Supporting rural people living with diabetes

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Melanie Gray Morris
Australian Diabetes Educators Association
Melanie Gray Morris and Paris Dounoukos

Equity in health means that people living in rural communities have the same access to care as those living in urban centres, including expert diabetes care. Treating a person with diabetes can be complicated, and it is important that GPs and other health professionals understand how to best support people with diabetes to get the best possible outcome.

Understanding the key components of the MBS, as well as the role of GPs, credentialled diabetes educators (CDEs) and other allied health professionals, can make all the difference in the care and management of a person with diabetes.

Diabetes Australia has recommended that people living with diabetes receive regular health checks under the Diabetes Annual Cycle of Care. Please note that the cycle of care for adolescents and children varies from the adult cycles of care and often includes more frequent checks.  

The recommendation is for the GP to check:

  • HbA1c at least every 6–12 months
  • blood pressure every 6 months
  • weight every 6 months
  • waist circumference every 6 months
  • urine albumin/kidney function test annually
  • blood fats test annually
  • medication review annually
  • smoking annually (no smoking).

Diabetes Australia also advises for the GP to refer to a:

  • CDE for a diabetes management review annually
  • dietitian for a healthy eating review annually
  • exercise physiologist for a physical activity review annually
  • podiatrist for foot assessment (low risk annually, high risk every 1–3 months)
    • The FootForward program is a useful guide and for low and very low risk individuals an annual exam is sufficient, for moderate risk individuals they should be screened every 3–6 months, including an initial screen within 6–8 weeks of diagnosis
  • optometrist (or ophthalmologist) for eye examination (at diagnosis and then every 2 years)
  • psychologist for emotional health assessment (as needed).

In addition, the Australian Diabetes Educators Association (ADEA) recommends an annual MedsCheck or Home Medicines Review by a pharmacist.

The Chronic Disease GP Management Plan (GPMP) and Team Care Arrangements (TCAs)

When managing a chronic condition like diabetes, a multidisciplinary team is necessary so that the patient will be eligible for both a GPMP (item 229 or 721) and TCAs (item 230 or 723).

The TCAs require that the GP consults with a multidisciplinary team that includes at least two other collaborating health or care providers (not including the patient’s informal or family carer). In the case of diabetes management, ADEA recommends that at least one of the those consulted should be a CDE.

Each person in the team must provide a different type of ongoing treatment or service (such as CDE, dietitian, exercise physiologist or podiatrist) but none need to be Medicare-eligible providers.

When documenting the TCA, team members should include:

  • the treatment and service goals for the patient (a CDE will be able to suggest the most appropriate goals for people with diabetes)
  • all treatments and services that collaborating providers have agreed to give (this should reflect the annual cycle of care listed above)
  • all of the actions that the patient will need to take to support a successful outcome. 

Having a CDE as part of a patient’s diabetes health care team is an important step to ensure the annual cycle of care is reflected in the TCA and that the most up-to-date evidence-based expertise in diabetes care is given.

Inpatients of a hospital or care recipients of a residential aged care facility are not eligible for GPMP or TCAs. However, care recipients in a residential aged care facility are eligible for MBS item numbers 232 or 731.

Following a GPMP and TCA, GPs can refer patients for up to five MBS-funded individual services per calendar year. ADEA recommends that these include CDEs, and other key allied health professionals such as dietitians, exercise physiologists, podiatrists, optometrists or psychologists. 

Patients with type 2 diabetes can be referred to group services, including one assessment for group services (item diabetes education 81100, exercise physiology 81110, dietetics 81120) and up to eight group allied health services per calendar year (item diabetes education 81105, exercise physiology 81115, dietetics 81125). The group services can be accessed in addition to the five individual allied health services each calendar year.  

There are many accessible services to which GPs can refer their patients with diabetes for expert treatment and outcomes as part of a TCA. When working with a CDE and other health care providers, the Annual Cycle of Care can help people living with diabetes to reach their health goals and live healthier lives.

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