinning teaching and learning, skills in
communication and counselling and experience and advanced knowledge in the care of people with diabetes and those
at risk of developing diabetes. The role of diabetes education is part of their requirement of employment.52
A Credentialled Diabetes Educator™ is a full member of the ADEA who has completed an ADEA accredited post graduate
Diabetes Education Course and in addition, has completed a supervised period of clinical placement and activities which
fulfil the continuing education and professional development requirements of the ADEA Credentialling Program.52
Qualifications of a Diabetes Educator:52
The formal qualifications of a health professional undertaking the role of a Diabetes Educator should include:
• Registered or endorsed to practice within their primary health field
• Full member ADEA
• Be Credentialled with the ADEA or working towards credentialing status. The ADEA recommends that all
health professionals practising in the Diabetes Educator role attain the experience, academic and professional
requirements necessary to be a Credentialled Diabetes Educator™
Core Competencies of Diabetes Educators53:
Whether diabetes education occurs in a major metropolitan, tertiary referral institution or a remote and isolated
community, key elements of practice pertaining to education are required to occur including:
• Provision of optimal clinical care to people with diabetes
• Provision of safe, effective client centred education to people with diabetes
• Fulfilling a health promotion and community education function
• Skills to organise and manage a diabetes service
• Be professional responsible and accountable
53
The Role of the Diabetes Educator in the Management of Adults with Type 2 Diabetes:
Diabetes education is a speciality practice requiring advanced knowledge, counselling and teaching skills. The role of
the Diabetes Educator includes the provision of diabetes education, clinical care, research, policy development, service
planning, and management as being essential to the future health of people with diabetes, people at risk of developing
diabetes and the wider community.52
The primary role of the Diabetes Educator is to integrate diabetes education and treatment using a holistic approach and
multidisciplinary team in accordance to professional standards, implementing problem solving approaches and evidence
and best practice strategies.52 The ADEA has clearly defined the role of the Diabetes Educator which includes:
35
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Clinician:
• Assessing clinical situations as well as assessing and addressing non-clinical variables that influence health
• Assessing fixed and modifiable predisposing factors to hyperglycaemia, hypoglycaemia, complications and
indicators of diabetes complications
• Liaising with the client, family, carer and other members of the diabetes care team in planning, implementing
and monitoring diabetes care
Educator:
• Assessing the current level of knowledge, attitude, skills and behaviour of the client and significant others in
relation to diabetes management
• Consulting with a client about whether, when, where and how to intervene
Counsellor:
• Using impartial, reflective and empathetic listening
• Clarifying and reflecting
• Providing feedback, constructive and empowering
Care Coordinator:
• Identifying needs that are not being met
• Referring to other specialist nursing, medical or allied health professionals with appropriate skills
• Regularly reviewing client progress
• Communicating and reporting to the health care team
Advocate:
• Considering, identifying and promoting the person’s best interests within and beyond the context of the
immediate consultation
• Promoting the interests of Australians with diabetes within and beyond the health sector
Consultant:
Providing expert advice and resource information to:
• Clients and their significant others
• Health professionals and colleagues
• The wider community
• Government and non-government organisations and agencies
• Developing specific diabetes care policies and procedures
Research and Quality Improvement:
• Undertaking clinical research
• Evaluating and utilising evidence and consensus recommendations in practice
• Participating in collaborative research and clinical trials
• Conducting QI programs and using the findings to inform and improve practice
Education:
Developing, facilitating and participating in:
• Client focused individual and group education programs
• Health Professional continuing education programs
• ‘Train the Trainer’ programs
• Programs introducing new diabetes care technology
• Continuing self-education and professional development
Management:
• Staff and resources
• Participation in employer policy/health service planning
• Developing of clinically focussed cost-effective programs to benefit the client, employer and the
community
• Maintenance of appropriate statistical records
36
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Leadership:
• Acts as a role model for colleagues and peers 52
Education programs developed and implemented by Diabetes Educators must meet the ADEA National Standards for
Diabetes Education Programs (2001).14 These standards are divided into three key areas that include:
• Outcome Standards – changes that can be demonstrated as a result of diabetes education
• Process Standards – processes required to meet the standards of education delivery, effectiveness of education,
it’s timeliness and appropriateness
• Structure Standards – resources required to support the processes and outcomes.14
The International Diabetes Federation has identified six key standards pertaining to the delivery of diabetes education
which include:
1 Make structured patient education an integral part of the management of all people with Type 2 diabetes:
• From around the time of diagnosis
• On an ongoing basis, based on annual assessment of need
• On request
2Use an appropriately trained multidisciplinary team to provide education to groups of people with diabetes, or
individually if group work is considered unsuitable. Where desired, include a family member or friend.
3Include in education teams a health-care professional with specialist training in diabetes and delivery of education
for people with diabetes
4Ensure the education is accessible to all people with diabetes, taking account of culture, ethnicity, psychosocial,
and disability issues, perhaps delivering education in the community or a local diabetes centre, and in different
languages
5 Use techniques of active learning (engagement in the process of learning and with content related to personal
experience), adapted to personal choices and learning styles
6Use modern communications technologies to advance the methods of delivery of diabetes education37
Referrals:
Ideally all patients should be referred to a Diabetes Educator upon diagnosis of diabetes and than be routinely reviewed.
Referrals maybe generated from health professionals, health agencies or clients themselves. Diabetes Educators maybe
referred to through a Team Care Arrangement in which case, patients can be reimbursed for services provided by private
educators through Medicare.
Referral to a Diabetes Educator is appropriate when there is:
- New diagnosis of diabetes or Impaired Glucose Tolerance or Impaired Fasting glucose
- Self management education indicated
- HbA1c > 8%
- Hypoglycaemic episodes
- Onset of complications
- Psychological, social, medical or adjustment issues/changes
- Difficulties with managing diabetes anticipated/experienced
- Change in management such as commencing insulin/ changes to other medications
- Prior to planned surgery or travel
- A person at risk for developing diabetes
- Patient is planning pregnancy/pregnant
- A woman with a past history of Gestational Diabetes
Flexible Competencies
In some areas of Queensland and in some circumstances, access to a Diabetes Educator is not always possible, requiring
other health professionals to provide diabetes education. The other health professionals that can provide some
elements of education are listed in the table under flexible competencies. These professionals can provide the elements
of diabetes education within their professional scope of practice. These professionals are responsible for ensuring
they provide accurate education within their scope of practice or for referring to other professionals if they do not have
the expertise in dealing with specific problems. They are also responsible for ensuring the person has understood the
education provided, correcting misconceptions and planning further education sessions if required.
37
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Definition of a Diabetes Resource Health Professional:
A Diabetes Resource Health Professional may be an Associate Member of the ADEA, who has a professional interest and
has attended diabetes-related professional activities pertaining to the care and management of diabetes mellitus. They
maybe supported by a Diabetes Educator. They may provide limited education and support for people and their families
with diabetes working within a reduced scope of practice compared to that of the Diabetes Educator. They may act as
an effective referral base to Diabetes Educators and/or diabetes centres. An example of a Diabetes Resource Health
Professional would be a Registered Nurse working within a General Practice setting.
Definition of a Nurse Practitioner:
A Nurse Practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and
expanded clinical role. The Nurse Practitioner role includes assessment and management of clients using nursing
knowledge and skills and may include but is not limited to:
• The direct referral of clients to other health are professionals
• Prescribing medications
• Ordering diagnostic investigations
(Policy on the Regulation of Nurse Practitioner in Queensland, QNC, 2005)54
3.2 Dietitian
Rationale
Overweight and obesity are strongly linked to the development of Type 2 diabetes. The prevalence of Type 2 diabetes is
three-seven times higher in obese than normal weight adults. Moderate weight loss improves glycaemic control, reduces
the risk of cardiovascular disease and can prevent the onset of diabetes in those with prediabetes. 55
There is unequivocal evidence that Type 2 diabetes can be delayed and possibly prevented by lifestyle interventions
generally resulting in weight loss and increased physical activity in those at high risk of developing diabetes. 56 The
United States Diabetes Prevention Program reported a 58% reduction in the incidence of diabetes when participants
were treated with lifestyle interventions including improved diet and exercise compared with a 31 % reduction in the
incidence of diabetes for the metformin treated group. Weight loss was the main predictor of diabetes risk reduction.
For every kilogram lost, risk of diabetes was reduced by 13%. The primary approach to achieving weight loss is through
diet and an increase in physical activity. The lifestyle intervention also reduced cardiovascular disease risk factors with
a reduction in blood pressure and triglyceride levels and reduced the need for medication for lipid and blood pressure
control.57
The Cochrane Review of Dietary Advice for the Treatment of Type 2 Diabetes Mellitus in Adults reports that dietary advice
plus exercise leads to a significant decrease in glycated haemoglobin of 0.9% at six months and a 1.0% decrease at
twelve months.56
There is growing evidence that the provision of Medical Nutrition Therapy (MNT) provided by dietitians can reduce the risk
of developing diabetes and improves diabetes outcomes in those with existing diabetes. Dietitians can help to achieve
lifestyle habits that lead to significant reductions in the incidence of diabetes related health outcomes and improved
cost effectiveness.58
Goals of Dietary Intervention in the Management of Type 2 Diabetes
The goal of nutrition intervention in the management of diabetes is to promote optimal client well being, reduce the risk
of complications and assist the management of existing complications.
The objectives of nutrition intervention are
1 To achieve and maintain optimal nutritional status
2To contribute to optimal metabolic control (blood glucose, lipids, blood pressure)
3To achieve and maintain desired body weight/waist circumference/ required weight reduction
4To achieve and maintain positive lifestyle behaviour changes including healthy food choices and physical activity
Role of the Dietitian in the Management of Adults with Type 2 Diabetes
Dietitians play an integral role in the management of people with Type 2 diabetes. The role of the dietitian is to facilitate
the development of knowledge, skills, attitudes and behaviours to enable the person with diabetes to make appropriate
food choices with an outcome of better diabetes management and a reduced risk of diabetes complications.13 The role of
the dietitian involves nutrition assessment, intervention, counselling, communication and evaluation. The dietitian aims
to provide interventions that:
38
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
• are outcome focused
• are consistent with evidence based approaches
• are based on the therapeutic aspects of diet for both treatment and prevention of disease
• are in accordance with professional standards and best practice guidelines
• promote a self management philosophy.
The nutritional management of Type 2 diabetes includes both general nutrition education and MNT 13
General Nutrition Education
General nutrition education can be provided by dietitians and qualified Diabetes Educators. General nutrition
education is a component of diabetes self management and can be provided in groups or individually. Individuals from
diverse cultural and linguistic backgrounds requiring an interpreter, who have impaired vision or hearing, significant
psychological/psychiatric conditions or who are actively non compliant are best seen individually. It is commenced at
diagnosis and continues on an ongoing basis.
Topics include13
• General information on the role of food in diabetes management
• Basic food composition
• General aims of dietary intervention
• Prevention and treatment of hypoglycaemia
• Role of carbohydrate containing foods with respect to medication
• Adjustment to carbohydrate intake with respect to usual physical activity
• Appropriate food choices for illnesses of short duration
• Tips for cooking, shopping, eating out and recipe modification to promote healthy food choices
• General recommendations regarding food requirements for travel, during fasting, shift work, religious or other
occasions
• General recommendations regarding alcohol consumption.
Medical Nutrition Therapy
Medical nutrition therapy (MNT) is individualised clinical nutrition intervention which can only be provided by qualified
Dietitians eligible for the Accredited Practicing Dietitian credential.13
People with Type 1 diabetes, Type 2 diabetes, Gestational Diabetes, co morbidities and/or complications, specific life
stage nutrition requirements or who are nutritionally compromised require MNT. A joint statement by the ADEA and
DAA recommends that all people with diabetes should have access to a dietitian for MNT in order to achieve optimal
nutritional management as part of their diabetes care. 13
MNT includes assessment, prescription, behavioural counselling and development of knowledge and skills. Detailed
guidelines for nutrition assessment and intervention are provided by the Dietitians Association Australia (DAA) Dietetic
Practice Guidelines for Adults with Type 2 Diabetes Mellitus.26
Nutrition assessment includes an assessment of the diabetes treatment regimen, anthropometric data, diet history,
blood glucose, glycosalated haemoglobin, blood pressure, lipids and renal function. Medical history and management,
knowledge, physical activity, psychological and social factors are also assessed.
The dietitian helps the patient to identify and agree to goals for long term management. This in conjunction with
the nutrition assessment forms the basis for the nutrition prescription which is then developed and implemented.
The nutrition prescription includes food and meal planning education based upon the individual’s required energy,
macronutrient and micronutrient intake. Specific guidelines are provided as required to addresses the management
of weight, blood glucose, lipids and blood pressure. Self management education is provided to enable the individual
to make required changes to their eating habits and to encourage self monitoring of blood glucose. If the patient has
no medical limitations, the dietitian may provide guidelines for physical activity or refer the patient to an exercise
physiologist or other exercise professional for an exercise prescription.
The dietitian will provide other members of the team with information regarding their assessment and intervention.
Follow up appointments will be organised by the dietitian to evaluate the effectiveness of medical nutrition therapy
(MNT) and to adjust therapy as required. Ongoing evaluation, education and communication will be provided and
recommendations made to the referring practitioner as appropriate.
39
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Qualifications
Mandatory
Possession of a degree or post graduate qualification in Nutrition and Dietetics or recognised equivalent and eligibility
for the status of Accredited Practicing Dietitian as governed by the Dietitians Association of Australia (DAA).
Highly Desirable
Accredited Practicing Dietitian (APD)
A firm commitment to continuing education in the area of diabetes in either a formal of informal context. Membership to
the Australian Diabetes Educators Association.
Standards of Professional Practice
To practice as a dietitian, dietitians must meet the Dietitians Association Australia Competency Based Standards
for Entry Level Dietitians.59 The Code of Professional Conduct provides guidelines on legal responsibilities, ethics,
professional conduct and practice for Accredited Practicing Dietitians.60
Referrals
Ideally all patients should be referred to a dietitian upon diagnosis of diabetes. The ADEA and DAA recommend that all
people with diabetes should have access to a dietitian for MNT in order to achieve optimal nutritional management as
part of their diabetes care.13 As a minimum patients must be referred to a dietitian if
- New Diagnosis
- HbA1c > 8%
- Episodes of hypoglycaemia
- Obesity
- Complications
- Patient is planning pregnancy/pregnant
- Change in management such as commencing insulin/ changes to other medications
- Sudden unexplained weight loss or gain
The DAA Dietetic Practice Guidelines for Type 2 Diabetes recommend that patients with Type 2 diabetes be referred to
a dietitian within the first month after diagnosis. A series of 2-3 visits following diagnosis is recommended totally 2.5
hours. A review three months after initial dietary intervention should be scheduled to evaluate the effectiveness of
nutritional management upon anthropometric and metabolic parameters. People with diabetes should receive ongoing
MNT every 6-12 months. Patients identified as requiring basic care should have at least one visit of 1-1.5 hours and
receive a follow up appointment after three months. Basic care is appropriate for self motivated individuals with near
target blood glucose levels, a good diabetes knowledge base, good nutrition and physical activity habits and blood
pressure and lipids within acceptable ranges. 26 The DAA Dietetic Practice Guidelines for Type 2 Diabetes outlines the
assessment and intervention recommended for each visit.
Note: Under Commonwealth Medicare arrangements, dietetic services are reimbursable items. To receive
reimbursement, services must be provided by an Accredited Practising Dietitian working in private practice who
has registered with Medicare Australia. The patient must have been referred to the dietitian through a Team Care
Arrangement.
Flexible Competencies
Where an APD is not available or access limited, qualified Diabetes Educators should facilitate access to an APD to
ensure appropriate nutritional management of the client. Consider using teleconferencing or other technology.
When access to an APD is not possible, other health professionals may be required to provide General Nutrition
Education. It is the responsibility of professionals to ensure they have the ability to carry out assessments and
interventions within their professional scope of practice and supply information that is accurate and consistent with the
current national recommendations/guidelines. It is the responsibility of the professional to refer to other professionals if
they do not have expertise in dealing with specific problems.
MNT can only be provided by a qualified dietitian. Dietitians are the professional group most skilled to effectively
integrate information from all areas to optimise the nutritional management of people with diabetes.
40
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
3.3 Indigenous Health Worker
Rationale
The prevalence of diabetes is two to four times higher in Aboriginal and Torres Strait Islander peoples than the nonindigenous population. Factors that contribute to the high incidence of disease in Aboriginal and Torres Strait Islander
peoples include lack of access to health care, social, political and environmental factors and specific health risk factors.
All health services have a responsibility to ensure they provide effective and appropriate services to the Aboriginal and
Torres Strait Islander people. These services should address any barriers including, economic, distance and cultural that
may limit access for Aboriginal and Torres Strait Islander people. 3
For Aboriginal and Torres Strait Islander peoples, it is culturally appropriate for diabetes education to be delivered
by trained Indigenous health workers. Indigenous health workers are the best placed to consider cultural factors,
environmental barriers and social obstacles to implementing interventions. The involvement of an Indigenous health
worker is recommended in any education intervention provided to Aboriginal and Torres Strait Islander people with
diabetes.
Goal of the Indigenous Health Worker in the Management of Type 2 Diabetes
To prevent and improve the management of diabetes in the Aboriginal and Torres Strait population.
Objectives
• To integrate diabetes management with cultural issues
• To coordinate health care services across service sectors and the continuum of care
• To improve lifestyle choices
• To increase self management including self monitoring
• To reduce the risk and onset of complications in this population
• To improve metabolic control(blood glucose, lipids, blood pressure)
• To increase knowledge of diabetes
• To reduce the impact of diabetes upon quality of life
The following is taken from The Queensland Health Aboriginal Health Worker and Torres Strait Islander Health Worker
Customised Competency Standards, May 1999.61
Role of the Indigenous Health Worker
Aboriginal health work and Torres Strait Islander health work is carried out in many different locations throughout
Queensland – rural, remote, provincial, urban, coastal, inland and island. In each different district, the role of the health
worker may vary.
Each local community health worker faces the challenge of integrating health practice within the unique cultural needs
of his/her community. Some health workers work alone, others in groups or teams and some are closely supervised by
other health professionals or managers. Some health workers must make very complex decisions alone and need to be
able to perform high level clinical interventions.
All health workers provide direct services to individuals, families and communities, plan to meet future health needs,
promote wellbeing and prevent ill health. Not all health workers undertake clinical practice, as the term “health” is used
holistically and includes environmental, spiritual, psychological and social wellbeing.
Indigenous health workers may perform the role of care coordinator and/or case- manager for Aboriginal and Torres Strait
Islander peoples and they can provide education and support that is culturally appropriate. They are able perform a
liaison role with other health service providers and act as an advocate for Aboriginal and Torres Strait Islander needs and
issues.
In consultation with health workers across the state and specific service providers (Queensland Health), national
competency standards have been adapted to Queensland Health standards and match each level of the Queensland
Health Indigenous Health Worker Career Structure.
The Indigenous Health Worker Career Structure for Queensland Health provides core responsibilities and roles for Health
Workers employed at various levels of the structure.
Level – 002 Health Workers at this level have a supervisor and they work in teams.
Level – 003 Health Workers at this level are less likely to have a supervisor and are more likely to work alone.
Level – 004 Health Workers at his level work very independently and many supervise the work of others. They are likely to represent and lobby on behalf of their organisation and or the community. They may do some
program development.
41
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Level – 006, 007 This is a high level of work with a high level of responsibility including management of staff and
programs. Work is more complicated, and Health Workers must manage difficult situations with little
support from others.
Diabetes Health Workers
Diabetes prevention and management services are delivered under direction, which may be provided as close
supervision or established guidelines that limit discretion.
Diabetes Health Worker – Advanced 004/TO2
Health Workers at this level have highly developed skills, knowledge and training in a specialised area.
Diabetes Health Worker – 006
The Diabetes Health Worker is responsible for the implementation, development and coordination of diabetes health or
more programs in specific care in a District or across District basis. Coordinating and ensuring the standard of delivery of
these programs in the communities is also a major responsibility.
Competencies
Deliver Diabetes Health Care
The following are competencies required to deliver diabetes health care services either as a separate program or within a
broad services model.
1 The provision of information to a community about diabetes prevention and management health services.
2Assess the need for diabetes prevention and management health services in the community
3Plan and implement care in consultation with other health professionals and other key community members.
Manage Diabetes Health Care
The following competencies are required to deliver, monitor and evaluate a broad range of diabetes services either by a
separate diabetes prevention and management health care program or within a broad service model.
1 Monitor and plan diabetes prevention and management health services
2Ensure diabetes prevention and management health services are delivered appropriately
3Develop expertise of staff in diabetes prevention and management.
Nutrition Health Care
Nutritional Health Care is delivered under direction which may be provided as close supervision or established
guidelines, which limit discretion.
Nutrition Health Worker – Advanced 004/TO2
Health Workers at this level have highly developed skills, knowledge and training in a specialised area.
Nutrition Health Worker – 006
The Nutrition Health Worker is responsible for the implementation, development and coordination of nutritional health or
more programs in specific care in District or across District basis. Coordinating and ensuring the standard of delivery of
these programs in the communities is also a major responsibility.
Competencies
Deliver Nutritional Health Care
The following are competencies required:
1 Provide information to the community about nutrition.
2Assess nutritional status of individuals and a community
3Plan and implement care
4Plan and implement change
Provide Nutritional Health Care
The following are competencies required:
1 Undertake activities according to a plan
2Give nutrition education
42
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
3Ensure nutrition and physical activity choices are available to the community and promote these choices
4Assess the nutritional status of the community
5 Support environmental changes which support nutrition and health
6Provide feedback on progress to supervisor and community on implementation of plan
7 Support improved access to healthy food and exercise facilities/ opportunities
Manage Nutritional Health Care
The following are competencies required:
1 Monitor and plan services to improve nutrition and health.
2Ensure nutritional services are appropriate
3Advocate on nutrition issues
Referrals:
All Aboriginal and Torres Strait Islander Peoples with diabetes particularly those in rural and remote areas should be
given the opportunity to access an Indigenous health worker.
With the high incidence of diabetes in Aboriginal and Torres Strait Islander Peoples, all health workers who provide
clinical care will be involved in the management of people with diabetes and can deliver care according to the
competencies outlined above. They should seek advice and appropriately refer to other health and diabetes services
providers in their area.
In remote areas, the health worker may be the main care provider with remote area nurses, doctors and other health
professionals visiting. They will have highly developed skills and are able to use more difficult competencies in different
situations.
3.4 Podiatry
Rationale
Diabetic foot complications are the most common reason for diabetes related complication hospital admissions. (Level
III-2 Evidence)40 Hospitalized diabetic foot complications are extremely costly, i.e.:
• Internationally recognised average length of stays over 15 days (III-2),62,46
• Average diabetic foot ulcer treatment costs (without amputation) range from approx $12 500 (1994 Australian
study)(III-2)40 to US$28 000(1999 study)63
Lower limb amputation in people with diabetes constitutes about 50% of all lower-limb amputations (III-2) 40,64 or an
annual incidence of approximately 0.2% – 1.4% in the diabetic population (III-2). 63 About half of those having an
amputation will have a subsequent amputation on the other limb (III-2)40 and some studies suggest a 40 - 50% five year
survival rate post-amputation (III-2).62
Almost all amputations are preceded by a foot ulcer (III-2).40 Approximately 15% of diabetics will develop a foot ulcer or
an estimated 1-4% annual incidence (III-2).63 Peripheral neuropathy, with or without peripheral vascular disease (PVD)
and foot deformity, is a major underlying risk factor in people with diabetes developing a foot ulcer (1).40,62,63 Peripheral
neuropathy affects approximately 12% of people with diabetes at diagnosis and 30% after 12 years (II).40 PVD affects
approximately 8% at diagnosis and up to 45% after 20 years duration (III-2).40
Studies have demonstrated regular Podiatry care of patients with high risk diabetic feet (as opposed to control ‘high
risk’ groups without podiatric care), reduces: re-ulceration, depth and infection rates of presenting ulcers and hospital
admission days (II).63
The European St Vincent Declaration on Diabetes, as well as the Australian National Diabetes Strategy and
Implementation Plan, have targeted the goal of reducing amputation rates by 50% by the year 2010. 64 Evidence suggests
coordinated multi-disciplinary foot care teams (necessitating a minimum of a physician and podiatrist) can reduce lower
limb amputation rates by up to 50% and ulceration costs up to 85% (III-2).40,65
If these targets are to be recognised then the basic evidence based practice (EBP) of diabetic foot risk assessment,
identification and management of those with feet ‘at risk’ or of higher risk of ulceration and amputation needs to be
prioritised.40
Unfortunately, studies suggest nearly 56% of people with diabetes do not receive an annual foot assessment and up
to 84% of persons presenting to hospital with a diabetic foot complication had an incomplete basic foot and/or ulcer
assessment (III-2).40,46 A recent retrospective study of a major tertiary Australian hospital highlighted the inadequate
coordination of multi-disciplinary care of patients admitted with diabetic foot complications, i.e. patients were admitted
under 11 different medical or surgical units, with an average of one interdepartmental referral per admission (IV).46
43
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
A number of tertiary Australian hospitals have addressed this lack of coordination by establishing Podiatry managed
Multi-disciplinary Diabetic Foot Ulcer Clinics. The podiatrist’s responsibilities include: triaging assessments,
coordinating case management and care by other specialties, and administrative management tasks. These podiatry
managed clinics have anecdotally improved cost effectiveness and clinical outcomes of diabetic foot intervention (Expert
Opinion (EO). 66
These Queensland Health Guidelines for Care and Referral of Adults with Type 2 Diabetes have been developed to
improve the knowledge required by primary care health professionals to implement evidence based assessment,
identification and management of the diabetic foot. This will subsequently reduce the substantial morbidity and costs
associated with diabetic foot complications across Queensland.
For further detailed evidence regarding the identification and management of the diabetic foot, please consult the Diabetes
Australia’s ‘National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus- Part 6: Identification and
Management of Diabetic Foot Disease’.40 http://www.diabetesaustralia.com.au/education_info/nebg.html
Goals of Podiatry Management of Type 2 Diabetes
The goal of podiatry management of Type 2 diabetes is to “reduce the prevalence of foot and lower limb complications in
Australians with Diabetes” 31
The podiatrist aims to provide expert care, advice and education for people with diabetes and other health professionals
involved with the diabetic foot.
The objectives of the Podiatrist are to:
1 Accurately assess and identify the Foot Risk Status
2Promote optimal metabolic control (blood glucose, lipids, blood pressure)
3Ensure appropriate plantar pressure reduction and footwear
4Increase knowledge and self care of diabetic foot complications
5 Increase awareness of the need for preventative foot care practices
6Promote EBP multidisciplinary team approaches to management
7 Promote infection control
8Achieve optimal wound care environments.
Role of the Podiatrist in the Management of Adults with Type 2 Diabetes
The role of the podiatrist involves providing and coordinating expert management of the person with diabetes across the
continuum of care. The specific podiatric management, and that of the multi-disciplinary team, depends entirely on the
patients assessed level of diabetic foot risk.
This guideline has primarily adopted the Diabetes Australia’s ‘National Evidence Based Guidelines for the Management
of Type 2 Diabetes Mellitus- Part 6: Identification and Management of Diabetic Foot Disease’ 40 categories for determining
the foot risk of people with diabetes, i.e.:
I Low Risk – people without any of the below defined complications 40
II
At Risk – people with
• Peripheral neuropathy or
• Peripheral vascular disease or
• Foot deformity 40
IIIHigh Risk – people with
• Foot deformity with peripheral neuropathy or peripheral vascular disease or
• Previous foot ulcer or amputation40
IVAcute Complication – people with
• Current foot ulcer +/- infection or
• Charcot/Neuroarthropathic Joint or
• Dry Gangrene or Acute Ischaemia 46
The diabetic foot risk can be easily assessed utilising foot risk assessment tools similar to the ‘Basic Foot Screening
Checklist’ (Appendix I). 47
The diabetic foot risk assessment can be performed by other primary healthcare professionals, i.e.:
• GPs and Diabetes Educators
• Competent Nurses, Indigenous Health Workers, and Allied Health Assistants who have attended education sessions
and passed competencies on the use of the diabetic foot risk assessment.
44
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Podiatric care has a role in all diabetic foot risk categories – although, the necessity for podiatry management is more
vital as the foot risk increases. The health sector in which podiatric care is provided (i.e. Private or Public, Community or
Hospital) may change to reflect the diabetic foot risk. Referral to the ‘Integrated Diabetic Foot Continuum of Care Clinical
Pathway’ (Appendix 2)48 is advised to determine the most appropriate and timely podiatry sector to access.
‘Low Risk’ Diabetic Foot Management
The international consensus for ‘low risk’ diabetic foot assessment and management is a minimum diabetic foot
assessment and inspection once per year (EO). 40
It is important to remember that “improvement in glycaemic control is effective in reducing the risk of the development
and progression of neuropathy (and peripheral vascular disease) in Type 2 diabetes” (II). 40
It is recommended that all people with diabetes should receive specific foot-care education. High level evidence
concludes foot-care education for persons with diabetes improves knowledge and self-management of their diabetic foot
condition and may prevent diabetic foot ulceration and amputation (I). 40
Education can be provided individually or in group situations. Education should allow the patient to understand and/or
implement various foot management issues and strategies.
Topics of diabetic foot education should include:
• Diabetes effects on foot health
• Recognising risk factor signs and symptoms in foot complications
• Understanding the importance and impact of controlling hyperglycaemia, hyperlipidaemia and hypertension on
foot health
• Basic daily foot inspection and care to maintain foot health
• Understanding the importance of appropriate footwear choices
• Identifying when and which health professionals to access when diabetic foot problems occur (especially
infections). 31
‘Low Risk’ diabetic foot assessment, education and management may not require podiatry involvement, although it is
advisable for patients to attend a podiatrist (in a group or individual situation), at least once, for early assessment and
education after initial diagnosis.
‘At Risk’ Diabetic Foot Management
The international consensus for ‘at risk’ diabetic foot assessment and management is that a diabetic foot risk
assessment and inspection should occur every 3 to 6 months (EO).40 The benefits of managing ‘at risk’ feet regularly
include the:
• application of preventative practices,
• monitoring the extent of foot risk, and,
• early identification and treatment of specific foot problems, limiting the risk of ulceration and amputation.
“The podiatrist is an essential member of the multi-disciplinary team” and should be regularly involved in these above
‘at risk’ assessments and inspections (II).40
The ‘at risk’ foot progression to a ‘high risk’ or ‘acute complication’ foot is commonly recognised to result from events
causing repetitive stress or friction on areas of high plantar pressure, callus and/or foot deformities (III-2).40 These events
occurring on an ‘at risk’ foot is frequently the precipitating factor which leads to ulceration and amputation (III-2).40
The podiatrists’ role in the ‘at risk’ foot should primarily concentrate on limiting factors that advance the development of
the ‘high risk’ foot. The podiatrist may do this utilising various management techniques:
• Consistently reinforcing the above education (See ‘Low Risk’ Diabetic Foot Management) and the importance of self
foot-care behaviour (I) 40
• Ensuring appropriate footwear provision –
–“plantar pressure can be reduced with moderately priced commercially available cross trainer shoes” (III-2) 40
–“therapeutic shoes in combination with podiatry care decrease amputation” (II) 40
• Construct insoles or orthotics to further reduce plantar pressures - “customised insoles have been shown to reduce
ulcer recurrence” (III-2) 40
• Manually debride callus (III-1) 31,40,46 and major pathological nails
• Ensure coordination of appropriate referrals to specialists for more severe ‘at risk’ foot complications (See Table 6
Complications- Feet )
45
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
‘At Risk’ diabetic foot assessment, education and management should involve regular podiatry management to apply
routine preventative education, plantar pressure reduction and risk monitoring techniques. A podiatrists scope of
practice is frequently best placed to provide coordination for ‘at risk’ diabetic foot management.
‘High Risk’ Diabetic Foot Management
The international consensus for ‘high risk’ diabetic foot management is that a diabetic foot examination should occur
every one to three months (EO).63,67
People with diabetes who have foot ulcers or with high risk feet should be cared for by a multi-disciplinary service which
should include a physician and podiatrist and have ready access to a specialist nurse, orthotist and surgeon (I). 40
Recommendations to prevent amputation in people with high risk feet include regular foot examination, education,
suitable footwear and orthotics, podiatry services, and early ulcer treatment including surgery where indicated (I).40
An evidence based multi-disciplinary foot-care team can :
• Improve ulcer healing rates
• Reduce ulcer recurrence rates
• Reduce amputations by up to 50% (III-2).40
The podiatrist should seriously consider utilising all the aforementioned management techniques used for the ‘at risk’
foot.
‘Acute Complication’ Diabetic Foot Management
Initial ‘acute complication’ diabetic foot management should occur as soon as practically possible and be reviewed
normally every 1-2 weeks, via a multi-disciplinary team (EO).46,67 Every new ‘acute complication’, or ‘acute complication’
with delayed healing, should be reassessed for:
1 Peripheral Neuropathy (I)
2Peripheral Vascular Disease (I)
3 Foot Deformity (I)
4Infection (I). 40,46
A number of ‘acute complication’ management principles should be considered at each treatment, as appropriate such
as :
• Debridement (eg sharp) of wound (III-1)
• Dressing regime (eg moist wound dressing) (EO)
• Pressure Off-Loading (eg Removable Cast Walker) (III-1)
• Antibiotics (i.e. for infection) (I).46
A number of specialist referrals should be considered with ‘acute complication’ management including:
• Vascular, Orthopaedic or Podiatric Surgeons
• Endocrinologist, Diabetes Educator or Dietitian
• Plaster Technician or Orthotist
• Radiologist
• Infectious Diseases Specialist (III-2).40
Note: Ulcers ‘probed’ to bone or with >2cm surrounding cellulitis should be urgently referred to a Hospital MultiDisciplinary High Risk Foot Team.62
This guideline recommends the use of Wraight et al’s (2005) ‘Clinical Assessment, Investigations & Management of
Acute Diabetic Foot Complications’ (Appendix 3) (I) 46 tool for each ‘acute complication’ presentation. The tool is a
“multi-disciplinary, evidence-based, clinical guideline for the assessment, investigation and management of acute
diabetes related complications”. (I) 46
The ‘high risk’, and ‘acute complications’ diabetic foot assessment, investigation and management, necessitates regular
podiatry management in the community and/or hospital environment. Podiatrists’ are often best placed to triage acute
diabetic foot complications prior to, or at, an admission, resulting in a reduction in:
• inadequate coordination of care
• lengthy waiting periods for outpatient specialist appointments
• overall costs to the health system
• amputation and associated morbidity (EO). 66
46
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Qualifications
Mandatory
Possession of a degree, or equivalent, in Podiatry, recognised by registration with the Podiatrists Board of Queensland.
Highly Desirable
A firm commitment to continuing education in the area of diabetes in either a formal of informal context. Recognition by
the Australian Podiatry Association as an Accredited Podiatrist within the Accredited Podiatrist Program or equivalent.
Standards of Professional Practice
Podiatrists practicing in Queensland are required to abide by the Podiatrist’s Board of Queensland’s ‘Guidelines for
Standards of Practice’ (2006).68
http://www.podiatryboard.qld.gov.au/DocsLibrary/Policies.htm
These guidelines are founded on the Podiatrists Registration Act (2001) 68 and specifically include for diabetes
management, Podiatrists:
• must comply with: Type 1 and Type 2 Diabetes best practice guidelines and the Australasian Podiatry Council’s
Diabetes Guidelines
• shall be responsible for the professional assessment, selection, and delivery of the management plan, particularly
for those with “high risk” foot status.68
Referrals
Community-based podiatrists normally accept referrals from all health care agencies, professionals and members of the
public. Hospital-based podiatrists normally require referral from a Medical Officer.
Ideally all patients should be referred to a podiatrist upon diagnosis of diabetes and have had a ‘Basic Foot Screen
Checklist’ (Appendix 1) 47 completed to determine whom to refer. Referral to the ‘Integrated Diabetic Foot Continuum of
Care Clinical Pathway’ (Appendix 2) 48 is advised to determine the most appropriate and timely podiatry sector to access
for the individual diabetic foot risk categories.
As a minimum patients must be referred to a podiatrist when there are:
Clinical signs or history of ‘At or High Risk Foot’, i.e.:
- Foot ulceration
- Foot amputation
- Neuroarthropathy or Charcot Foot
- Peripheral neuropathy
- Peripheral vascular disease
- Foot deformity
Note: The numbers of podiatrists working within Queensland Health are limited, and thus, these podiatrists may only
receive,‘at risk”, ‘high risk’ and/or “acute complication” diabetic foot referrals depending on the particular health service
districts protocols.
Under Commonwealth Medicare arrangements, private podiatry services are reimbursable items. To receive
reimbursement services, a GP must place a patient on a Team Care Arrangement, and then, refer to the private podiatry
practitioner who has registered with Medicare Australia.
Flexible Competencies
Unfortunately the healthcare system does not currently provide easily accessible education or podiatry services for people
with diabetes whose feet are “at risk”. 40 Thus, the utilisation of the ‘Integrated Diabetic Foot Continuum of Care Clinical
Pathway’ (Appendix 2) 48 may aid the provision of podiatry care.
Where a Podiatrist (public or private) is not available, or access extremely limited, General Practitioners and/or Diabetes
Educators should coordinate ‘low’ and/or ‘at risk’ foot management and education. When access to a podiatrist is
not possible, some elements of diabetic foot intervention may need to be provided by other healthcare professionals,
including competently trained;
• Indigenous Health Workers (Refer to Warnock’s (2005) Indigenous Diabetic Foot Project) – www.sarrah.org.au/
SARRAH/WhatsNew.asp 93
• Nurses
• Allied Health Assistants.
Podiatrists can facilitate accredited continuing education for other healthcare professionals in diabetes foot care.
47
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
‘High risk’ and ‘acute complications’ management should definitely involve a podiatrist. If there is absolutely no access
to a podiatrist, management can be coordinated by General Practitioners and/or Diabetes Educators with the aid of a
Physician, Vascular Surgeon, Orthopaedic or Podiatric Surgeon, Infectious Diseases Specialist, Orthotist and/or Wound
Care Nurse.
Consideration of teleconferencing, telehealth or other technology to access and consult a podiatrist should be
undertaken for ‘at risk’, ‘high risk’ and ‘acute complication’ diabetic foot management.
It is the responsibility of the aforementioned professionals to refer to other professionals if they do not have expertise in
dealing with specific problems.
Podiatrists are the professional group most skilled to effectively integrate foot information from all areas to optimise the
foot and lower limb management of people with diabetes.
3.5 Psychologists
Rationale
Increasingly the treatment of diabetes is moving from a focus on compliance where an individual carries out the
treatment as directed by a health professional to a model of empowerment in which the emphasis is on the individual
being responsible for the self management of their diabetes.69,70,71 Psychologists are involved in promoting self
management through changing attitudes and motivation71,72 and encouraging appropriate lifestyle changes to reduce the
risk of complications.73
Individuals with diabetes have been found to experience disproportionately high rates of psychological disorders and
symptoms.74 Depression and anxiety disorders have been found to be the most common diagnoses, occurring far more
often in individuals with diabetes than in the general population.75,76,77 Research suggests that depression is two to
three times more prevalent in people with diabetes compared to the general population, affecting approximately one
out of every five individuals.75, 76 Recent studies further suggest that depression may be an independent risk factor
for developing Type 2 diabetes.78,79 Co-morbid depression is significantly associated with poorer diet and medication
adherence, functional impairment, increased health care use and expenditure 80,81 and poor glycaemic control.82 Anxiety
symptoms have also been found to be highly prevalent in individuals with diabetes, with 14% meeting the criteria for an
anxiety disorder.76,83 Even when individuals with diabetes do not meet criteria for a clinical diagnosis of depression or
anxiety, some studies suggest that approximately 40% are likely to experience significantly elevated levels of depressive
and anxious symptomatology. 76, 83
Given the growing number of older individuals diagnosed with Type 2 diabetes, the impact of diabetes on cognitive
abilities is becoming increasingly important.84 Research suggests that diabetes is associated with both subtle declines
in cognitive function (as assessed by neuropsychological tests) and more profound declines in function (as assessed by
clinical dementia criteria). 84,85, 86
A variety of other psychological conditions, including binge eating disorder, can also present in individuals with diabetes
and compromise their ability to manage their diabetes. 87,88
The Global Guidelines for Type 2 diabetes (IDF Clinical Guidelines Task Force, 2005)37 states “There is RCT support for
the efficacy of antidepressant treatment (in a mixed group of Type 1 and Type 2 diabetes with major depressive disorder)
and for cognitive behaviour therapy (in Type 2 diabetes with major depression ).37,41,89 There is growing evidence that
psychological counselling can contribute to improved adherence and psychological outcomes in people with diabetes.90
A systematic review and meta-anlaysis has shown that, overall, psychological interventions are effective in improving
glycaemic control in Type 2 diabetes.”91
Goal
The goal of psychological intervention in the management of Type 2 Diabetes is to promote the optimal physical and
emotional health of the person with diabetes.
The objectives of psychological intervention are to
1 optimise the individual’s adjustment to the diagnosis
2optimise the emotional state of the individual
3optimise health behaviours and self management
4optimise adherence to treatment
5 optimise relationships with family and other health professionals that impact upon the management of the
diabetes
6identify cognitive deficits and optimise management of the effects of deficits upon lifestyle and diabetes selfmanagement.
48
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Role of Psychologists in Management of Type 2 Diabetes
The role of the psychologists includes
• assessment of well being and psychological status including cognitive functioning
• provision of emotional support and counselling
• provision of behaviour therapy to facilitate self management, the implementation of treatment recommendations
and healthy lifestyle choices
• management of psychological and social disorders and issues
• provision of staff training, education and advice
According to the American Diabetes Association, assessment of psychological and social status should be included
as part of the medical management of diabetes. Psychological screening would include but not be limited to
attitudes about the illness, expectations for management and outcomes, affect/mood, quality of life, financial, social
and emotional status and mental history. Screening for depression, eating disorders, and cognitive impairment is
recommended when adherence to treatment is poor.9
Self management is critical to the effective treatment of diabetes. Psychologists help the individual to implement self
management including appropriate lifestyle choices by facilitating changes in attitudes and motivation.71,72 Psychologists
can assess and provide interventions to address nutrition, weight management, physical activity and smoking. This
process involves, assessing readiness to change, developing personal goals, reducing barriers to change, providing
problem solving skills and providing follow-up.
Psychologists play a significant role in the assessment and management of the psychological issues associated with
diabetes such as anxiety, depression, anger, stress, adjustment, adherence and cognition. Psychologists can provide
emotional support and counselling to help the individual and family adjust to the diagnosis, treatment and expected
outcomes and to help address family, work, financial, relationship and sexual issues.
Anxiety, stress and depression can severely impact on ability to manage on a daily basis and to undertake self-care
behaviour. Engaging in cognitive behaviour therapy provides an opportunity to learn strategies to cope with life
difficulties and to engage in behaviours that can promote a healthy lifestyle.
Psychologists are actively involved in providing consultancy and staff training in self management and strategies to
manage emotional difficulties.
Qualifications
Mandatory
Registered as a Psychologist in Queensland
Highly Desirable
Post-graduate studies in Clinical or Clinical Health Psychology
Standards of Professional Practice
Competency based standards for psychologists have been developed by the Australian Psychological Society and have
been incorporated into undergraduate and post-graduate training in psychology.
All Psychologists in Queensland are required to abide by the Australian Psychological Society Code of Ethics as they have
been endorsed by the Psychologist Board of Queensland.
Referrals
Ideally individuals experiencing one or more of the following difficulties should be referred to a Psychologist
• Difficulty adhering to diabetes treatment
• Difficulty implementing required lifestyle changes/self care behaviours
• Significant stress
• Sexual dysfunction
• Anxiety/frustration/anger
• Depression
• Frequent admissions for DKA
• HbA1c > 8%
• Needle Phobia
49
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
• Cognitive difficulties
• Complex mental health history
• Family/interpersonal conflict re diabetes care
According to the American Diabetes Association, it is preferable to incorporate psychological treatment into routine
care rather than wait for identification of a specific problem or deterioration in psychological status. Screening of
psychological status should occur at diagnosis, during regular scheduled reviews, during acute episodes requiring
hospitalisation, at onset of complications, with persistent poor glucose control or with poor adherence to treatment.9
Note: Under Commonwealth Medicare arrangements, private psychology services are reimbursable items. To receive
reimbursement services a GP must place a patient on a Team Care Arrangement, and then, refer to the private
psychologist who has registered with Medicare Australia.
Flexible Competencies
In situations where ready access to a psychologist is limited, it is essential that members of the diabetes team undertake
training that enables them to screen and provide brief intervention for emotional difficulties, lifestyle risk factors and
ability to undertake self-management. Consultation/ liaison with a psychologist is recommended.
Referral to a psychologist is essential when emotional disorders; lifestyle risk factors and other factors are impacting on
ability to undertake self-management activities.
3.6 General Practitioner
The clinical role of the GP may vary considerably, depending on the setting, patient circumstances and requirements of
care. One of the most crucial ongoing roles however is that as co-coordinator of patient care. Australians with diabetes
have complex and changing support from a variety of health professionals - doctors, nurses, allied health personnel,
pharmacists and community support groups. It is generally the GP who makes the diagnosis and stabilizes the patient
over several weeks, with the assistance of dietitian, diabetes educator and other relevant health providers. This includes
ensuring the patient understands the effects and challenges of diabetes, its optimal management and the many supports
available to them in controlling the process long term.
The general practice is the central repository of relevant health information for the patient and health care team, and
instigator of appropriate care planning and quarterly review. The GP also checks annually to ensure important prevention
and early detection assessments are completed. As patients are whole people and have active and changing physical,
emotional and psycho-social dimensions to their health, the general practice is their reference point for wholistic and
continuing care.
3.7 Referral To Other Health Professionals
Referral criteria to the following professionals are listed below
Endocrinologist
• Existing co-morbidities/complications requiring review
• Patient considering pregnancy or pregnant
• HbA1c persistently > 8% following intervention by Diabetes Educator/Dietitian
• Review of pharmacological management required
Exercise Physiologists/ Physiotherapist
• Conditions affecting activity levels/functional capacity eg. Musculo-skeletal conditions
• Provision of specific physical activity prescription
• Supervision of exercise in individual or group settings
Pharmacist
• Review of medications/education
- action, effectiveness
- dose, timing, combinations
- side effects
- contraindications
- compliance
- changes
- insulin, Oral hypoglycaemic agents
50
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Ophthalmologist/Optometrist30
• Type 2 diabetes within first year of diagnosis
• If patient is or becomes pregnant conduct a comprehensive eye examination within the first trimester
• Refer to Ophthalmologist/Optometrist every two years if no retinopathy and yearly once Diabetic retinopathy is
identified
Urgent Referral to Ophthalmologist essential if
• Diabetic retinopathy is found that is at a greater level than the presence of occasional microaneurysms30
• Diabetic Macular Oedema
• Declining visual acuity30
Nephrologist
• Impaired renal function, eGFR < 60ml/min/1.73m2
Vascular Surgeon
• Symptoms and signs of ischaemia of lower limbs
• Arterial ulceration
• Carotid bruits
Oral Health7
• Dental or periodontal problems
• Yearly for routine review
51
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Appendices
Appendix 1
Basic Foot Screening Checklist
National Association of Diabetes Centres
Australasian Podiatry Council
Preventing Foot Complications in Diabetes
Background
Foot problems account for much of the morbidity, amputations and hospitalisations in people with
diabetes. Most foot problems are preventable when identified early, treated appropriately and
when people are educated to avoid these problems.
Aims
1. To identify the ‘high risk’ foot using as indicators:
•
history of previous foot ulceration or amputation
•
peripheral neuropathy
•
peripheral vascular disease
•
foot deformity
2. To identify active foot problems checking for:
•
infection
•
ulcerations
•
calluses or corns
•
any skin breaks
•
nail disorders
3. To prevent amputations
Screening
1. Ask the patient if they have experienced :
•
previous foot problems
•
symptoms of neuropathy
•
intermittent claudication
2. Look at both feet to find any active problems
3. Check foot pulses
4. Test for neuropathy by assessing protective sensation (with a 10 gram
monofilament)
5. Assess footwear
6. Assess education need
7. Assess self care capacity including vision, mobility, social factors
All people with diabetes need to have their feet examined using these 7 simple
steps every 12 months or more often if problems are identified.
National Diabetes Foot Screening Project
January 2004
52
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
National Association of Diabetes Centres
Australasian Podiatry Council
Basic Foot Screening Checklist
1. Ask the patient
neuropathic symptoms
intermittent claudication
previous foot ulcer
amputation
specify
2. Look at both feet
Y
Y
N
Y
N
N
N
SITE______________________ DATE ____/____/______
infection
ulceration
calluses or corns
skin breaks
nail disorders
foot deformity
Y
Y
Y
Y
Y
Y
LEFT
3. Check foot
Y
N
N
N
N
N
N
RIGHT
Dorsalis pedis
Y
N
Y
N
Posterior tibial
Y
N
Y
N
pulses
LEFT
4. Test for
Monofilament
neuropathy
Y
RIGHT
N
Y
N
detected at sites
marked - o
5. Assess footwear
style
condition
fit
Good
Good
Good
Poor
Poor
Poor
6. Assess education need
Does the patient understand the effects of diabetes on foot health?
Can the patient identify appropriate foot care practices?
Are the patient’s feet adequately cared for?
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
7. Assess self care capacity
Does the patient have impaired vision?
Can the patient reach own feet for safe self care?
Are there other factors influencing ability to safely care for own feet?
All people with diabetes need to have their feet screened with these 7 simple steps
every 12 months or more often if problems are identified
National Diabetes Foot Screening Project
January 2004
53
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
National Association of Diabetes Centres
Australasian Podiatry Council
Action Plan following Basic Foot Screening
DATE OF REFERRAL ____/_____/____
PATIENT NAME
SERVICE PROVIDER ____________________
Is the foot high risk ?
If yes, why ?





Yes

No 
(re-check in 12 months)
history of previous foot ulceration or amputation
peripheral neuropathy
peripheral vascular disease
foot deformity
other
___________________________________
Action*
Record details of personnel referred to. Where resources are unavailable,
indicate and describe alternative care provision
1. Ulceration or significant infection
•
referred to multidisciplinary team :
2. ‘High risk’ foot
•
referred to podiatrist and/or
multidisciplinary team :
•
referred for medical assessment at
least every 6 months and foot
examination every 3 months :
3. Active foot problem
•
referred to podiatrist
4. Symptomatic peripheral vascular disease
•
referred to vascular surgeon :
•
involving endocrinologist / physician :
5. Symptomatic peripheral neuropathy
•
referred to endocrinologist :
6. Foot deformity or abnormality
•
referred to podiatrist :
7. Inadequate knowledge or foot care practices
•
referred to :
•
or education provided

Yes
*The patient’s General Practitioner or Local Medical Officer will usually be responsible for coordinating
the patient’s care and should be informed of referrals, interventions and progress
National Diabetes Foot Screening Project
January 2004
54
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Appendix 2
Intergrated Diabetic Foot Continnum of Care Clinical Pathway
Integrated Diabetic Foot Continuum of Care Clinical Pathway
National Health Priority Area directives and the new Commonwealth Government Medicare Plus initiative, has emphasised
the need to re-establish communication between Private and Public Podiatry services. This collaboration will aim to provide
seamless clinical care to our escalating Diabetic Population as well as strengthen the overall standing of our profession.
The Integrated Diabetic Foot Continuum of Care Pathway allows for the maximum utilisation of Medicare Plus and
available government funding, supporting consumers across the disease morbidity continuum. We envisage this will
provide benefits to private and public services and our patient population as a whole, via:
• increased access to appropriate and collaborated services,
• increased understanding and confidence in and within Podiatry services from clients and other health professions, &
• an overall reduction in foot ulceration and amputation rates toward the European St Vincent Declaration on
Diabetes Goal, “50% Amputation Reduction by 2010”.
Using the Chart
The Podiatrist can ascertain the consumer’s risk status based on the University of Texas Diabetes Risk Classification Scale
simply by
• Detection of 10g monofilament,
• Palpation of pedal pulses,
• Assessing for foot deformities, ulcers, infections and/or amputations.
Once the risk status has been identified the consumer’s most appropriate management plan can be determined (i.e.
Private, Public Podiatry or Medical Consultant). Specific leaflets will also be available to distribute to the patient as an
initial more specific risk information source.
Please state reason for referral, medical history and risk category on all referrals.
QH Public Podiatry Service
Queensland Health Podiatry uses up-to-date evidence based management to:
• Reduce morbidity associated with National Health Priority Areas (i.e. Diabetes, Injury Prevention, Arthritis &
Musculoskeletal Conditions)
• Maintain and improve mobility of older persons and younger disabled clients to strengthen their independence
• Provide optimum education/health promotion to clients, carers and other health professionals on pedal health
• Improve overall professional development in accordance with latest evidence based management of pedal health.
Public Podiatry services are offered through-out a range of settings and locations across Queensland, including:
• Hospital Endocrinology, Vascular &/or Orthopaedic Depts. etc.,
• Primary and Community Health Services,
• More Allied Health Services Program (MAHS) through rural Divisions of General Practices,
• Respite Services & Residential Aged Homes
Within the area of Diabetes and the High Risk Foot, Public Podiatrists, as members of a Multi-discipline Diabetes
clinical team specifically target ‘At Risk’ and ‘High Risk’ Diabetic Foot complications to reduce and prevent ulceration
and amputation of the lower limb. These teams also often provide group education services to the ‘Newly Diagnosed’
diabetic population.
New Medicare items for Allied Health Services
From 1 July 2004, people with chronic conditions and complex care needs (eg Diabetes) who are being managed through
an Enhanced Primary Care (EPC) multidisciplinary care plan may be eligible for up to 5 allied health services per year on
referral from their GP.
GPs must use the EPC allied health or dental care referral form to refer patients to an eligible, HIC registered allied health
professional or dentist.
Allied health professionals and dentists may set their own fees. However, for each allied health item, the Medicare
schedule fee is $51.75 with a Medicare rebate of $44.00
For more information contact HIC on 132 150 or www.hic.gov.au/providers
Your Local Public Podiatrist is:
(Place Stamp Here)
55
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Appendix 2
Intergrated Diabetic Foot Continnum of Care Clinical Pathway
Referral Source: GP; Nurse; AH; Specialist
Low Risk
High Risk
At Risk
Cat 0
Cat 1
Cat 2
Cat 3
Cat 4
Cat 5
PVD/Ischaemic
Protective
Sensation Intact
and
Nil PVD
Loss Protective
Sensation and
Nil PVD and
Nil Foot Deformity
Loss Protective
Sensation and
Foot Deformity
+/- callous
Loss Protective
Sensation and
Previous Foot
Ulcer, Amputation
or Charcot Foot
Loss Protective
Sensation, Noninfected Foot Ulcer
Present and/or
Acute Charcot Foot
Loss Protective
Sensation,
Infected Foot Ulcer
Present and/or
Acute Charcot Foot
Absent Foot pulses
Hx Claudication,
Vascular ulceration
Gangrene
Foot Health
Leaflet 0
Foot Health
Leaflet 1
Foot Health
Leaflet 2
Foot Health
Leaflet 3
RV in 12
Months on
EPCP Referral
RV in 3-4
Months on
EPCP Referral
RV in 2-3
Months some on
EPCP Referral
Patient happy
to pay
continue 1-8
Week Reviews
Patient happy
to pay for Wound
Care Program
1-2X/52 RVs
Refer Public Pod
for non-EPCP
Reviews
Refer Public Pod
for non-EPCP
Reviews
Refer Public Pod
for 1-8 Weekly
‘At Risk’ Reviews
Refer Public Pod
for Urgent Wound
Care Program or
Casting
(EPCP Cover)
Private Podiatrist
Foot Health Leaflet 4 (Foot Ulcers)
(Patient Pays Extra Visits)
Community Public Podiatrist
Immediate
Referral to GP or
Hospital A&E
& Pod with details
of Infection (ie
Superficial or
Deep)
Consultant
Input
• Endocrinologist
• Vascular
• Wound CNC
• Orthopaedic
• Infectious Dz.
Hospital Podiatrist
Legend
EPCP = Enhanced Primary Care Plan
A&E = Accident and Emergency
Dz = Diseases
CNC = Clinical Nurse Consultant
PVD = Peripheral Vascular Disease
Hx = History
RV = Review
References
1 Armstrong DG et al. J. Amer. Podiatr. Med. Assn. 1996; 86:311-316
2 Lanarkshire NHS Trust, Scotland, Diabetes Services - Diabetic Foot Management
3 Health Insurance Commission 2004 Health Care Providers: Fact Sheets
http://www.hic.gov.au/providers/resources/incentives_allowances
/medicare initiatives/pa8666 allied fact sheet.pdf
56
Foot Health
Leaflet PVD
Vascular Ulceration
or Gangrene
Immediate Referral
to Hospital A&E
/Vasc Dept
Otherwise
Referral to Public
Pod for
Doppler/PPG
Studies or
Hospital Vasc
Department
Community
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
Appendix 3 Wraight Et Al’s Clinical Assessment and Investigations and Management of Acute Diabetic Foot Complications
57
Guidelines for Care and Referral of Adults with Type 2 Diabetes 2006
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64