Initial Assessment

Including brief contact/screening

Continue to Diagnosis

Who to Screen for Diabetes Mellitus Type 21

  • People ≥55
  • All people with clinical cardiovascular disease
  • People ≥45 who have one or more of the following risk factors:
        - Obesity (BMI ≥30 kg/m²)
        - Hypertension
        - First degree relative with Type 2 Diabetes
  • Women who have a history of Gestational Diabetes
  • Women with Polycystic Ovarian Syndrome who are obese
  • All Aboriginal and Torres Strait Island women should be screened at their first ante-natal appointment 11
  • Aboriginal and Torres Strait Islanders aged 35 and over. In high prevalence areas of early onset diabetes, screening at 15-18years is recommended 11
  • People from diverse cultural and linguistic backgrounds aged 35 and over (specifically Pacific Islanders, people from the Indian subcontinent, and people of Chinese, South East Asian, Mediterranean and Middle Eastern origin)
  • People with Impaired Glucose Tolerance (IGT), Impaired Fasting Glucose (IFG)

Contact Patient’s Community Pharmacy for more information14
http://www.findapharmacy.com.au/

Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 701 Brief Health Ax
  2. 703 Standard Health Ax
  3. 705 Long Health Ax
  4. 707 Prolonged Health Ax
  5. 715 Aboriginal & Torres Strait Is Health Ax

Diagnosis of Diabetes

Assessment
Prevention
Diagnosis

Assessment

Management

Hx

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

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Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 701 Brief Health Ax
  2. 703 Standard Health Ax
  3. 705 Long Health Ax
  4. 707 Prolonged Health Ax
  5. 715 Aboriginal & Torres Strait Is Health Ax
Assessment

Management

3 Month Review
  • 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)
  • 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

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Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 721 GPMP
  2. 723 TCA
  3. 900 DMMR
  4. 729 Care Plan other provider
  5. 731 Care Plan AGF
  6. 735 Organise CC >15 but <20 mins
  7. 739 Organise CC >20 but <40 mins
  8. 743 Organise CC >40 mins
  9. 747 Participate CC >15 but <20 mins
  10. 750 Participate CC >20 but <40mins
  11. 758 Participate CC >40 mins
  12. 903 RMMR
  13. 10997 Nurse
  14. 10950-10970
  15. 10987
  16. 81100-81125
  17. 81300-81360
Management

3 Month Review

6 Month Review

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

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Name:
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Comments:
 
Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 721 GPMP
  2. 723 TCA
  3. 900 DMMR
  4. 740 or 742 or 744 Organise Comm CC
  5. 759 or 762 or 765 Participate Comm CC
  6. 746 or 749 or 757 Organise d/c CC
  7. 768 or 771 or 773 Participate d/c CC
  8. 729 Care Plan other provider
  9. 731 Care Plan AGF
  10. 734 or 736 or 738 Organise ACF CC
  11. 775 or 778 or 779 Participate ACF CC
  12. 903 RMMR
  13. 10997 Nurse
  14. 10950-10970
  15. 10987
  16. 81100-81125
  17. 81300-81360
3 Month Review

6 Month Review

6 Month Review

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

Post Feedback

Name:
Email:
Comments:
 
Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 721 GPMP
  2. 723 TCA
  3. 900 DMMR
  4. 740 or 742 or 744 Organise Comm CC
  5. 759 or 762 or 765 Participate Comm CC
  6. 746 or 749 or 757 Organise d/c CC
  7. 768 or 771 or 773 Participate d/c CC
  8. 729 Care Plan other provider
  9. 731 Care Plan AGF
  10. 734 or 736 or 738 Organise ACF CC
  11. 775 or 778 or 779 Participate ACF CC
  12. 903 RMMR
  13. 10997 Nurse
  14. 10950-10970
  15. 10987
  16. 81100-81125
  17. 81300-81360
6 Month Review

9 Month Review

12 Month Review

See quarterly review.

Post Feedback

Name:
Email:
Comments:
 
Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 721 GPMP
  2. 723 TCA
  3. 900 DMMR
  4. 740 or 742 or 744 Organise Comm CC
  5. 759 or 762 or 765 Participate Comm CC
  6. 746 or 749 or 757 Organise d/c CC
  7. 768 or 771 or 773 Participate d/c CC
  8. 729 Care Plan other provider
  9. 731 Care Plan AGF
  10. 734 or 736 or 738 Organise ACF CC
  11. 775 or 778 or 779 Participate ACF CC
  12. 903 RMMR
  13. 10997 Nurse
  14. 10950-10970
  15. 10987
  16. 81100-81125
  17. 81300-81360
9 Month Review

12 Month Review

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

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Goals for management Referral Criteria MBS Website

Potential item numbers for use - click for restrictions

  1. 2517 or 2521 or 2525 COC (in surg)
  2. 2518 or 2522 or 2526 COC (out of surg)
  3. 721 GPMP or review
  4. 723 TCA or review
  5. 732 GPMP/TCA
  6. 900 DMMR
  7. 740 or 742 or 744 Organise Comm CC
  8. 759 or 762 or 765 Participate Comm CC
  9. 746 or 749 or 757 Organise d/c CC
  10. 768 or 771 or 773 Participate d/c CC
  11. 729 Care Plan other provider
  12. 731 Care Plan AGF
  13. 734 or 736 or 738 Organise ACF CC
  14. 775 or 778 or 779 Participate ACF CC
  15. 903 RMMR
  16. 10997 Nurse
  17. 10950-10970
  18. 10987
  19. 81100-81125
  20. 81300-81360