Hx

• Symptoms
• Risk factors for complications and existing complications (Absolute Cardiovascular Risk NVDPA Guidelines)
• Medication requirements and contraindications
• SNAP (Smoking, Nutrition, Alcohol, Physical Activity - RACGP SNAP Guidelines and NHMRC Alcohol Guidelines)
• Immunisation status²
• Knowledge
• Psychological status
• Impact of cultural and disability issues

Ex

• Weight, height, waist circumference and calculate BMI²)
• Cardiovascular System (including blood pressure²)
• Neuropathy (including postural hypotension)
• Eye examination performed by an Ophthalmologist, Optometrist or appropriately trained GP/Diabetes Physician ⁶
• Dental Health
• Foot Risk Assessment & inspection (Foot Resources)

Ix

• Biochemistry: HbA1c, total cholesterol, LDL-C, triglycerides, HDL-C, creatinine, eGFR, LFTs, microalbuminuria¹⁹
• Perform urinalysis²
• ECG every 2 years in asymptomatic people >50 years and who have ≥one other cardiovascular risk factor¹²

• Referral requirements– consider disciplines of Diabetes Education, Dietetics, Endocrinology, Pharmacy, Oral Health, Vascular Surgery, Podiatry, Indigenous Health, Ophthalmology/Optometry, Psychology, Exercise and Nephrology

• Negotiate goals of management and devise management plan with patient (Forms)
• Confirm appropriateness of coordination of care with patient
• Consider opportunities for Case Conferencing /GP Management Plan and/or Team Care Arrangement as per MBS
• Manage acute symptoms²
• Treat existing complications ²
  
• Optimise risk factors for complications² (QUIT)
• Optimise control of glycaemia, blood pressure and blood lipids² (Hypertension Guidelines)
• Prescribe medication and provide education (NPS)

• Provide diabetes information and education (Diabetes Australia QLD, Sweet Program, Driving, Better Health Channel)
• Provide emotional support and counselling (Booklet)
• Encourage self management behaviour (Self Management Courses)
• Address cultural and disability issues as required (Resource)
• Implement proactive lifestyle interventions such as Lifescripts⁹ - Target weight loss if required (NHMRC)
• Complete appropriate Diabetes Patient Record form
• Add patient details to the Diabetes Register and appropriate recall system
• Register on the National Diabetes Services Scheme (NDSS)

• Organise required referrals

Assessment

Hx

• Patient attendance regarding previous referrals/appointments
• Current and any new symptoms
• Medication requirements, effectiveness, contraindications and side effects
• SNAP⁸
• Knowledge and self care skills²
• Psychological status

Ex

• Weight², waist circumference, height and calculate BMI
• Blood pressure²
• Foot Inspection

Ix

• Biochemistry
      - blood glucose levels²
      - HbA1c if Aboriginal/ Torres Strait Island
        background or insulin treated/poor blood glucose control
• Referral requirements

Management

• Assess achievement of relevant management goals and adjust as required
• Manage acute symptoms²
• Treat ongoing complications²
• Address risk factors for complications²
• Optimise control of glycaemia, blood pressure and blood lipids²
• Adjust medication as required
• Provide ongoing diabetes education
• Provide counselling and support as required
• Continue to encourage self management and care
• Address cultural/disability issues as required
• Implement proactive lifestyle interventions
• Complete appropriate Diabetes Patient Record form
• Update management plan

• Organise required referrals

Assessment

As for quarterly review plus

Ix

• HbA1c
• LDL, triglycerides and HDL

• Referral needs

Management

As for quarterly review plus

• Consider opportunities for Case Conferencing/GP Management Plan and/or Team Care Arrangement as per MBS

Assessment

As for quarterly review plus

Hx

• Risk factors for complications
• Assess immunisation requirements (Influenza, Pneumococcal, Tetanus)²

Ex

• Examine eyes for visual acuity, fundal or retinal abnormality at least every two years. If any Non-Proliferative Diabetic Retinopathy is detected, examinations should be conducted annually or at 3-12 month intervals depending on the level of Diabetic Retinopathy⁶
• Foot risk assessment and inspection
• Cardiovascular System
• Peripheral nervous system

Ix

• Review lipids, U&E s, LFTs, eGFR
• Check urinary microalbumin²
• ECG every 2 years in asymptomatic people >50 years and who have >one other cardiovascular risk factor¹²
• Referral requirements

Management

As for quarterly review plus

• Revise and update management goals and plan
• Confirm appropriateness of coordination of care with patient
• Consider opportunities for Case Conferencing/GP Management Plan/Review and/or Team Care Arrangement as per MBS
• Administer required immunisations
      - Influenza-once per year²
      - Pneumococcal
          Non-Aboriginal and Torres Strait Islanders:
          < 65 – single dose and revaccinate age 65 or
          after 10 years whichever later
          > 65 – single dose and revaccinate 5 years later
          Aboriginal and Torres Strait Islanders:
          < 50 – single dose and revaccinate age 50 or
          after 10 years whichever later
          > 50 – single dose and revaccinate 5 years later
      - Tetanus-booster age 50 unless booster has been       given within 10 years²
• Organise required referrals