diabetes mgt from victorian govt dept (janet laverick)

7/29/2019 Diabetes Mgt from Victorian Govt Dept (Janet Laverick)

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Improving Victorias oral healthMay 2007

Diabetes self-managementGuidelines for providing services to people

newly diagnosed with Type 2 diabetes

March 2007


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ii Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Published by the Victorian Government Department

of Human Services

Melbourne, Victoria

Copyright State of Victoria 2007

This publication is copyright, no part may be reproduced by

any process except in accordance with the provisions of the

Copyright Act 1968.

This document may also be downloaded from the

Department of Human Services website at:

http://www.health.vic.gov.au/communityhealth/

publications/diabetes.htm

Authorised by the State Government of Victoria,

50 Lonsdale Street Melbourne.


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Diabetes self-management: Guidelines forproviding services to people newly diagnosed withType 2 diabetesGuidelines for providing services to people newly diagnosed with Type 2 diabetes iii

Foreword

In Australia, the burden of chronic disease is increasing

rapidly. In Victoria, approximately 70 per cent of the totalburden of disease is attributed to six groups: cardiovascular

disease, cancers, injuries, mental health conditions,

asthma and diabetes. As of 2001, approximately one million

Australians were diagnosed with Type 2 diabetes. A few

decades ago Type 2 diabetes was known as adult-onset

diabetes, mainly affecting older people. The prevalence of

Type 2 diabetes in younger people, including children and

adolescents, is increasing at an alarming rate and is linked

to increasing rates of obesity.

Victorias primary health care system must be able to

respond in an appropriate and cost-effective way tothis challenge. Self-management is about people being

actively involved in their health care. The approach has

been recognised by the Commonwealth Government and

the Victorian Government as a key component of chronic

disease management including diabetes.

The diabetes self-management funding is a component of

Victorias commitment under theAustralian Better Health

Initiative (ABHI): a joint Australian, State and Territory

Government initiative. The funding will support early

intervention for people with high risk and newly diagnosed

with Type 2 diabetes to assist them to become an active

partner in the management of their health.

The diabetes self-management guidelines are aimed at

Primary Care Partnerships and their member agencies (in

particular community health services, rural health services

and Divisions of General Practice) to support the provision

of planned, managed, integrated and proactive care for

people with chronic disease. I encourage you to use the

guidelines to improve the health outcomes for people with

chronic disease.

Janet Laverick

Director Primary Health Branch


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iv Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Contents

Foreword iiii

1. Introduction 1

1.1 About the guidelines 1

1.2 The impact of diabetes 2

1.3 A coordinated approach to chronic disease 4

1.4 Overview of diabetes self-management funding 5

2. Chronic disease management 7

model for primary care

3. Diabetes self-management 9service delivery

3.1 Client assessment and care planning 9

3.2 Self-management 11

3.3 Client monitoring 14

4. Diabetes self-management 16

supporting systems

4.1 GP liaison 16

4.2 Client recruitment and referral pathways 17

4.3 Clients with multiple chronic conditionsor complex needs 17

4.4 Decision support tools 18

4.5 Flexibility in service provision 18

4.6 Addressing health inequalities 19

5. Funding and reporting 215.1 Funding and reporting for CHSs 21

5.2 Funding and reporting for PCPs 21

5.3 Funding for workforce development 21

Appendix 1

A summary model of community

care through community health

services for people with

Type 2 diabetes 22


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Diabetes self-management: Guidelines forproviding services to people newly diagnosed withType 2 diabetesGuidelines for providing services to people newly diagnosed with Type 2 diabetes

1.1 About the guidelines

Care for people with chronic disease, such as Type 2diabetes, usually involves multiple health care providers in

multiple settings. To provide this care within an integrated

system, health care providers must work collaboratively

to coordinate and plan care and services. This requires a

commitment from health care providers and agencies to

work together to achieve shared goals.

People with Type 2 diabetes need a responsive person-

centred and effective system of care. These diabetes

self-management guidelines aim to support member

agencies of Primary Care Partnerships (PCPs), in particular

Community Health Services (CHSs), Rural Health Services

(RHSs) where applicable, and Divisions of General Practice

(DGP), to implement new diabetes self-management

funding in the context of a chronic disease management

(CDM) approach across the service system. The guidelines

also provide support for CHSs, PCPs and DGP as part of the

broader integrated chronic disease management (ICDM)

work. They should be used in conjunction with the Chronic

Disease Management Program Guidelines.

Self-management is about people being actively involved

in their health care. The approach is underpinned by anumber of principles1 and has been recognised by the

Commonwealth Government and the Victorian Government

as a key component of diabetes management and CDM

more broadly.

Diabetes self-management funding supports work already

being undertaken by CHSs and PCPs. For example:

All PCPs now receive recurrent funding for ICDM which

builds on the established PCP role in facilitating service

system integration and change management across

member agencies.

Core business for CHSs includes providing services to

people in the community who have chronic disease.

Many CHSs, particularly those in receipt of Early

Intervention in Chronic Disease funding, are working

on internal systems changes to ensure services are

delivered within a CDM model of care.

1 ational Health Priority Action Council (HPAC) 2006,ational Health Priority Action Council (HPAC) 2006, NationalChronic Disease Strategy, Australian Government Department ofHealth and Ageing, Canberra

1. Introduction

While these guidelines are targeted at CHSs (or RHSs where

applicable) and PCPs that receive direct funding (recurrentfor CHSs/RHSs and one-off funding for PCPs), they are also

intended to support agencies in their work with people who

have chronic disease.

The diabetes self-management guidelines should be used in

conjunction with:

Chronic Disease Management Program Guidelines2

Primary Care Partnership Planning and Reporting

20062009 guidelines3

Audiences

Community Health Services

funded under diabetes self-management

Funding provided to CHSs (or RHSs where applicable)

for diabetes self-management has been made available

to CHSs that are not in receipt of Early Intervention in

Chronic Disease funding. However, as stated in the Early

Intervention in Chronic Disease guidelines, the diabetes

self-management funding also builds on the work already

being done by CHSs and PCPs to support people in the

community who have chronic disease. Specifically, it

provides CHSs with additional funding to increase servicedelivery to people with Type 2 diabetes, but also expects

that CHSs will work on internal systems changes to deliver

services that are consistent with evidence-based chronic

care. Refer section 5.1.

PCPs

PCPs have been provided with one-off funding to facilitate

service system integration and change management across

member agencies. In particular, general practice (through

DGP) and CHSs will need to be involved. Refer section 5.2.

Other agenciesAlthough funding for this initiative has been targeted to

CHSs, all CHSs see significant numbers of people with

chronic disease who would benefit from self-management

interventions and approaches. These guidelines could be

applied to other agencies wanting to develop and/or embed

self-management into practice.

2 http://www.health.vic.gov.au/communityhealth/downloads/cdm_program_guidelines.pdf

3 http://www.health.vic.gov.au/pcps/strategy/index.htm#reporting


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Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Rationale for self-management

There is a strong evidence base internationally for self-management and a growing evidence base within the

Australian context. The most recent and largest initiative to

test self-management models within the Australian health

care system was the Australian Government funded Sharing

Health Care Initiative. The initiative included a series of eight

demonstration projects conducted over three years using

a range of models including the Stanford Model, Flinders

Model and Telephone Coaching. All eight projects found

that people reported improved health outcomes, a better

quality of life and reduced use of health services4. These

trends were also found in Indigenous and culturally andlinguistically diverse (CALD) client groups, which were part

of most projects.

The National Chronic Disease Strategy5 outlines a number

of key directions for self-management which have been

built into these guidelines. Embedding self-management

principles has been identified as a key to maximising the

quality of life of people with a chronic disease and reducing

the risk of complications.

1.2 The impact of diabetesDiabetes has an enormous impact on people, their families,

the community and the health system. It has been proven

that people with Type 2 diabetes have significantly lower

productivity and participation rates. The costs for Type 2

diabetes have been rising rapidly over recent years. The

Australian Institute of Health and Welfare projects6 that

government expenditure on Type 2 diabetes will increase

by over 600 per cent between 2001 and 2031.

The facts on diabetes means the government must act

to ensure a strong focus on:

prevention of diabetes

early detection and intervention

quality service provision, including self-management

to prevent complications.

4 ational Evaluation of the Sharing Health Care Initiative: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/chronicdisease-nateval

5 ational Health Priority Action Council (HPAC) 2006, ationalChronic Disease Strategy, Australian Government Department ofHealth and Ageing, Canberra

6 Australian Institute of Health and Welfare 2006,Australian Institute of Health and Welfare 2006,Australias Health2006, Canberra

Diabetes the facts7

Diabetes is a disease in which the body does not produce orproperly use insulin. Insulin is a hormone that is needed to

convert sugar, starches and other food into energy needed

for daily life. The cause of diabetes is unknown. Both family

history and lifestyle factors, such as obesity, poor diet and

lack of exercise, are risk factors. The major types of diabetes

are gestational diabetes, prediabetes, Type 1 diabetes and

Type 2 diabetes.

Gestational diabetes8

Occurs during pregnancy and usually goes away after the

baby is born.Affects 38 per cent of pregnant females.

Increases the risk of developing Type 2 diabetes later in

life with a 3050 per cent chance of developing Type 2

diabetes within 15 years of pregnancy.

Prediabetes5

Occurs when a person's blood glucose levels are higher

than normal but not high enough for a diagnosis of Type 2

diabetes.

Many people live with prediabetes unaware of the

condition and its impact on their health.Type 1 Diabetes5

Affects 10-15 per cent of Australians with diabetes.

Is an autoimmune condition.

Results from the body's failure to produce insulin.

Type 2 Diabetes6

In 2001, approximately one million Australians were

diagnosed as having Type 2 diabetes.

Up to 50 per cent of all cases remain undiagnosed.

Is largely a preventable chronic disease.

By 2031, it is projected 3.3 million will have Type 2

diabetes.

Increases two to five times the risk of having a heart

attack or stroke.

7 ational Reform Agenda,ational Reform Agenda, 2006: Victorias plan to address the growingimpact of obesity and type 2 diabetes, Consultation Draft, Council ofAustralian Governments

8 Diabetes Australia,Diabetes FactSheets, viewedFebruary 2007,Diabetes Australia, Diabetes Fact Sheets, viewed February 2007,International Diabetes Institute Diabetes Research, Education and Care


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Without adequate management a person with Type 2

diabetes is likely to develop complications such as renalimpairment and peripheral vascular disease.

Insulin is still produced by the pancreas, but is less

effective than normal. This is known as insulin resistance.

The prevalence of Type 2 diabetes in younger people,

including children and adolescents, is increasing at an

alarming rate. A few decades ago Type 2 diabetes was

known as adult-onset diabetes, mainly affecting older

people. The prevalence of Type 2 diabetes in children

and adolescents is linked to the increasing rates of obesity

in this group. Obesity rates for children aged 715 years,

based on studies conducted in 1985 and 1995, grew forboys from 1.4 per cent to 4.5 per cent and grew for girls

from 1.2 to 5.3 per cent. It has been estimated that in

2004, 2025 per cent of children and adolescents were

overweight or obese.9

Diabetes and chronic diseasein disadvantaged subgroups

The link between diabetes and an ageing population

and various subgroups within the population has been

recognised.8

Subgroups include (but are not limited to):

Aboriginal and Torres Strait Islander communities

people from CALD backgrounds

rural and regional communities

people from lower socioeconomic groups.

These subgroups warrant attention to minimise the impact

of chronic disease on the individual, their family and the

broader community.

Aboriginal and Torres Strait Islander communities

Aboriginal and Torres Strait Islander communities haveparticularly high rates of diabetes, with up to 30 per cent of

some communities being affected by diabetes. High levels

of ill health among Indigenous Australians10,9 have been

linked to:

adverse socioeconomic conditions compared with general

Australian standards including lower incomes, poorer

educational outcomes and lower rates of home ownership

9 Australian Institute of Health and Welfare 2006,Australian Institute of Health and Welfare 2006,Australias Health

2006, Canberra10 ational Public Health Partnership 2001,ational Public Health Partnership 2001, Eat Well Australia: An

Agenda for Action for Public Health Nutrition 20002010, StrategicInter-Governmental utrition Alliance, Canberrahttp://www.nphp.gov.au/publications/signal/eatwell1.pdf

poor housing

exposure to violenceextent of control and perceptions of mastery in the

workplace and wider society

higher exposure to life stressors such as the death of

a family member or close friend, overcrowding at home,

alcohol and other drug problems, serious illness or

disability, and not being able to get a job

food insecurity.

Rural and regional communities

People living in rural and remote areas of Australia have

poorer health and higher levels of health risk factorscompared with those living in urban areas. This is despite

the perceived health advantages of living in rural areas

(clean air, less traffic, more relaxed lifestyle)11. Rurality itself

is not the main factor leading to poorer health among people

outside major cities. Factors associated with rurality are the

causes of comparative health disadvantage in those areas.

Such factors include:

socioeconomic disadvantage (including lower incomes

and education levels)

geographic isolation and difficulties with access to

health careshortage of health care providers and services

greater exposure to injury

greater difficulties in transport and communications

sparsely distributed populations leading to diseconomies

of scale

insufficient supply of affordable and quality fresh food

unsupportive environment for physical activity.

Lower socioeconomic groups

Socioeconomic status (SES) is a strong predictor of

health. The lower a persons SES, the shorter his or her lifeexpectancy and the more prone he or she is to a wide range

of chronic diseases and conditions. Diabetes prevalence

is almost 2.5 times higher for the lowest SES groups. The

link between SES and health begins at birth and continues

through life. There is a strong, but indirect, association in

11 Australian Institute of Health and Welfare 2006, Chronic Diseases andAssociated Risk Factors in Australia, 2006, AIHW, Canberra, http://www.aihw.gov.au/publications/phe/cdarfa06/cdarfa06.pdf


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which SES affects health and health affects SES. Some

factors that can lead to SES effects on health12,11

include:differential access to high quality health care

individual factors such as smoking, exercise, nutrition,

stress and depression

social environments such as neighbourhood, work,

interpersonal support or conflict

violence and discrimination

long-term effects of prenatal and early childhood

environmental factors

structural factors that affect equitable access to food.

1.3 A coordinated approach

to chronic disease

A coordinated statewide response to diabetes is being

developed (currently out in draft for public comment)13

and will be part of the ational Reform Agenda to address

the growing impact of chronic disease. Diabetes self-

management funding is one of many strategies that will

make up this statewide response. Strategies will be based

on evidence of what works and have a strong focus on

prevention, early detection and early intervention. Already

this focus has been given impetus by packages such asthe COAG Australian Better Health Initiative, of which this

funding is a part.

People with Type 2 diabetes require services from a broad

range of health care providers, are likely also to live with

other chronic conditions, and will use health services

throughout their life. Managing the burden of disease into

the future requires a robust health system that integrates

prevention and care over time and different stages of

disease, integrates the care of different conditions, and

integrates care across different services and service

providers.

12 ational Public Health Partnership 2001, Eat Well Australia: AnAgenda for Action for Public Health utrition 2000-2010, StrategicInter-Governmental utrition Alliance, Canberra http://www.nphp.gov.au/publications/signal/eatwell1.pdf

11 Australian Institute of Health and Welfare 2006, Chronic Diseases and

Associated Risk Factors in Australia, 2006, AIHW, Canberra, http://www.aihw.gov.au/publications/phe/cdarfa06/cdarfa06.pdf

13 National Reform Agenda: Victorias plan to address the growingimpact of obesity and type 2 diabetes, Consultation draft,December 2006

The diabetes self-management funding is for the provision

of self-management interventions to high risk people newlydiagnosed with Type 2 diabetes. The services provided under

this funding should:

operate within a broader CHS CDM model

be linked to an ICDM approach across the local PCP.

Under the ICDM funding, PCPs have an important role in

bringing agencies together to develop systems that support

a coordinated approach to the planning and delivery of

services for people with chronic disease. PCPs are focusing

on service system integration over the next three years for

this client group by strengthening their service coordination

work. In particular, ICDM activities include:

strengthening referral systems to include regular feedback

and communication mechanisms that share service

outcomes between agencies, and between agencies and

general practice or between agencies and/or providers

developing clinical pathways for certain chronic diseases,

such as diabetes

supporting a self-management mapping process and

developing a plan to address gaps and facilitate workforce

development

developing inter-agency care planning models thatinclude and promote the participation of GPs, private

allied health practitioners and state-funded health

practitioners in multidisciplinary care through the Medical

Benefits Scheme (MBS) CDM items, such as Team Care

Arrangements.

These service system activities are essential in supporting

and helping to inform service delivery initiatives and

change management processes, such as diabetes self-

management.


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Self-management mapping

The self-management mapping process is a PCP activitythat has strong links to diabetes self-management funding

and will inform future systems development for the initiative.

The information from the self-management mapping will be

invaluable to planning and developing the initiative.

Mapping data will assist PCPs and members to identify:

current gaps in the provision of self-management

interventions

workforce capacity and gaps

capacity vs. demand issues

referral pathways into self-management interventions.This data will be key to PCP and members planning around

workforce development, coordinating the delivery of

self-management interventions across their catchment,

ensuring that interventions target high risk subgroups,

defining agency and general practice roles in providing self-

management interventions and support.

PCPs should prepare for this mapping process by identifying

agencies to be involved (state and Commonwealth funded,

public and private), conducting planning to ensure maximum

agency participation, and planning how the process can be

used for capacity building.

1.4 Overview of diabetes self-management

funding

The diabetes self-management funding is a component of

our commitment under the Australian Better Health Initiative

(ABHI): a joint Australian, State and Territory government

initiative. The initiative will provide early intervention to

people with high risk and newly diagnosed Type 2 diabetes

to support them to become good self managers of their

health. High risk includes subgroups of the communitythat experience higher levels of chronic disease and find it

more difficult to access services. High risk groups include

Indigenous Australians, people from CALD backgrounds,

regional and rural communities, and those who experience

socio economic disadvantage.

It is important that people newly diagnosed with Type 2

diabetes have access to a range of services that arewell coordinated between health care providers. Early

intervention services should aim to provide:

information about diabetes and managing diabetes

assistance with monitoring and maintaining healthy

blood glucose levels

support for self-management (at an organisational and

clinical level)

information and assistance to manage lifestyle risks

links to community groups and programs that will support

lifestyle change

assistance to cope with the impacts of a long term

health condition

effective communication and referral between service

providers.

Early intervention services are best provided in the

primary care setting and delivered by a range of health

care providers, including GPs. The GP is the primary health

professional involved in detection and diagnosis and has

a central role in the ongoing medical management of the

disease. Allied health and nursing professionals have an

important role in providing education, self-managementsupport, foot care, lifestyle support (including dietary

management) and referral. The development of care plans

may be appropriate, through use of the MBS care planning

items, if the relevant criteria are met.

The diabetes self-management funding provides:

on-recurrent PCP funding in 200607 for work with

general practice (through DGP) to build on current activity

at the local level, focusing on people with chronic disease

and complex needs. While these funds need to be used to

ensure people newly diagnosed with Type 2 diabetes are

referred into self-management programs, they should alsosupport a broader approach to working with DGP, building

on existing effort as part of service coordination and ICDM.

on-recurrent funding in 200607 for staff training and

development, which will be managed by Department of

Human Services regions.

Recurrent CHS (or RHS where applicable) funding for

delivery of self-management interventions. Fourth quarter

targets only for 200607 and full year targets from 200708.


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The funding has an emphasis on providing people with self-

management support that assists them and their families(and/or carers) to gain the skills and resources to actively

manage their health. Effective client self-management is:14

enhanced if started early

a key component of successful chronic disease

management

leads to improved health and wellbeing outcomes.

Self-management support goes beyond traditional

knowledge-based client education to include processes that

develop client problem-solving skills, improve self-efficacy,

and support application of knowledge in real-life situations

that matter to clients. Self-management is the ability of the

client to deal with all that a chronic disease entails, including

symptoms, treatment, physical and social consequences,

and lifestyle changes.13

The funding for service delivery, in summary, should provide:

1. Client assessment.

2. Care planning (where this does not meet criteria for MBS

related care planning).

3. Self-management intervention.

4. Client monitoring.

These guidelines provide specific advice about servicedelivery within each of these areas. This should build

on existing capacity to provide services to people with

diabetes. Funding should be used to address the gaps in

providing the services described in these guidelines.

Refer to section 5 for more funding information.

14 ational Health Priority Action Council (HPAC) 2006,ational Health Priority Action Council (HPAC) 2006, NationalChronic Disease Strategy, Australian Government Department ofHealth and Ageing, Canberra


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Core business for CHSs includes integrated population-

based health promotion initiatives and providing servicesand programs to people with chronic disease, including

those with diabetes. Therefore, this funding and the

supporting diabetes self-management guidelines should add

value to existing services and programs involved in ICDM.

The diabetes self-management funding should operate

within a broader CHS CDM model that includes recognising

the importance of the interrelationships among individuals

and the social, cultural, environmental, behavioural and

biological factors that influence their health.

PCPs core activities include strengthening service

coordination systems across agencies for people withchronic disease, with a focus on self-management, care

planning, and referral and communication mechanisms.

Key agencies involved in ICDM include CHSs and DGP.

Therefore, this funding should be integrated with and add

value to existing service system development across these

agencies and with general practice. Service coordination

work should align with the new Victorian Service

Coordination Practice Manual15 which describes practice

standards for initial contact, initial needs identification,

assessment, care planning and referral.

To achieve this, the Primary Health Branch of the

Department of Human Services has adopted the Wagner

Chronic Care Model16,17 for managing chronic disease in

the primary care setting. Wagner proposes that managing

chronic disease requires nothing less than a transformation

of health care, from a system that is essentially reactive

responding mainly when a person is sick to one that is

proactive and focused on keeping a person as healthy as

possible. The Chronic Care Model is a systems-based model

that summarises the essential elements for improving care in

health systems at the community, organisation, practice and

client levels. The model can be applied to a variety of chronic

diseases, health care settings and target populations.

15 http://www.health.vic.gov.au/pcps/publications/sc_pracmanual.htm

16 Improving chronic illness care:Improving chronic illness care:

http://www.improvingchroniccare.org/change/model/components.html

17 WagnerE, Glasgow R, Davis C et al, 2001 uality Improvement inWagner E, Glasgow R, Davis C et al, 2001 uality Improvement inChronic Illness Care: A collaborative Approach,Journal of QualityImprovement, Volume 27 umber 2, February

Self-management is a key element in the model. The

elements are interdependent components, building uponone another. Evidence-based principles under each

element, in combination, foster productive interactions

between informed clients and health care providers. As

its ultimate goal, the Chronic Care Model envisions an

informed, activated client interacting with a prepared,

proactive practice team, resulting in high quality, satisfying

encounters and improved outcomes. The Chronic Disease

Management Program Guidelines provide details of the

model in the context of CHS and PCP functions.

Table 1 provides examples of how diabetes self-

management can operate within a broader chronic caremodel. This list is not exhaustive; it is provided to illustrate

the links and interdependence between the six elements

of the models. Local capacity, resources and requirements

will need to be considered in developing diabetes self-

management services.

2. Chronic disease management model for primary care


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Table 1: Chronic Care Model examples18

Health System

The Chronic Care Model

Community

Improved Outcomes

Self-Management

Support

DeliverySystemDesign

ClinicalInformation

Systems

DecisionSupport

Informed,Activated

Patient

EffectiveSelf-Management

Prepared,Proactive

Practice Team

ProductiveInteractions

Source: Wagner E, Glasgow et al 2001

The six elements of the model

Community Examples

All staff have been trained and have access to Internet-based service directories which include community information.

Linkage to community programs (as appropriate) for people with diabetes and recorded on the care plan.

Self-management programs (including diabetes education program) include exercise sessions conducted at local leisure centres.

Health system Examples

CHS strategic plan articulates a commitment and describes a plan to integrate funding (including diabetes self-management funding)

and provide a seamless and integrated chronic disease management (CDM) program.

Identification of clinical leaders to support staff.

Management and staff roles for planning, implementing and monitoring CDM are clearly defined.

Policies and procedure are in place that clearly support multidisciplinary teamwork and the diabetes team meets regularly.

Self-management support Examples

Self-management needs are routinely assessed for all clients with chronic disease including diabetes, using the Flinders Partners inHealth Scale (PIH)18 or other identified tool.

All clients with sub optimal self-management skills are referred to self-management interventions (a range of interventions are availabledepending on client need), clients with diabetes are offered a diabetes education group program or individual sessions (including face toface and telephone contact).

Delivery system design Examples

A referral pathway to the CHS for diabetes care exists and is well known and used by GPs.

CHS nursing staff conduct assessment clinics every fortnight within two large local general practices; assessment clinics take referrals

for a range of programs.GPs are available for case conferencing with CHS nurses (and other CHS staff via teleconference) for complex clients.

Follow up appointments between the GP and CHS for clients with chronic disease are coordinated.

Decision support Examples

Clients with chronic disease referred to the CHS are provided with a pocket size booklet to record their own health information(developed through the CHS and DGP).

Diabetes guidelines and client handouts are evidence-based and sourced from Diabetes Australia.

Interagency care planning occurs for all clients with more than two chronic conditions (including diabetes) using the Service Coordination Plan,coordinated by a key worker.

Clinical management systems Examples

Clinical indicator data collected by the GP is shared with the CHS following client consent.

Reports about CHS diabetes care are generated every 12 months and shared with GP practices, reports include no. of people: referred for service,completing diabetes program, having a written care plan (with GP input), meeting lifestyle goals etc.

18 http://som.flinders.edu.au/FUSA/CCTU/Hand%20out%20Flinders%20Model%20June%202006.pdf


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3. Diabetes self-management service delivery

Given the emphasis on an integrated approach to

delivering health services, CHSs in receipt of diabetes self-management funding should use the funding to add value

to existing CDM programs by prioritising high risk clients

newly diagnosed with Type 2 diabetes. The initiative provides

CHSs with an opportunity to review their broader CDM

program and workforce capacity (in which the diabetes self-

management initiative should be embedded) to ensure it is:

based on evidence of what works

supported by systems (based on the Wagner Chronic Care

Model elements) that ensure best practice is routine

targeted at high risk clients who experience poorer health

and have difficulty accessing services.

The diabetes self-management funding builds on the

components of care that should be part of all CDM

programs, that is:

assessment

care planning

self-management interventions

linkage to community programs

client monitoring or follow-up.

Aspects of service delivery within these components will

vary depending on the chronic disease and on local servicemodels.

Therefore, the following describes the service delivery

requirements for high risk clients newly diagnosed with

Type 2 diabetes, without prescribing a model in which it is

to be implemented. The model should be determined at the

local level, to meet the needs of the local community and fit

within the local service system.

Agencies receiving diabetes self-management funding under

this initiative need to ensure the following service delivery

components are provided. A summary model of care isprovided at Appendix 1.

3.1 Client assessment and care planning

Assessment

All clients referred for a diabetes self-management service

must have access to a client assessment conducted by

an appropriately qualified health professional. A diabetes

assessment should include:

routine assessment procedures

taking anthropometric measurementsassessing knowledge and providing information

on diabetes

managing blood glucose levels

assessing lifestyle risk factorsassessing coping skills and social supports

screening for mental health issues.

Taking anthropometric measurements

Includes:

weight

body mass index (BMI)

waist circumference.

This provides the client and health professional with

baseline data from which changes over time can be

measured. Being overweight or obese is a leading risk factorfor Type 2 diabetes and most people diagnosed with the

disease are overweight. An American trial, The Diabetes

Prevention Program, studied people with prediabetes and

found that those who increased their physical activity most

days of the week and lost 5 to 7 per cent of their body

weight reduced their risk of developing diabetes by 58 per

cent. The Shape-Up test on the Diabetes Australia website19

combines BMI and waist circumference to give clients an

idea of their risk for Type 2 diabetes. Although the tool is only

a guide aimed at healthy adults it can assist clients gain an

awareness of this risk factor.

The CHS and DGP should work together to establish a

process that ensures measurements are only taken by one

health professional and shared with the team (with client

consent). Often GPs collect this information, so CHSs

should not duplicate this assessment.

Assessing knowledge of diabetes

Includes:

assessing clients confidence and skills to manage

diabetes (self-efficacy).

Simply assessing knowledge is not enough because

knowledge does not necessarily equal behaviour change.

A client with a lot of knowledge may not put this knowledge

into practice. Assessment (that includes self-efficacy)

may be undertaken using a tool (such as the Flinders tools

Partners in Health Scale, Cue and Response) or through

a structured interview process. Self-efficacy has a greater

correlation with behaviour change. Clients should be asked

to rate how confidant they are to make changes based on

their knowledge.

19 http://www.diabetesnsw.com.au/diabetes_prevention_pages/take_the_shape_up_test.asp


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0 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Managing blood glucose levels

Managing blood glucose levels is a very importantcomponent of managing diabetes and should be done

together by the client, GP and other health professionals.

The GP may have started this process so the role of other

health professionals may be to assist the client to:

gain and use a home meter

understand hyperglycaemia and hypoglycaemia

understand use of insulin (if appropriate) and other

medication

access the ational Diabetes Services Scheme.

Assessing lifestyle risksThere is often a causal link between lifestyle risk factors

and Type 2 diabetes. Assessment of lifestyle risks can be

done through the use of a tool such as the GP lifestyle

script screening, based on the SAPW framework

(smoking, nutrition, alcohol consumption, physical activity,

weight management)20. Where lifestyle risks are identified

clients should be encouraged to set goals around

managing these risks.

Assessing coping skills

A persons support network and their ability to deal with

the emotional impacts of diabetes is important and will

impact on their ability to self-manage. We know that

effective self-management occurs in the context of strong

social connectedness. Good self-managers receive

support from their family, friends and/or community. It is

often psychosocial issues that limit self-management.

With training, health professionals without a professional

background in counselling can and should provide basic

psychosocial support. It is imperative that mechanisms are

in place to support health professionals in this role. This

is important as sadness, a sense of loss and other similar

emotions (that is not depression) are a normal experience

with chronic disease.

Although depression is not a recognised side effect of

diabetes, people with diabetes have a higher incidence of

depression. Certainly literature, such as the National Survey

on Mental Health and Wellbeing and the Victorian Burden of

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

Disease21, states that people with chronic medical diseases

commonly experience depression and anxiety. Because ofthis association, an awareness of and screening for mental

health issues is important. Studies show that undiagnosed

depression will make it harder for people to self-manage, for

example, take medications, eat properly and keep health

care appointments22. CHS staff should be aware that clients

with depression may be able to access private counsellors

under new MBS items for mental health, through GP referral.

Care planning

All clients referred for a diabetes self-management service

will require a care plan. Assessment outcomes identifiedareas where further support is required. This will assist the

client and health professionals determine the plan of care.

Practice standards for care planning are described in the

new Victorian Service Coordination Practice Manual23.

The manual identifies three levels of care planning: service

specific care planning, intra-agency care planning and inter-

agency care planning. Care planning under this funding may

occur at all three levels. Service specific plans may include

a GP management plan, a self-management plan, and a

foot care plan. However, it will also be important to develop

models for intra-agency and inter-agency care planningbecause medical management, allied health management

and self-management should be coordinated.

Clients with complex needs may also be eligible for a Team

Care Arrangement under the MBS-CDM items. For these

clients, it will be important that CHS staff provide input

into the care planning and coordination of services, with

the GP and, potentially, specialists and private allied health

professionals.

The care planning process should be a dynamic,

consultative process that includes the client (and family/carers as appropriate) and health care providers, and meets

the clients health needs in a holistic way. Treatment options

should be provided so clients can make informed decisions

about their care. Goals and actions should be measurable

and articulate who is responsible, so that review and

reflection is possible.

21 http://www.health.vic.gov.au/healthstatus/bodvic/bod_current.htm

22 University of Arkansas for Medical Sciences (UAMS), Depressionmakes chronic diseases harder to handle, http://www.uams.edu/today/2003/021003/chronic.htm

23 http://www.health.vic.gov.au/pcps/publications/sc_pracmanual.htm


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Care plans should include the following elements:

issues/problemsgoals, actions, target dates, responsible agents

regular review dates

participants

checklist evidence of need

method of planning.

Goal setting

Goal setting is an essential component of care planning

for people with chronic disease. It should follow a health

professional and client interaction that identifies problems

from the clients perspective, and barriers to makingchange. Goal setting should involve the client setting short

term and long term goals. The goals should be realistic,

proposing behaviours that clients are confident they can

achieve. Confidence can be measured by asking the client

to estimate their confidence on a 0 to 10 scale that they

can achieve their goals. Experience shows that if the answer

is 7 or higher, the goals are likely to be achieved. If the

answer is below 7, the goals should be made more realistic

in order to avoid failure.

It is important that goals are client-centred, that is, they are

developed by the client and are relevant to the client. The

purpose of clients setting their own goals is to increase their

confidence in managing diabetes. Confidence fuels internal

motivation. Health professionals need to support clients to

do this initially. The Commonwealth Sharing Health Care

Initiatives 20012004, found that health professionals had

difficulty shifting their practice from a traditional medical

model of care to a client self-management focus which

included care planning where clients set personal goals

rather than health professionals setting clinical goals.24

Goal setting support tools Flinders self-managementcare plan and ACIC self-management support tool25

are examples to guide discussion between the health

professional and client. The tools assist the health

professional and client to determine goals, identify steps to

24 ational Evaluation of the Sharing Health Care InitiativeDemonstration Projects 2005 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/chronicdisease-nateval

25 http://www.improvingchroniccare.org/tools/PDFs/self_mngmt_support.pdf

achieve their goals, identify barriers to reaching their goals,

and plan for overcoming these barriers, including obtainingneeded resources.Goals for self-management should

include:

managing blood glucose levels

managing lifestyle risks

engaging in normal activities of daily life that are

important to the client.

Goals should be documented on the care plan.

3.2 Self-management

Self-management is described as26:The client (and their family/carers as appropriate) working

in partnership with their health care provider to:

know their condition and various treatment options

negotiate a plan of care

engage in activities that protect and promote health

monitor and manage the symptoms and signs of the

condition(s)

manage the impact of the condition on physical

functioning, emotions and interpersonal relationships.

Self-management is the ability of the client to deal with allthat a chronic disease entails, including symptoms, treatment,

physical and social consequences, and lifestyle changes.

Self-management support

Self-management support is the care and encouragement

provided to people (and their family/carers as appropriate)

with chronic disease to help them understand their

central role in managing their conditions, making informed

decisions about care, and engaging in healthy behaviours.

Self-management support goes beyond traditional

knowledge-based client education to include processes thatdevelop client problem-solving skills, improve self-efficacy,

and support application of knowledge in real-life situations

that matter to clients.



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Good self-management support involves collaboration

between client and health care provider, where theprovider is coach as well as clinician and the client

and family are managers of daily care. It also includes

helping clients (and their family/carers as appropriate)

identify and achieve appropriate behavioural and lifestyle

changes. This often means identifying the attitudes and

beliefs that clients hold about their health, and addressing

the barriers to behaviour change.

As identified, self-management support should include family

and/or carers. Supporting behaviour change for individuals

may include supporting changes being made within a family.

For example, an individual who wants to make changes totheir diet may need support from family members who do the

food shopping and/or meal preparation.

Self-management interventions

Self-management interventions support and cover all

aspects of self-management as described above. While the

diabetes self-management funding should provide a range of

interventions that are flexible in content and delivery to suit

individual client needs and preferences, it is important that

interventions aim at achieving the following client outcomes:

engagement or re-engagement in life-fulfilling activitiesengagement in health promoting behaviours and

reduction of lifestyle risks

learned skills and techniques to manage symptoms and

overcome health problems

a positive attitude to life and being able to live with the

disease without it controlling life

self-monitoring of clinical indicators, insight into living with

a health problem and setting realistic limitations

ability to confidently interact with health professionals and

use the health system appropriatelysocial engagement and the ability to seek support from

interpersonal relationships and community organisations

improved general emotional wellbeing

support client sustaining the lifestyle changes over the

longer term.

Table 2 illustrates the broad range of self-management

interventions that have been developed from one-on-

one interventions to group-based programs. This enables

interventions to be provided to suit the local capacity and

the needs of the client.

Table 2: Examples of self-management interventions27

Individual

Population

Type of intervention Examples

Face-to-faceconsultation

Flinders University modelof clinician-administeredsupport

Telephone coaching Coaching patients OnAchieving CardiovascularHealth (COACH) program

Internet individualcourse

ew South Wales ArthritisFoundation course

Internet group course UK ational HealthServices

Expert Patients Programonline

Group: ongoing cycle Rehabilitation programs

Group: formal/structured

Stanford Universityprogram

Written information on-governmentorganisation publications

Television/multimedia,social marketing

Back pain beliefscampaign;

uit anti-smokingcampaign

Source: Joanne Jordan and Richard Osborne January 2007

Generic evidence-based self-management interventions

Includes:

Stanford Model

Flinders Model

motivational interviewing for behaviour change.

The most common behavioural models that underpin self-

management interventions28 are the:

social learning theory that includes problem solving and

goal setting to improve self-efficacycognitive behavioural approach which aims to motivate

clients to adjust thought distortions that impact behaviour.

27 Jordan J and Osborne R 2007, Chronic Disease self-management

education programs: challenges ahead, Medical Journal of Australia,Volume 186 umber 1, p. 1

28 Joanne Jordan, Joan ankervis, Caroline Brand and Richard OsborneChronic Disease self-management education programs: where should

Victoria go?, Final Technical Report 200506


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Diabetes self-management: Guidelines forproviding services to peoplenewly diagnosed withType 2 diabetesGuidelines for providing services to people newly diagnosed with Type 2 diabetes

Generic self-management models are appropriate for people

with diabetes; however, they need to be provided by anappropriately qualified allied health professional (such as

a dietitian or physiotherapist) and combined with diabetes

education. The advantage of self-management interventions

that combine education with behavioural models is that they

build client knowledge as well as self-efficacy.

Stanford Model

Developed by Stanford University,29 the model is a

structured group program that runs over six sessions for

people with arthritis or osteoporosis, or any chronic health

problem. Sessions are facilitated by two trained leaders

and cover:

techniques to deal with problems such as frustration,

fatigue, pain and isolation

appropriate exercise for maintaining and improving

strength, flexibility, and endurance

appropriate use of medications

communicating effectively with family, friends, and health

professionals

nutrition

how to evaluate new and alternative treatments.

Flinders Model

Developed by the Flinders Human Behaviour and Health

Research Unit,30 the model is a generic set of tools and

processes. It enables clinicians and clients to undertake

a structured process that allows for assessment of self-

management behaviours, collaborative identification of

problems and goal setting, leading to the development of

individualised care plans. The tools include the Partners in

Health Scale, Cue and Response Interview, Problem and

Goals Assessment and Self-Management Care Plan.

Motivational interviewing

Based on the Prochaska and Declemente Model, a cognitive

behavioural approach, motivational interviewing is a

counselling approach that prepares clients for behaviour

change. Using the technique, health professionals

encourage clients to identify lifestyle behaviours that they

would like to change and to articulate the benefits and

difficulties of making that change. The interviewer uses

directive questions and reflective listening to help clients

come to their own decisions by exploring their uncertainties.

29 http://patienteducation.stanford.edu/programs/


This style of interview, asking the patient provocative

questions and discussing the responses, can often helpuncover important behaviour change issues.

Relapse Precontemplation

Determination/preparation

ContemplationMaintenance

Action

Stages of Change Model

The Stages of Change Model identifies the stages

through which clients pass. The model is based on

the premise that behaviour change is a process, not

an event, and that individuals have varying degrees

of motivation or readiness to change. Motivational

interviewing has been proven effective in assisting

clients move through stages of change and preventing

relapse. Research has found that providing motivation is

much more successful31 than simply providing clients

with knowledge.

Disease specific evidence based self-management

interventions

These interventions have been proven to be effective

through rigorous evaluation (for example, control group,before and after time series) and have demonstrated

improved client outcomes.

In 2002, the Department of Human Services funded the

Hume Moreland PCP, through the Diabetes Prevention

and Management Initiative, to develop a lifestyle group

program for people with diabetes. The program, called One

Step Ahead, combines self-management support, exercise

and diabetes education. The program was implemented

in four health services and evaluated by The University of

Melbourne. Evaluation results showed that participants were

31 Bodenheimer T and Lorig K, Patient Self-management of ChronicDisease in Primary Care, http://jama.ama-assn.org/cgi/content/full/288/19/2469


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highly satisfied with the program and client health outcomes

included improved self-reported physical activity levels andstatistical improvements in blood glucose control at six and

12 months post-program completion. A program manual

was developed out of the initiative along with a workforce

development strategy. The program manual describes:

the structure and content of the six session program

all necessary resources

information about conducting the program.

It is anticipated that both the program manual and

workforce development strategy will be available on the

Department of Human Services website in early 2007.

Under the diabetes self-management funding, it is expected

that self-management interventions will be provided to

clients over the period of approximately 12 months. This

may include a period of service intensity, for example, a

group program. However, intensity should step up or down

to regular but infrequent contact as clients support needs

change, for example, telephone contact every three months.

3.3 Client monitoring

A team approach to diabetes management starts with

the client and their GP, and adds allied health, specialistand education services as required, particularly following

diagnosis. The diabetes self-management funding is aimed

at CHSs providing a range of services to people following

diagnosis and ensuring they have adequate supports in

place for long-term management. Therefore, it is important

that people with Type 2 diabetes have a regular GP. If not,

they should be supported to find a GP they trust. It is also

important that communication occurs between the CHS

and GPs of clients receiving services.

GP communicationCommunication between the GP and other health care

providers is important to maintain the team approach to

care. Agreements and protocols around communication

between the GP and CHS should be established (if not

already in place) to ensure this occurs and should be

consistent with the practices, processes, protocols and

systems described in the Victorian Service Coordination

Practice Manual. Referral32 and communication pathways

are also discussed in section 4. It is recommended that

the diabetes self-management guidelines be used in

conjunction with the manual.

32 http://www.health.vic.gov.au/pcps/coordination/ppps.htm

Communication agreements should be part of broader

ICDM inter-agency care planning models. Models mayvary in sophistication but should always be underpinned

by processes for sharing information and coordinating

care. For example, a basic level care planning model may

simply include sharing service specific care plans between

agencies. At a more sophisticated level, the model may

include discussion between health care providers from

different agencies around client goals which leads to

the development of one new coordinated care plan that

synthesises all information from service specific plans.

Following the package of services and self-management

support provided to clients, the CHS should take a stepdown approach and communicate with the GP regarding

ongoing management. A step down approach may include

one or more of the following options:

The client exiting from service with an opportunity for

re-contact should other issues arise or through invitation

to additional or refresher diabetes self-management

programs.

Annual podiatry appointments.

Ongoing but infrequent telephone coaching.

Ongoing managementAs well as self-management interventions, clients may

require allied health (for example, podiatry, dietetics),

nursing and/or counselling services. Clients should be

assisted to access these services via appropriate referral.

These services may or may not be funded directly by the

diabetes self-management funding, and may or may not be

provided by the CHS, depending on how funding is used

and what services outside the CHS are more appropriate

(such as MBS funded allied health and dental).

Clients should also be educated about, and linked to, otherhealth and community services that can provide routine

ongoing care and support. Ideally, as part of an annual cycle

of care (sourced from the Australian Government Health and

Ageing website Medicare online), the GP will facilitate the

following:


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Other important health care checks include:33

a dental check up

a foot assessment by a podiatrist

an eye examination for retinopathy by an eye specialist/ophthalmologist or experienced optometrist.

Clients should have a good relationship with their GP and

be linked into services prior to exiting the CHS. Services

may include MBS funded allied health, dental and/or

counselling.

Lifestyle modification

A healthy lifestyle for people with diabetes means enjoying

healthy eating, maintaining a healthy weight, being

physically active, learning to manage stress and thinking

positively. Where lifestyle risks exist, support for lifestylemodification is important. Best practice guidelines for

people with diabetes (as per the International Diabetes

Institute34) include:

cessation of smoking

alcohol intake of 2 standard drinks/day for men and

1 standard drink/day for women

a healthy diet that includes reducing saturated fat and

ensuring carbohydrates are low in glycaemia index and

high in fibre

33 http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A.29&qt=oteID

34 http://www.diabetes.com.au/living.php?regionID=52&page=overview

at least 30 minutes of moderate physical activity on most,

preferably all, days.

There are many programs and supports provided by

community organisations and peak bodies, or available onthe Internet, that can assist people make lifestyle changes.

Providing clients with support for lifestyle modification will

require up skilling staff to:

provide support where appropriate

make referrals or assist client to make links with these

programs and supports.

Community linkages

Community programs, networks and clubs can often provide

people with diabetes the support necessary to assist

them maintain a healthy lifestyle. Community programsinclude strength training programs at neighbourhood

houses, Weight Watchers groups, yoga classes, church

networks. The list is endless and the health system must

learn to make the most of such resources. Many PCPs

have been involved in supporting electronic records that

include such information. Health care providers should

discuss possibilities with their clients. Helping clients

gain support from their community to make and maintain

lifestyle changes is very important. Care plans may include

facilitating referrals or supporting clients to make links with

community programs.

Table 3: Diabetes Annual Cycle of Care33

Assess diabetes control by measuring HbA1c At least once every year

Ensure that a comprehensive eye examination is carried out At least once every two years

Measure weight and height and calculate BMI At least twice every cycle of care

Measure blood pressure At least twice every cycle of care

Examine feet At least twice every cycle of care

Measure fat profile (lipids), including HDL (good cholesterol), LDL(bad cholesterol), total cholesterol and triglycerides

At least once every year

Test for microalbuminuria (protein levels in urine for indicationsof early kidney damage)

At least once every year

Provide self-care education Patient education regarding diabetes management

Review diet Reinforce information about appropriate dietary choices

Review levels of physical activity Reinforce information about appropriate levels of physical activity

Check smoking status Encourage cessation of smoking (if relevant)

Review medication Medication review


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The evidence for a systems approach to embedding ICDM is

overwhelming. The Sharing Health Care Initiative found thatprojects best able to meet the challenges of implementing

self-management into the community35:

were organisationally mature, with good infrastructure and

support, including organisational and clinical leadership

supporting self-management

had strong relationships with key stakeholders (for

example, community groups and DGP)

established or capitalised on pre-existing relationships

with a range of health service providers including GPs

were flexible in their approach and design and able to

respond to client feedback

employed a variety of approaches to recruitment and

implementation, depending on the target group

built capacity from an organisational perspective,

most notably in the areas of network partnerships and

knowledge transfer.

4.1 GP liaison

Allocation of non-recurrent funds

DGP are key PCP member agencies and have considerable

expertise in communicating with, and advocating on behalf

of, GPs. Therefore, it is expected that the PCP will work with

the local DGP to develop a work plan that builds on existing

GP liaison activity to ensure that referral pathways between

GPs, the CHS and other relevant services are in place to

support the diabetes self-management initiative. The non-

recurrent funding should support PCP activity on ICDM. The

delivery of the work plan should be negotiated between the

PCP and DGP and could include funds allocation to the DGP

to support delivery of some or all of the outcomes against

the work plan.

The work plan should include effective strategies for:

informing GPs and their staff about the diabetes services

and programs delivered by the CHS

encouraging GPs to systematically refer patients with

newly diagnosed diabetes

sharing patient information between the general practice

and CHS, and effectively communicating with GPs

35 ational Evaluation of the Sharing Health Care Initiative:http://www.health.gov.au/internet/wcms/publishing.nsf/Content/chronicdisease-nateval

developing care plans aligned with MBS guidelines, with

appropriate participation of the CHS and other relevantagencies, with GPs and, potentially, private allied health

services, in care plans aligned with MBS guidelines.

GP liaison activity

GP liaison activity for this initiative should be consolidated

with broader CDM GP liaison activity, to ensure consistent

systems are established between GPs and the CHS.

This will require strong DGP leadership in the design

and implementation of systems to support coordinated

chronic care that includes GPs as referrers, providers of

medical perspectives in care plans and key members ofmultidisciplinary care teams. CHSs are encouraged to work

with their local DGP to develop an agreed plan for building

on existing capacity for liaison with general practice and

further embedding ICDM systems.

GP liaison activity could include:

canvassing GP views and awareness of CHS

providing input into the development of CHS resources for

GPs and their clients

supporting practice staff to make appropriate referrals

(practice staff visits to the CHS or CHS visits to practices)

encouraging GPs to support their clients attending self-

management programs

establishing appropriate systems that meet the needs of

clients and GPs.

Flexibility and innovation should be used in the development

of systems to ensure general practice involvement with the

CHS in delivering diabetes care. Most importantly, systems

need to work for the people they service. For example,

where accessibility is an issue, the CHS may negotiate

with a large general practice to conduct group programs

for their clients within the practice on a day that clients arealso booked for appointments with their GP. To facilitate

coordinated care planning, the CHS may establish an

agreement with a practice to conduct assessment clinics

(carried out by a CHS nurse) within the practice and provide

input into care planning and case conferences.

4. Diabetes self-management supporting systems


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Establishing systems to identify appropriate clients to be

referred from the GP to the CHS will include discussionabout clients who are eligible for Team Care Arrangements

and MBS funded allied health. The DGP (and potentially

GP representatives) should be involved in making

recommendations about a local model that provides for both

these scenarios.

4.2 Client recruitment and referral

pathways

Experience has shown that client recruitment into self-

management programs is most effective when health

professionals facilitate the referral. Often the health

professional with the greatest influence is the GP. Therefore,

it is important that client recruitment and referral pathways

developed as part of chronic disease care, particularly

diabetes care, include self-management interventions as

routine and are offered to all clients and family/carers by

their health care providers.

In a recent study in Victoria, it was found that, in general,

poor recruitment of clients into self-management

interventions is due to poor engagement with health

professionals for the following reasons:36

They have not been well informed.

They are uncertain about the benefits for their clients.

They lack a structured or uniform process to refer their

clients.

They need hard evidence relating to the outcomes for

their clients or at least outcomes at a local level.

The report recommends that a whole of system approach

be taken to planning and implementing self-management

interventions. This includes establishing standard referral

pathways, communication pathways within and between

health sectors for client self-management referral, feedback

and continuity of care processes, and promotion/marketing

strategies that include educating health professionals in the

benefits and importance of self-management interventions.

Referral pathways should be underpinned by the Service

Coordination strategy and include quality information

sharing, feedback and agreed response times. Recruitment

criteria should be clearly defined and become part of initial

needs identification, which involves screening of client

needs, determining access and priority, and assessing risk.

36 Jordan, ankervis, Brand & Osborne (2006),Jordan, ankervis, Brand & Osborne (2006), Chronic Disease Self-management Education Programs Where Should Victoria Go?FinalTechnical Report

It is expected that GPs will be a primary source of referral

for CHS diabetes self-management programs. Therefore, theDGP will be key to developing clear pathways and supporting

general practice referrals. DGP should encourage the use of

the Statewide Referral Tool for GP referrals.

CHSs should consider strategies to ensure that high risk

clients are recruited into the program, particularly those

who have difficulty accessing services due to geographic

location, ethnicity, language barriers, limited literacy levels

or who lack the confidence to be good self-managers of their

own health care. Transport for clients in rural and regional

areas is often reported to be a major barrier in accessing

health services and programs. CHSs could play a role inassisting clients overcome these barriers with strategies

such as facilitating car pooling, organising volunteer

transport, conducting programs offsite in more accessible

venues (such as church halls, club halls).

4.3 Clients with multiple chronic

conditions or complex needs

It is not uncommon for people with diabetes to be diagnosed

with other chronic conditions and/or have complex needs.

Clients with multiple chronic conditions and/or complexneeds may benefit from a key worker whose role would

include:

coordinating service specific assessments and other

assessments as required

ensuring that a coordinated (inter-agency) care plan is

developed, monitored and reviewed

being involved in a Team Care Arrangement (as

appropriate)

communicating and liaising (including service outcome

communication) with other health care providers

(including GP and private allied health providers)coordinating a multidisciplinary case conference (as

appropriate)

being a contact for the client should their condition

deteriorate and/or circumstances change that may

impact on the management of their diabetes

providing support for carers (as appropriate)

making referrals to community-based activities (as

appropriate)

taking a flexible approach to ongoing follow up

following up clients who drop out of the program.


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At a minimum, the key worker should have contact with the

client at three months, six months and 12 months as part ofthe client monitoring phase.

CHSs should work closely with the DGP to ensure that

clients who may be eligible for allied health services through

the MBS-CDM items have access to these services and that

service duplication does not occur. The MBS-CDM items

include:

preparation and review of a GP Management Plan

coordination and review of Team Care Arrangements

contribution to a multidisciplinary care plan being

prepared by another health or care provider.37

4.4 Decision support tools

Decision support includes:

supporting practitioners to deliver best practice care

using resources, tools and best practice guidelines

supporting clients to make decisions about their own

health and health care behaviour.

Decision support tools are becoming more common in

health care and can take a variety of formats, such as

printed guidelines, Internet supports, computer software

programs (IPPS is an example of a decision support tool

for program planning), and decision algorithms (for example,

a risk rating tool for diabetes). Health care providers should

use evidence-based tools to support them to deliver best

practice diabetes care. These are best sourced from peak

bodies, such as Diabetes Australia Victoria and International

Diabetes Institute. It is important that clients receive

consistent messages from all their health care providers and

this can only be achieved through:

embedding evidence-based guidelines into daily clinical

practice

sharing evidence-based guidelines and information with

clients to encourage their participation

using proven provider education methods.

An example of a decision support tool is the commonly

used stoplight analogy to teach clients about monitoring

and managing their chronic condition. Many providers

suggest that a copy of this document is kept by the client

in a prominent place (for example, at home or work).

37 Commonwealth Department of Health and Ageing,Commonwealth Department of Health and Ageing,www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease

Red

Stop to assess

ellowellow

Caution in planning

GreenGreen

Go to action

The stoplight tool divides various signs and

symptoms (for example, daily blood glucose levels)

into green, yellow and red management zones.

Green indicates stability and good control over the

condition, yellow indicates caution and suggestssteps for regaining control, and red indicates a

medical crisis that requires a providers attention.

Effective use of tools in the management of diabetes can

empower health care providers to make good clinical

judgments, involve clients in self-management, and provide

timely and efficient care, all of which contribute to improved

outcomes.

It may be appropriate for the CHS to work with the PCP to

develop a decision support tool to be used by numerous

member agencies. For example, this is relevant where a localdiabetes risk or triage tool is required to ensure that clients get

the right care, at the right time by the right service provider

(which may be the CHS, GP, RDS, HARP). Some PCPs have

already done this work and are willing to share their learnings,

in particular the tools that they have developed.

Refer Chronic Disease Management Program Guidelines.

4.5 Flexibility in service provision

To ensure diabetes services and program respond to the

needs of local communities and individuals, flexibility must

be built into the design of these services and programs.

For example, it is likely that people newly diagnosed with

Type 2 diabetes will include middle age adults still working.

Therefore, after hours services and programs (including

week nights and/or weekends) should be offered.


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Flexible approaches to self-management

interventionsSelf-management interventions must take into account that:

ot all people respond well to group programs, due to

issues of culture, language, education and preference.

Therefore, individual appointments should be offered

where group programs are not appropriate.

Group programs are appropriate for some Indigenous

and CALD communities, however programs need to

be reviewed and modified to ensure they are culturally

appropriate. Where clients are literate in their own

language, translated written materials may be appropriate,

otherwise different approaches are required.

Cultural differences in definitions of health and

expectations around health care behaviours impact on

self-management, so interventions must be sensitive to

these differences and explore meanings around living a

healthy life.

Running group programs in rural settings may require

running groups with smaller numbers and running groups

for people with a variety of diagnoses.

Individual appointments can take a range of forms

based on need, for example, one-on-one appointments,telephone coaching, Internet support.

It should also be recognised that the term self-management

is a fairly new concept and is not well understood outside of

the health workforce. Therefore, careful planning should be

taken to market these interventions. Involving community

and consumer representatives in planning recruitment and

marketing strategies and developing resource materials will

be important.

4.6 Addressing health inequalities

Evidence tells us that low health status and unequal burden

of chronic disease is consistently experienced by high risk

subgroups within the community, including:

Indigenous Australians

people who experience socioeconomic disadvantage (and

who often have low literacy and education levels)

rural and remote populations

CALD communities.

Providing self-management interventions to Indigenous

Australians and people from CALD backgrounds does

not simply involve providing interpreters and translatedmaterials. It requires working with these communities

to explore and identify culturally appropriate concepts,

terminology and meaning. It also means undertakingmulti-faceted health promotion strategies, tailored to the

needs and characteristics of local populations, to raise

the profile of self-management across these communities.

CHSs are encouraged to work with ethno-specific

agencies, Migrant Information Centres and Aboriginal

Controlled Community Organisations that have expertise

in working with these subgroups.

Factors shown to contribute to the success of self-

management interventions include:

understanding health beliefs and expectations and

adapting interventions to meet these beliefs

increasing levels of health literacy and self-efficacy

tailoring information and materials

improving the communication skills of health care

providers

working with clients, their carers, families and

communities

addressing issues related to affordability in program

design, so that interventions present no barrier to take-up

addressing social, economic and environmental issues,

such as access to fresh food and improving access toprimary health care services

employing people from the target populations, including

Aboriginal health workers and bilingual health workers

ensuring that language barriers are addressed through the

use of interpreters, translation of materials or production

of pictorial materials

routinely following up clients (or recalling them for review)

who are at a higher risk of developing complications

supporting local communities to identify actions

that could increase the availability, accessibility and

appropriateness of self-management interventions

supporting local communities to identify social, economic

and environmental barriers to adopting healthy lifestyles

and addressing these through local health promotion

initiatives.

Australian work

Some work has already been conducted within Australia

to adapt the Stanford self-management group program to

better suit Chinese (Mandarin and Cantonese speaking),

Greek and Italian subgroups. The ational Health and

Medical Research Council funded a research project(control trial) called Peer-Led Self-Management of Chronic

Illness for Chinese, Vietnamese, Greek and Italian People.


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0 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Information about this work and the research project is

available on the web.38

The Commonwealth-funded Sharing Health Care Initiative

projects also focused on disadvantaged population

subgroups. Five projects were Indigenous-specific, two

focused on socioeconomic disadvantage, and two included

a focus on CALD subgroups. Information on the outcomes

of these projects and resources developed is available

on the web39. It is recommended that CHSs use these

learnings and resources.

Indigenous Australians

Findings from the Sharing Health Care Initiative workingwith

diabetes mgt from victorian govt dept (janet laverick)

Documents