Guidelines for Care and Referral of Adults with Type 2 ... Guidelines for Care and Referral of...

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

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ForewordDiabetes is a national and state health priority. The AusDiab study indicated that approximately 940 000 people in Australia have diabetes.� Every day 275 Australians develop diabetes2. The prevalence is increasing in Australia with the number of people with diabetes expected to double by 20�0.3 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 �% decrease in HbA�c has been associated with a 2�% reduction in risk for all end points related to diabetes, including a 2�% reduction in deaths related to diabetes, �4% reduction in myocardial infarction and a 37% reduction in microvasclar complications . Each �0 mmHg decrease in systolic blood pressure has been associated with reductions in risk of �2% for any complication related to diabetes, �5% for deaths related to diabetes, ��% for myocardial infarction and �3 % 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 �999 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 � 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 2005-20�5.

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

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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

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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 .........................................................................................................................................................................�0

1.4. Management of Diabetes Mellitus in Adults- Queensland Health Standard Care Pathway 2006 ......................................................................................................�0

1.5. Education .................................................................................................................................................................................................�0

• Diabetes Self Management Education (DSME) ..............................................................................................................................�0 • Group Education .....................................................................................................................................................................................�0

1.6. Incentives Supporting Diabetes Care ...................................................................................................................................�0

• Practice Incentive Program (PIP) ........................................................................................................................................................�0 • Patient Register and Recall/Reminder System .............................................................................................................................. �� • Service Incentive Payment (SIP) ........................................................................................................................................................ �� • Outcomes ................................................................................................................................................................................................. �� • Practice Nurse Incentive ....................................................................................................................................................................... �� • Chronic Disease Management (CDM) Medicare Items .............................................................................................................. �� − GP Management Plan (GPMP, Item 721) ...................................................................................................................................... �� − Review of a GP Management Plan (GPMP, Item 725) ............................................................................................................... �� − Coordination of Team Care Arrangements (TCA- Item 723) .................................................................................................... �� − Coordination of a Review of a Team Care Arrangement (Item 727) ...................................................................................... �� − Contribution to a Multidisciplinary Care Plan Being Prepared by

Another Health or Care Provider (Item 729) ............................................................................................................................... �� − Contribution to a Multidisciplinary Care Plan Being Prepared by

Another Health or Care Provider for a Resident of an Aged Care Facility (Item 731) .......................................................�2 • Allied Health and Dental Care Item Numbers ................................................................................................................................�2 • Home Medicines Review (HMR) .........................................................................................................................................................�2

1.7. Services/Resources to Assist the Management Of Type 2 Diabetes ...............................................................�2

• Diabetes Australia ..................................................................................................................................................................................�2 • National Diabetes Services Scheme (NDSS) ..................................................................................................................................�2 • Diabetes Management in General Practice ....................................................................................................................................�2 • Diabetes Patient Record Forms .......................................................................................................................................................... �3 • Diabetes Network ................................................................................................................................................................................... �3 • Resources to Assist with the Management of Aboriginal and Torres Strait Island Peoples .............................................. �3 • Smoking, Nutrition, Alcohol and Physical Activity (SNAP) ...........................................................................................................3 • Lifestyle Prescriptions ........................................................................................................................................................................... �3 • Chronic Disease Self Management Programs ................................................................................................................................�4 • QUIT ............................................................................................................................................................................................................�4 • Healthy Weight Program .......................................................................................................................................................................�4 • Lighten UP ................................................................................................................................................................................................�4 • Local Councils .........................................................................................................................................................................................�4 • Heart Foundation ....................................................................................................................................................................................�4

1.8 Government Strategies ..................................................................................................................................................................�4

• National Service Improvement Framework for Diabetes .............................................................................................................�4

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• Queensland Strategy for Chronic Disease ......................................................................................................................................�4 • Aboriginal and Torres Strait Islander Health .................................................................................................................................. �5

1.9 Guidelines ............................................................................................................................................................................................... �5

• Australian National Evidence Based Guidelines (NHMRC) ........................................................................................................ �5 • Other Guidelines .................................................................................................................................................................................... �5

Chapter 2 Guidelines for Care and Referral of Adults with Type 2 Diabetes ..........................................................................................................................................................................�6

2.1 Table 2 Assessment ..........................................................................................................................................................................�6

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 Table7SpecificIssues .................................................................................................................................................................... 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

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• 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 ..............................................................................................................................................................4�

• Rationale ...................................................................................................................................................................................................4� • Goals and Objectives ............................................................................................................................................................................4� • Role ............................................................................................................................................................................................................4� • 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 ........................................................................................................................................................... 5� • Nephrologist ............................................................................................................................................................................................ 5� • Vascular Surgeon .................................................................................................................................................................................... 5� • Oral Health/Dentist ............................................................................................................................................................................... 5�

Appendix ........................................................................................................................................................................................................52

� 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

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Chapter 1 Background

1.1 Introduction

AimThe 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 GoalsThe 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

HbA�c <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

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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 deliveryThe delivery of health services has to change to accommodate the increasing impact of chronic diseases. The Queensland Strategy for Chronic Disease 2005-20�5 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.

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Aboriginal and Torres Strait Islander PeoplesThe 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, �0

• 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.��

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.�2

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.

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1.3 Annual Cycle of CareMedicare 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 2006The 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 EducationDiabetes 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.”�3 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.�4,�5 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.�4,�5 The team will include as a minimum, a Credentialed Diabetes Educator, a dietitian and a podiatrist. �4 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. �4,�5

For further information refer to the Australian Diabetes Educators Association’s National Standards for Diabetes Education Programs. �4

Group EducationDeakin 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. �6 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 CareAustralian 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.

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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.

OutcomesA 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 IncentiveFunding 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 ItemsChronic 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.

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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 NumbersPatients 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 DiabetesDiabetes Australia - QueenslandDiabetes 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: �300 �36 588 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.

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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 NetworkThe 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 � 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)-�

• Warnock’s Indigenous Diabetic Foot Resources and Workshops

http://www.sarrah.org.au/IDF=12�

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.�8 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 Website-

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-lifescripts-index.htm

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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 �800 0�� 04�. http://www.arthritis.org.au/content/view/28/47/

QUITQuitline is a 24 hour counselling service for people who want to give up smoking.

Quitline: �3� 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 ProgramsThe 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 UpLighten 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 CouncilsSome 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 FoundationThe 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

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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 2003�0

• Productivity Commission’s Strategic Framework for Overcoming Indigenous Diseases20

• Cultural Respect Framework for Aboriginal and Torres Islander Health 2004-20092�

• National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-20�022

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

6 Blood Glucose Control

7 *Lipids 39

8 Renal Disease

9 Education.

*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 2001�4

• 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, �99928

• 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 3�

• 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

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Chapter 2 Guidelines for Care and Referral of Adults with Type 2 DiabetesThe 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 AssessmentWhat 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=1168NDSS ph: �300 �36 588http://www.diabetesaustralia.com.au/ndss/index.htmlDiabetes Australia - Queenslandhttp://www.daq.org.auph: �300 �36 588

Symptoms7

• Polyuria• Polydipsia• Polyphagia• Weight loss• Nocturia• Malaise• Altered vision• Recurrent infections• Neuropathic foot symptoms• Sexual issues

Diagnosis-comprehensive review of symptoms3 mths-check current and new symptomsEvery 12 Months (12 mths)- comprehensive review

Primary Care Coordinator

Consider referral to:Diabetes EducatorDietitianIndigenous Health WorkerPodiatristOphthalmologistOptometristPsychologist


(RACGP)Standard Care PathwayAnnual Cycle of Care (RACGP)

Complications• Macrovascular disease• Renal disease• Eye damage• Neuropathy (Sensory, motor, autonomic nerves)• Foot disease

Diagnosis and �2 mths


Consider referral to:EndocrinologistNephrologistsOphthalmologistOptometristNeurologistCardiologist


(RACGP)Standard Care PathwayAnnual Cycle of Care

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What Frequency Who Referrals Resources

Vascular SpecialistPodiatristPsychologistDiabetes EducatorDietitian

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.htmhttp://www.nhmrc.gov.au/publications/subjects/diabetes.htmSee Section 2.4.2: Table 6 Complications-Feet and Section 3.4: Podiatry

ECG6 Diagnosis and every 2 yrs if > 50 yrs & > � risk factor

GP/Medical Officer Consider referral to:Cardiologist

Risk Factors for Complications & Investigations• Blood glucose • HbA1c

• Blood pressure• Lipids - LDL - HDL - Triglycerides• Renal function - Urea - Creatinine - eGFR

Diagnosis, Every VisitDiagnosis, 3-6 mths3mths if Aboriginal, Torres Strait Islander/ on insulin or poor controlDiagnosis, Every visitDiagnosis, 6 mths

Diagnosis, �2 mths


Consider referral to:Diabetes EducatorDietitianIndigenous Health WorkerExercise ProfessionalPsychologistEndocrinologistNephrologistsCardiologistPodiatrist

Standard Care PathwayAnnual Cycle of CareEvidenced 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


• Urine - Microalbuminuria - albumin - nitrates - leucocytes• Liver Function Tests• Height


Diagnosis, �2 mthsDiagnosis/as appropriate

http://www.nhmrc.gov.au/publications/subjects/diabetes.htm

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• Weight, BMI

• Waist circumference

• Personal history

• Family history

• Life- SNAP - Smoking - Nutrition - Alcohol - Physical Activity

Diagnosis, 3 mths

Diagnosis, 3 mths

Diagnosis

Diagnosis

Diagnosis, 3 mths

SNAP �7,�8

http://www.racgp.org.au/guidelines/snap/

Self CareHome blood glucose monitoringFoot checks and careLifestyle (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 assessment-Diagnosis and �2 mths Foot inspecection-3 mths


Consider referral to :Podiatrist

See Section 2.4.2: Table 6 Complications-Feet and Section 3.4: Podiatry sectionAppendix �- 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.htmlhttp://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 abnormalityIf retinopathy detected- 3-�2 mths depending on level of diabetic retinopathy

Appropriately trained GP/Medical Officer

Consider referral to:Ophthalmologist Optometrist


http://www.nhmrc.gov.au/publications/synopses/cp56 covr.htm

Psychological Status9

• Adjustment• Depression• Anxiety• Stress• Anger• Cognition

Diagnosis, 3 mths


Consider referral to:Psychologist

ADA Standards of Medical Care in Diabetes, Psychological Assessment and Care, 20069

�8

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• Behaviour

• Social

(see section 2.5 Table 7: Specific Issues-Psychological Issues for details)

http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s4#SEC9

Canadian Diabetes Association Clinical Practice Guidelines-Psychological Aspects of Diabetes4�

http://www.diabetes.ca/cpg2003/chapters.aspx?psychologicalaspectsofdiabetes.htm

Depression Anxiety Stress Scales 2� 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 Diversity-A Guide for Health Professionals http://www.health.qld.gov.au/multicultural/cultdiv/default.asp

Disability Diagnosis,

As required


Disability Services Qld http://www.disability.qld.gov.au/

Medications

• Symptoms

• Blood glucose

• Complications

• Risk factors for complications

Diagnosis, 3 mths GP/Medical Officer Consider referral to:

Endocrinologist

Pharmacist

20



Immunisations7 Diagnosis, �2 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


Patient record

Diabetes Patient Record Forms7

(RACGP)

2.2 Table 3 Management


Determine Primary Care Coordinator

Diagnosis, �2 mths Patient and General Practitioner/ Medical Officer


Diabetes Educator


Remote Area Health Nurse

Register with NDSS Diagnosis Patient and Credentialed Diabetes Educator/ GP/Medical Officer

National Diabetes Services Scheme (NDSS)

http://www.diabetesaustralia.com.au/ndss/index.html ph: �300 �36 588

Goals

Negotiate goals and objectives with the patient

Review achievement of goals


3 mths

Primary Care Coordinator and Patient

Consider referral to: Psychologist

Management Plan

• Develop management strategies to meet goals

• Consider development/ review of “GP Management Plan”

• Consider establishment/ review “ Team Care Arrangement”

• Manage acute symptoms

• Optimise blood glucose

Diagnosis, 3 mths

Diagnosis, 6mths

Diagnosis, 6 mths

Diagnosis, 3 mths

Diagnosis, 3 mths

Primary Care Coordinator and patient

GP/Medical Officer



Diabetes Educator

Dietitian

Endocrinologist

Exercise Professional

Podiatrist

Psychologist

Pharmacist

Nephrologists

Ophthalmologist

Optometrist

GP Management Plan (MBS Item:721)

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease-forms/$FILE/sform72�gpmp.pdf

2�



• Optimise blood pressure

• Optimise lipids

• Treat complications

• Optimise risk factors

Diagnosis, 3 mths

Diagnosis, 6mths

Diagnosis, As required

Diagnosis, 3mths

Neurologist

Cardiologist

Vascular Specialist

Team Care Arrangement (MBS Item: 727 )

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease-forms/$FILE/sform723tca.pdf

Standard Care Pathway

Annual Cycle of Care

Self Management/Care/DSME�3

Encourage

• Home blood glucose monitoring

• Self foot examinations and care

• Lifestyle (see below)

Diagnosis, 3mths/as required

Diabetes Educator ADEA National Standards for Diabetes Education Programs 200��4

ADA National Standards for Diabetes Self Management Education�5

Lifestyle

Encourage required lifestyle changes

• Smoking

• Nutrition Refer for Medical Nutrition Therapy

• Alcohol

• Physical Activity

For more details see section 2.4.� Table 5 Risk factors- Smoking and Alcohol and 2.5 Table 7 Specific Issues-, Diet, and Exercise

Diagnosis, 3mths Primary Care Coordinator

Dietitian


Dietitian


Physiotherapist

Psychologist


Group programs

Support Groups e.g. Diabetes Australia Healthy Lifestyle Workshops

Flexible Competencies

Diabetes Resource Health Professional/RN

Lifestyle Prescriptions �9

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-lifescripts-index.htm#kit

Australian Dietary Guidelines 27

http://www.nhmrc.gov.au/publications/synopses/dietsyn.htm

Lighten Up to a Healthy Lifestyle

The Healthy Weight Program

Australian Physical Activity Guidelines28

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-physical-activity-adults-pdf-cnt.htm

QUIT

http://www.quitnow.info.au/

22



Smoking Cessation Guidelines for Australian General Practice 34

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-publicat-tobacco.htm/$FILE/smoking_flip.pdfNHMRC Australian Alcohol Guidelines: Health Risks and Benefits35

http://www.nhmrc.gov.au/publications/_files/ds9.pdfChronic Disease Self-Management Programs eg. Kate LorigFlinders, Arthritis FoundationDiabetes Australia - QueenslandDiabetes 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: EndocrinologistPharmacistDiabetes Educator


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.htmlhttp://www.nhmrc.gov.au/publications/subjects/diabetes.htm

Diabetes EducationSee Table 4- General Education and Counselling

Diagnosis 3 mths/as required


Consider referral to:Diabetes EducatorDietitianPodiatristExercise Professional

Table 4: General Education and Counselling

22

23



Physiotherapist

Psychologist


Group programs

Support Groups e.g. Diabetes Australia Healthy Lifestyle Workshops

Flexible Competencies

Diabetes Resource Health Professional/RN

Immunisations

Administer required immunisations

Diagnosis, �2 Months GP/Medical officer Diabetes Management in General Practice7

Emotional Support and Counselling


Consider referral to: Psychologist

Address Impact of Cultural Issues



Consider referral to: Indigenous Health Worker

See resources listed for assessment of cultural issues-Section 2.� Table 2 Assessment

Address disability issues



Disability Services Qld

http://www.disability.qld.gov.au/

Notify Driver Licensing Authority

Diagnosis Primary Care Coordinator

Austroads Assessing Fitness to Drive43

http://www.austroads.com.au/aftd/index.html

Add details to Patient Register +/- Recall system

Diagnosis

Update as required


Diabetes Register/Recall System

• Document goals, treatment and management in patient record/ GP Management Plan


Flexible Competencies:

Practice Nurse

• Communicate management plan to patient and other providers of patient care

• Consider establishment of patient held record

Organise Required Referrals


24


2.3 Table 4 General Education and CounsellingThe following table include questions patients may ask. These are designed to promote patient focused education.

What Content Who Referrals Resources

Definition

What is diabetes?

• Define diabetes

• Differentiate between Type � and Type 2



Diabetes Educator

Dietitian


Flexible Competencies-

Diabetes Resource Person, Practice Nurse, RN,

Podiatrist,

Pharmacist,

Psychologist,

Exercise professional

NDSS

Diabetes Australia - Queensland

Diabetes Australia Qld: Diabetes link (diabetes service directory)

http://www.daq.org.auDiabetes Management in General Practice7

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

I feel fine-are you sure I have diabetes and do I really have to treat it?

• No symptoms/signs (stress importance of treating diabetes even if no symptoms are present)

• Polyuria

• Polydipsia

• Polyphagia

• Weight loss

• Nocturia

• Malaise

• Altered Vision

• Recurrent infections

• Poor wound healing

• Neuropathy

• Claudication

• Sexual Issues

Complications

What are the effects of diabetes?

• Macrovascular disease

• Renal Disease

• Eye damage

• Neuropathy (Sensory, motor, autonomic nerves)

• Foot Disease

• Sexual issues

• Infections

25



Risk Factors for Diabetes44

Why did I get diabetes?

• Family history• Ethnic background• Weight• Gestational diabetes• Age• Lifestyle• Depression• Other eg hypertension,

hyperlipidaemia


Consider referral to:Psychologist , CounsellorFlexible Competencies Diabetes Resource Health Professional, Practice Nurse, RNDietitianPodiatristPharmacistExercise professional

NDSSDiabetes 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.htmlhttp://www.nhmrc.gov.au/publications/subjects/diabetes.htm

General Treatment of DiabetesCan you cure Diabetes?

How will my diabetes be treated?How can I manage my diabetes?

• Explain no cure• Treatment Goals

- Blood Glucose Control - Manage acute symptoms - Minimise complications

and the risk of complications.

- Targets• Explain the role of

- Diet/healthy eating- Exercise/activity- 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 DietitianIndigenous Health WorkerFlexible CompetenciesDiabetes Resource Health Professional, RNExercise ProfessionalPodiatristPsychologistPharmacistPractice Nurse


NDSSDiabetes Australia - QueenslandStandard Care PathwayAnnual Cycle of Care

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

HypoglycaemiaWill I have a hypo?What do I do if I have a hypo?How can I prevent hypos?

• Causes• Treatment• Prevention

26



Home Blood Glucose Monitoring

How do I know if my glucose is well controlled?

How do I test my blood glucose at home?

• Discuss the role of the Blood Glucose Meter

• Organise a Blood Glucose Meter if appropriate

• Complete NDSS form

• Provide education regarding the use of a Blood Glucose Meter


Refer to Diabetes Educator

Flexible competencies

Pharmacist

NDSS subagent

NDSS


Patient Resources

Where can I get more information?

Provide list of resources with contacts details

Refer as required



NDSS


Frequency of Review

How often do I need to have a check up and by whom?

Discuss

• Frequency of review

• Referrals

• Team approach

• Self monitoring and management

• Model of Care/Clinics/ GP

• Ensure patient details registered on recall system/register



Diabetes Educator,

Dietitian,

Indigenous Health Worker,

Podiatrist,

Psychologist,


Endocrinologist,

Ophthalmologist

Optometrist

Neurologist

Cardiologist

Vascular specialist

Support groups associations


Managing your diabetes - What you should know (patient brochure) Queensland Health and Diabetes Australia - Queensland



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

• Complications

• Lifestyle difficulties

• Poor blood glucose control

• Medication issues

• Foot disease especially infections

• Change in vision

• Chest pain

• Unwell/ vomiting/infection/poor intake

• Emotional Issues



Diabetes Educator,

Dietitian,

Indigenous Health Worker,

Podiatrist,

Psychologist,


Endocrinologist,

Ophthalmologist

Optometrist

Neurologist

Cardiologist

Vascular specialist

Support groups associations


Diabetes Management in General Practice �


Managing your diabetes - What you should know (patient brochure) Queensland Health


27


2.4 Prevention and Management of Complications

2.4.1 Table 5 Risk Factors


Blood Glucose Control

• Review, manage and provide education including;

q Self monitoring

q Lifestyle

q Medication

q Other contributing factors eg illness, other medications



Diabetes Educator

Dietitian

Endocrinologist

Psychologist

NDSS

SNAP �7,�8

Lifestyle Prescriptions�9


Weight • Negotiate with the patient to set realistic weight loss goals

• Review and provide education/counselling

q Diet

q Medical Nutrition Therapy

q Exercise

q Medication

q Surgery

• Provide Lifestyle Prescription

Primary Care Coordinator and patient

Dietitian

Dietitian/Primary Care Coordinator

GP/Medical Officer

Refer to Dietitian



Weight Control Group

Psychologist

Surgeon

SNAP�7,�8

Weight Watchers

http://www.weightwatchers.com.au/

Lighten Up�9

NHMRC Guidelines-Overweight and Obesity in Adults- A Guide for General Practitioners29

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/obesityguidelines-guidelines-adults.htm


Chronic Disease Self Management Programs

Lipids39 • Review and encourage lifestyle changes especially diet and exercise

• Emphasise importance of weight loss if required

• Review and improve blood glucose control if possible

• Review medication requirements

• Monitor lipids


GP/Medical Officer


Dietitian


Endocrinologist

SNAP�7,�8

National Evidenced Based Guidelines for the Management of Type 2 Diabetes Mellitus Lipid Control39


http://www.nhmrc.gov.au/publications/subjects/diabetes.htmChronic Disease Self Management Programs


28



Blood Pressure38 • Review lifestyle (SNAP) and recommend appropriate changes

• Emphasize importance of weight loss if required

• Review medications and compliance

• Consider ACE Inhibitor initially and combination therapy if required

• Emphasize importance of compliance with medications

• Monitor at every visit


GP/Medical Officer/


Dietitian

Diabetes Educator


Endocrinologist

SNAP�7,�8

National Evidenced Based Guidelines for the Management of Type 2 Diabetes Mellitus-Diagnosis and Management of Hypertension38

http://www.nhmrc.gov.au/publications/subjects/diabetes.htmChronic Disease Self Management Programs


Smoking • Emphasize benefits of stopping

• Counsel

• Consider lifestyle prescription

• Refer to QUIT

• Consider nicotine adjunctive therapy or Bupropion34



Psychologist

Diabetes Educator

RN

Practice Nurse

Diabetes Resource Person

QUIT

Smoking Cessation Guidelines for Australian General Practice34

Smoke Check

Lifestyle Script�9

Chronic Disease Self Management Programs

Alcohol • Assess intake

• Educate re recommended intake

• Provide counselling to reduce intake if required



ATODS

Counsellor

Psychologist

Lifestyle Scripts �9

NHMRC Australian Alcohol Guidelines: Health Risks and Benefits35

2.4.2 Table 6 ComplicationsWhat Content Who Referrals Resources

Feet40

Low Risk Foot

(i.e. without Neuropathy, PVD, Foot Deformity, Ulceration or Amputation)

• Ensure annual screen for Foot Risk Status, i.e. assess for: q Peripheral Neuropathyq Peripheral vascular

disease (PVD)q Foot deformityq Ulceration & Amputation

Refer to Basic Foot Screening Checklist 47

(See Appendix 1)• Inspect for Foot

Complications• Educate :

q Effects of hyperglycaemia on feet

q Self foot careq Footwear choicesq Services available to

assist

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 �: 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

28

29



At Risk Foot

(i.e. Neuropathy,

PVD or

Foot Deformity)

• Consider further assessment and management of:

q Neurological status,

q Vascular (i.e. Doppler, PPG, Duplex),

q Biomechanical & Foot Deformity,

q Dermatology (eg callus),

q Footwear.

• Reinforce above diabetic foot care education

Podiatrist, GP, Diabetes Educator

IHW trained in foot care


Endocrinologist

Vascular Surgeon

Orthopaedic Surgeon or Surgical Podiatrist

Neurologist or Orthotist

Refer <0.5 Ankle Brachial Index or <40mmHg Toe Pressures for further vascular investigations &/or Vascular Specialist

Australian Podiatric Councils & Diabetes Australia Australian Podiatric Guidelines for Diabetes 3�

http://www.apodc.com.au/apodc/diabetes.

Warnock’s Indigenous Foot Project

High Risk Foot

(i.e. Foot Deformity with Neuropathy &/or PVD, Previous Ulcer or Amputation)

Acute Diabetic Foot

(i.e. Foot Ulcer,

Foot Infection,

Ischaemic Pain,

Charcot Foot)

• Ensure appropriate pressure off-loading, pathological skincare, foot care & footwear.

• Reinforce above diabetic foot care education.

• Use‘ClinicalAssessment,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

Podiatrist, GP, Wound Care Nurse, Diabetes Educator

If > 2cm cellulitis and/or can probe wound to bone include urgently:

Endocrinologist

Vascular Surgeon

Infectious Disease Specialist

Orthopaedic Surgeon or Surgical Podiatrist


Endocrinologist, Vascular or Orthopaedic Surgeon or Surgical Podiatrist, Infectious Diseases Specialist, Plaster Technician & Orthotist

Appendix 3: Wraight et al’s Clinical Assessment and Investigations and Management of Acute Diabetic Foot Complications46

QH Podiarty resources

http://qheps.health.qld.gov.au/odb/hau/allied/html/disciplines/podiatry.htm

Eyes30 • Ensure regular eye examinations

q Assess visual acuity

q Check for fundal or retinal abnormality

q Check Cataracts

q Check for Retinopathy/Diabetic Macular Oedema

• Optimise control of blood glucose and blood pressure

• Inform patient of the indications for urgent presentation to Ophthalmologist

Appropriately Trained GP/Medical Officer

Outreach Eye Team


Refer to Ophthalmologist/ Optometrist within � 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



http://www.nhmrc.gov.au/publications/synopses/cp56 covr.htm

30



Cardiovascular Disease6

• Assess and treat risk factors aggressively

q Smokingq Weightq Blood pressureq Activityq Lipidsq Depression

• Lifestyle

Reemphasize importance of lifestyle changes (consider lifestyle scripts)

• Assessforatrialfibrillation

• Resting ECG6

Perform every 2 years in people aged over 50 years who have one or more risk factors

• Consider aspirin6


GP/Medical Officer

Consider referral to

Cardiologist

Endocrinologist

Diabetes Educator

Dietitian


Psychologist

National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus-Prevention and Detection of Macrovascular Disease 6

http://www.nhmrc.gov.au/publications/subjects/diabetes.htmLifestyle Prescriptions�9

Kidneys7,9 • Provide education and treatment for:

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 radio-contrast media

• Provide Medical Nutrition Therapy

GP/Medical Officer

Dietitian

Refer to Nephrologist and Dietitian if renal impairment is detected (eGFR < 60)

ADA Standards of Medical Care in Diabetes 20069



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

2.5 Table 7: Specific IssuesWhat Content Who Referrals Resources

Medications • Review medicationsq Side Effectsq Actionsq Doseq Timingq Contraindicationsq Effectivenessq Combinationsq Change in health status

GP/ Medical Officer

Consider referral to

Endocrinologist

Accredited Pharmacist for Home Medicines Review

Pharmacist

Diabetes Educator


ADEA (02) 6287 4822

www.adea.com.au

MIMS

http://www.mims.com.au/

3�



• Alter medications as required

• Educate

q Side effects

q Importance of compliance

Diabetes Educator

Pharmacist

Oral Hypoglycaemic agents (OHAs)

• Review blood glucose control, HbA1c

• Commence tablets as required

• Educate and counsel

q Reasons

q Actions

q Side Effects

q Dose

q Timing

q Importance of compliance

q Implications for commercial driver’s licence

GP/Medical Officer

Diabetes Educator

Pharmacist

Consider referral to :

Endocrinologist

Diabetes Educator

Pharmacist


MIMS

Insulin • Review blood glucose control, HbA1c

• Commence insulin as required

• Educate and counsel

q Actions

q Complications/side 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


GP/Medical Officer


Consider referral to :

Diabetes Educator

Dietitian

Endocrinologist

Pharmacist

RN

Diabetes Resource Health Professional


MIMS

NDSS

NDSS Subagents

Community Pharmacists

32



Diet • Provide General Nutrition Education.

• Provide Medical Nutrition Therapyq Nutrition assessmentq Goalsq Individualised nutrition

prescriptionq Counselling/educationq Evaluation

Primary Care CoordinatorDietitian

Refer to Dietitian See section 3.2:DietitianAustralian Dietary Guidelines27

Diabetes Australia - QueenslandHealthy Eating WorkshopsDietetic 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/s36ADA Standards of Medical Care in Diabetes, 2006, 9


Exercise • Assess contraindications/cardiac risk/ensure medical clearance for exercise

• Assess current/past exercise patterns

• Explainthebenefitsofexercise/motivate

• Provide exercise prescription (consider using a Lifestyle Prescription)

• Educate and counselq Precautionsq Blood glucoseq Medication/insulinq Foodq Foot wear


Refer to Cardiologist if cardiac riskConsider referral to Exercise ProfessionalGroup PsychologistFlexible Competencies:RNDiabetes Resource Health ProfessionalPractice NursePodiatristDietitian

National Physical Activity Guidelines for Australians28


Standards of Medical Care in Diabetes 20069

ADA Physical Activity/Exercise and Diabetes 5�

Psychological Issues • Examine and address poor adherence/poor control

• Consider psychological issuesq Adjustmentq Depressionq Anxietyq Stressq Angerq Cognitionq Behaviourq Relationships

Primary Care Coordinator/Psychologist

Consider referral to: Psychologist Support GroupSocial Worker

Global Guideline for Type 2 Diabetes-Psychological Care, IDF, 2005 37

http://www.idf.org/webdata/docs/IDF%20GGT2D.pdf

32

33



• Address factors impacting upon management

q Family issues

q Work

q Adherence

q Adjustment

q Financial Impact

q Sexual implications

• Provide treatment/counselling as required

• Monitor regularly

ADA Standards of Medical Care in Diabetes, Psychological Assessment and Care,20069

http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s4#SEC9Canadian Diabetes Association Clinical Practice Guidelines-Psychological Aspects of Diabetes4�

http://www.diabetes.ca/cpg2003/chapters.aspx?psychologicalaspectsofdiabetes.htmAustralian Psychological SocietyDepression Anxiety Stress Scales 2� and 4242

The Kessler Psychological Distrress Scale (K10)92

APA Practice Guidelines for the Treatment of Psychiatric Disorders36

(American Psychiatric Association)

Sick Days Provide management strategies including;

• Blood glucose testing

• Medications

• Meals and fluids

• When to notify the Doctor



Diabetes Educator

Dietitian


Practice Nurse

Diabetes Australia - QueenslandGuidelines for Sick Day ManagementDiabetes Management in General Practice7

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

Gastroenterologist

Pregnancy • Preconception issuesq Blood Glucose controlq Medicationsq Folateq Educate re complications

of pregnancy, congenital abnormalities and complications of diabetes (retinopathy, hypertension, nephropathy)

• Pregnancyq Team care arrangement


Refer to:

Obstetrician,

Endocrinologist

Ophthalmologist

Diabetes Educator,

Dietitian

Paediatrician


Midwife

Position Statement- The Australasian Diabetes in Pregnancy Society (ADIPS) Consensus Guidelines for the Management of Type � and Type 2 Diabetes in Relation to Pregnancy,200533

ADIPS Gestational Diabetes Mellitus- Management Guidelines32

33

34



q Blood glucose control

q Medicationsq Eye reviewq Monitoringq 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 upq Blood glucose controlq Contraceptionq Ongoing assessment

and management as per Standard Care Pathway/as required

http://www.adips.org/

Driving • Discuss and assess effects of:

q Treatment

q Medications

q Complications

q Hypoglycaemia

q Eyes

• Assessfitnesstodriveaccording to Driving Licensing Authority Standards

• Complete and provide patient with Medical Certificate.Retainacopyin patient record. Inform and counsel patient of outcome

GP/Medical Officer

Diabetes Management in General Practice

Assessing Fitness to Drive 200343

www.austroads.com.au/aftd/index.htm


Travel Provide advise re

• Planning

• Insurance

• Food

• Medications

• Monitoring

• Medical letter


GP/Medical Officer


Diabetes Educator


RN

Practice Nurse



Sexual Issues I am having sexual problems

• Optimise blood glucose control

• Consider micro vascular and macrovascular causes

• Review medications

• Offer treatment as appropriate and provide counselling



Endocrinologist

Relationships Australia

35


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)

2 To help decrease the risk of complications

3 To improve quality of life

4 To develop the knowledge and skills required to make appropriate choices to maintain or improve health

5 To ensure care is coordinated

6 To 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 accountable53

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:

36


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

37


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).�4 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.�4

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

2 Use 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.

3 Include in education teams a health-care professional with specialist training in diabetes and delivery of education for people with diabetes

4 Ensure 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

6 Use 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

- HbA�c > 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 CompetenciesIn 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.

38


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

RationaleOverweight 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 3� % 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 �3%. 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 DiabetesThe 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

2 To contribute to optimal metabolic control (blood glucose, lipids, blood pressure)

3 To achieve and maintain desired body weight/waist circumference/ required weight reduction

4 To 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 DiabetesDietitians 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.�3 The role of the dietitian involves nutrition assessment, intervention, counselling, communication and evaluation. The dietitian aims to provide interventions that:

39


• 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 �3

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 include�3

• 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.�3

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. �3

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.

40


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

ReferralsIdeally 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.�3 As a minimum patients must be referred to a dietitian if

- New Diagnosis

- HbA�c > 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 CompetenciesWhere 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.

4�


3.3 Indigenous Health Worker

RationaleThe prevalence of diabetes is two to four times higher in Aboriginal and Torres Strait Islander peoples than the non-indigenous 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 DiabetesTo 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 �999.6�

Role of the Indigenous Health WorkerAboriginal 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.

42


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 WorkersDiabetes 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 – 006The 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.

CompetenciesDeliver 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.

2 Assess the need for diabetes prevention and management health services in the community

3 Plan 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

2 Ensure diabetes prevention and management health services are delivered appropriately

3 Develop expertise of staff in diabetes prevention and management.

Nutrition Health CareNutritional Health Care is delivered under direction which may be provided as close supervision or established guidelines, which limit discretion.

Nutrition Health Worker – Advanced 004/TO2Health Workers at this level have highly developed skills, knowledge and training in a specialised area.

Nutrition Health Worker – 006The 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.

CompetenciesDeliver Nutritional Health Care

The following are competencies required:

1 Provide information to the community about nutrition.

2 Assess nutritional status of individuals and a community

3 Plan and implement care

4 Plan and implement change

Provide Nutritional Health Care


1 Undertake activities according to a plan

2 Give nutrition education

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3 Ensure nutrition and physical activity choices are available to the community and promote these choices

4 Assess the nutritional status of the community

5 Support environmental changes which support nutrition and health

6 Provide 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


1 Monitor and plan services to improve nutrition and health.

2 Ensure nutritional services are appropriate

3 Advocate 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

RationaleDiabetic 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 �5% 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 20�0. 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

44


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” 3�

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

2 Promote optimal metabolic control (blood glucose, lipids, blood pressure)

3 Ensure appropriate plantar pressure reduction and footwear

4 Increase knowledge and self care of diabetic foot complications

5 Increase awareness of the need for preventative foot care practices

6 Promote EBP multidisciplinary team approaches to management

7 Promote infection control

8 Achieve optimal wound care environments.

Role of the Podiatrist in the Management of Adults with Type 2 DiabetesThe 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 LowRisk–people without any of the below defined complications 40

II AtRisk–people with

• Peripheral neuropathy or

• Peripheral vascular disease or

• Foot deformity 40

III High Risk – people with

• Foot deformity with peripheral neuropathy or peripheral vascular disease or

• Previous foot ulcer or amputation40

IV Acute 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 ‘BasicFootScreeningChecklist’(AppendixI). 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.

45


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 ‘IntegratedDiabeticFootContinuumofCareClinicalPathway’(Appendix2)48 is advised to determine the most appropriate and timely podiatry sector to access.

‘Low Risk’ Diabetic Foot ManagementThe 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). 3�

‘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 ManagementThe 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) 3�,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 )

46


‘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.

‘HighRisk’DiabeticFootManagement

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.

‘AcuteComplication’DiabeticFootManagement

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)

2 Peripheral Vascular Disease (I)

3 Foot Deformity (I)

4 Infection (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’toboneorwith>2cm surrounding cellulitis should be urgently referred to a Hospital Multi-Disciplinary High Risk Foot Team.62

This guideline recommends the use of Wraightetal’s(2005)‘ClinicalAssessment,Investigations&ManagementofAcuteDiabeticFootComplications’(Appendix3) (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

47


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.


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

ReferralsCommunity-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 ‘BasicFootScreenChecklist’(Appendix1) 47 completed to determine whom to refer. Referral to the ‘IntegratedDiabeticFootContinuumofCareClinicalPathway’(Appendix2) 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 CompetenciesUnfortunately 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.

48


‘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

RationaleIncreasingly 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.69,70,7� Psychologists are involved in promoting self management through changing attitudes and motivation7�,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 80,8� and poor glycaemic control.82 Anxiety symptoms have also been found to be highly prevalent in individuals with diabetes, with �4% 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 ).37,4�,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.”9�

GoalThe 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

2 optimise the emotional state of the individual

3 optimise health behaviours and self management

4 optimise adherence to treatment

5 optimise relationships with family and other health professionals that impact upon the management of the diabetes

6 identify cognitive deficits and optimise management of the effects of deficits upon lifestyle and diabetes self-management.

49


Role of Psychologists in Management of Type 2 DiabetesThe 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.7�,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

MandatoryRegistered as a Psychologist in Queensland

Highly Desirable

Post-graduate studies in Clinical or Clinical Health Psychology


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.

ReferralsIdeally 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

50


• 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 CompetenciesIn 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 PractitionerThe 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 ProfessionalsReferral 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

5�


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

52


Appendices

Appendix 1 Basic Foot Screening Checklist

National Diabetes Foot Screening Project

January 2004

Australasian Podiatry Council National Association of Diabetes Centres

Preventing Foot Complications in Diabetes

BackgroundFoot 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.

Aims1. 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

Screening1. 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.

53



January 2004


Basic Foot Screening Checklist1. Ask the patient neuropathic symptoms Y N

intermittent claudication Y Nprevious foot ulcer Y Namputation Y N

specify SITE______________________ DATE ____/____/______

2. Look at both feet infection Y Nulceration Y Ncalluses or corns Y Nskin breaks Y Nnail disorders Y Nfoot deformity Y N

5. Assess footwear style Good Poorcondition Good Poorfit Good Poor

6. Assess education needDoes the patient understand the effects of diabetes on foot health? Y NCan the patient identify appropriate foot care practices? Y NAre the patient’s feet adequately cared for? Y N

7. Assess self care capacityDoes the patient have impaired vision? Y NCan the patient reach own feet for safe self care? Y NAre there other factors influencing ability to safely care for own feet? Y N

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

LEFT RIGHT3. Check foot

pulsesDorsalis pedis Y N Y N

Posterior tibial Y N Y N

LEFT RIGHT4. Test for

neuropathyMonofilamentdetected at sites marked - o

Y N Y N

54



January 2004


Action Plan following Basic Foot Screening

DATE OF REFERRAL ____/_____/____

PATIENT NAME SERVICE PROVIDER ____________________

Is the foot high risk ? Yes No (re-check in 12 months)

If yes, why ? 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

55


Appendix 2 Intergrated Diabetic Foot Continnum of Care Clinical Pathway

Integrated Diabetic Foot Continuum of Care Clinical PathwayNational 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 ChartThe 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 ServicesFrom 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 �32 �50 or www.hic.gov.au/providers

Your Local Public Podiatrist is:(Place Stamp Here)

56


Appendix 2 Intergrated Diabetic Foot Continnum of Care Clinical Pathway

(EPCP Cover) Private Podiatrist (Patient Pays Extra Visits)

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,

Infected Foot Ulcer Present and/or

Acute Charcot Foot

Absent Foot pulses Hx Claudication,

Vascular ulceration Gangrene

Loss Protective Sensation, Non-

infected Foot Ulcer Present and/or

Acute Charcot Foot

Protective Sensation Intact

and Nil PVD

Consultant Input

• Endocrinologist

• Vascular

• Wound CNC

• Orthopaedic

• Infectious Dz.

Foot Health Leaflet0




FootHealthLeaflet4(FootUlcers)Foot Health LeafletPVD

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

Immediate Referral to GP or

Hospital A&E & Pod with details

of Infection (ie Superficialor

Deep)

Vascular Ulceration or Gangrene

Immediate Referral to Hospital A&E

/Vasc Dept

Patient happy to pay for Wound

Care Program 1-2X/52 RVs

Otherwise Referral to Public

Pod for Doppler/PPG

Studies or Hospital Vasc Department

Refer Public Pod for non-EPCP

ReviewsRefer Public Pod

for 1-8 Weekly ‘AtRisk’Reviews

Refer Public Pod for Urgent Wound Care Program or

Casting

Refer Public Pod for non-EPCP

Reviews

Cat 0 Cat 1

Low Risk

Cat 2 Cat 3

At Risk

Cat 4 Cat 5

High Risk

PVD/Ischaemic

Referral Source: GP; Nurse; AH; Specialist

Community Public PodiatristCommunity

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� Armstrong DG et al. J. Amer. Podiatr. Med. Assn. �996; 86:3��-3�6 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

57


Appendix 3 Wraight Et Al’s Clinical Assessment and Investigations and Management of Acute Diabetic Foot Complications

58


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