Responsibility for the management of the rising number of people with type 2 diabetes sits pretty much in the lap of primary health care. Jayne Lehmann explores the role all primary care health professionals have in increasing the number of people with type 2 diabetes achieving their glycaemic targets.

The Chronic Disease Management system, put in place via Medicare in 2004, provides GPs with the ability to refer to allied health professionals in their local community. Increasing access to the additional skills of these allied health professionals was meant to significantly improve health outcomes in people with chronic conditions like diabetes. It would seem we have a way to go with 50% of people with diabetes currently NOT achieving their glycaemic targets.

Nurses in general practice will usually be the ones working with the patient to draft the chronic disease management plan and team care arrangement, with the GP and two allied health providers given the opportunity to input into the plan. Five Chronic Disease Management referrals are then allocated annually.

In diabetes care this will often include one of the following:

• The majority of referrals allocated to a podiatrist to cut their toenails
• Referrals shared between, for example, dietitian, podiatrist or exercise physiologist with none allocated for diabetes education due to the practice nurses’ role within the practice in diabetes care
• Referrals provided for 2-3 allied health providers, for example a Credentialled Diabetes Educator, dietitian, podiatrist or exercise physiologist.
• No referrals provided as the practice isn’t participating in the Chronic Disease Management program.

There may also be additional plans and referrals made via Mental Health Plans and the Type 2 diabetes Group Education Referrals, the latter popular with Exercise Physiologists providing these services.

At the same time the skills of the practice primary care nurses are utilised and often extended to increase support to people with diabetes within their general practice as they:

• Create the initial plan with the patient
• Act as a signatory to the Team Care Arrangement
• Coordinate the finalisation of the plan
• Run diabetes mini clinics
• Gather data for the annual cycle of care.

This has created confusion about which individuals should be referred to Credentialled Diabetes Educators (CDE) and many CDEs report a significant drop-off in referrals from local GPs. It’s not a matter of using one or the other as there is a place for both the practice nurse and CDE. Working smarter by interrogating the data held in general practice databases would further inform referral pathways. For example identify individuals with glycosylated haemoglobins over 7.5% and refer them to a CDE for a step-wise approach to referral and utilisation of more specialised skills where they will work best.

Creating successful diabetes care teams

Successful team care has health professionals working together with proactive input between professionals and with the individual with diabetes. The shared goal currently comes from the plan however many health professionals provide additional diabetes support are are not named in the person’s plan.

There is also a significant challenge communicating between health professionals. Email access to a GP is rarely possible and phoning a practice often results in hit and miss phone calls as busy health professionals try to catch each other. Allied health professionals have to send a letter to the GP after the first and last appointment with the patient as a condition of receiving Medicare reimbursement for these services.  I find I need to write to the GP after each appointment as there is information they need to be aware of, follow-up or consider when they see the patient at their next appointment.

In return I would have to say rarely is information or any blood results sent back to me from GPs or other allied health professionals after the initial plan is distributed. I also wonder if the next care plan is influenced by the letters I send back because I assume it is the GP reading them not the primary care nurse.

Encouraging all primary care health professionals to be involved with the management of their patients’ diabetes is likely to extend the impact of the Chronic Disease Management program.

Other health professionals in the local community also influence diabetes care outcomes. For example, the community pharmacist talks to people about their medication and provide the NDSS products, the community nurse might be monitoring blood glucose levels during wound care, the physiotherapist helps resolve an injury preventing someone from walking each day as a part of their diabetes care.

You don’t need to be named in a plan to be a part of a person’s diabetes care team!

A person’s diabetes care team includes any health professional supporting a person with their diabetes but they are often not included in the plans created within general practice. It would be great to see plans acknowledging the role of this extended round of health professionals. It would also reinforce all health professionals do indeed have a role.

We might not have the paperwork quite right, all work in different buildings and don’t have the same company logo on our work shirts but we are no less a team. To the person with diabetes trying to live their day with diabetes, they simply want us to work together, share information and help them to have a good quality of life. They want us to be THEIR Diabetes Team no matter if we are named in the care plan or not!

For primary diabetes care to further evolve, health professionals will need to address the issues that leave us siloed and generally poorly connected. Improving communication channels, using an inclusive approach to the breadth of the individual’s diabetes team, using a stepped approach to diabetes education and making case conferences a possibility to discuss the more challenging diabetes management cases is bound to enable us to get more people to achieve their glycaemic targets.