Pre-diabetes Referral PathwayDiabetes Service

Marion Hawker, CDE, CNC DiabetesGNC Diabetes Service

A new model of care for pre-diabetes patients

• Lifestyle changes can slow/prevent progression to type 2 diabetes.

• The GNC Diabetes Service developed a new model for facilitating these lifestyle changes.

Physical activity can help reduce blood glucose

levels and make the body more sensitive to insulin

A healthy eating plan can help reduce body weight

and control blood glucose levels

Rationale for a new model

The new model of care for patients diagnosed with pre-diabetes was developed in order to:•tailor service provision to patient need•provide relevant information and support for pre-diabetes patients over an extended period of time•enhance the capacity of GNC Diabetes Service to provide education and clinical care for higher risk patients and those with more complex care needs

GNC Diabetes Service focus

• The main focus of the service is to provide education and medical management for people with diagnosed diabetes.

• Increasingly, patients are being referred with co-morbidities, with more complex diabetes management issues, and with a greater risk of diabetes complications.

• Pre-diabetes patients are not (usually) on medication for their condition, and hence require less intensive education/support – a preventive approach is needed.

Who can provide this education and support?

• For people with pre-diabetes: – Tailored telephone coaching can support and motivate

patients to make necessary lifestyle changes.– Education can be provided in primary care settings by

general practice medical and nursing staff, in addition to their role in monitoring glycaemic issues.

– Community seminars and supermarket tours are offered by the Australian Diabetes Council.

– Private or community dietitians and other HPs such as exercise physiologists can assist with healthy eating and weight loss, by facilitating behaviour change.

The old pre-diabetes referral pathway

• Pre-diabetes patients were offered a group face-to-face education program based on a self-management approach, comprising 2 two hour sessions.

• If unsuited to groups, they were seen individually by a GNC Diabetes Service Diabetes Nurse Educator (DNE) and a Dietitian.

• Feedback was provided to the referring GP when the patient was discharged from the GNC Diabetes Service.

The new pre-diabetes referral pathway• DNE assesses over the phone the level of support

needed to make and maintain required lifestyle changes.• If appropriate for telephone health coaching the patient

is registered with the HNELHD Connecting Care Service which will contact the patient and offer one of two health coaching services, both free of charge.

• If not appropriate for telephone health coaching they are referred for an individual consult with a Community Dietitian or with a Diabetes Dietitian. This may be due to:

language difficulties, cognitive or hearing deficits the patient having more complex issues a higher risk of diabetes and future complications:

Personal health coaching by telephone Two health coaching options, both free of charge:

1.Healthpathways Australia Conducted by Australian Registered Nurses and Allied Health Professionals who deliver proactive, scheduled telephone calls, reinforce and support GP and health provider care plans, drive meaningful behaviour change and improve awareness of health conditions.

2. Get HealthyTelephone coaches support patients to develop and reach personal health goals, create action plans, maintain motivation, identify problem areas and create solutions for successful change. The service provides up to 10 free coaching calls.

Keeping GPs in the loop

• The Diabetes Service sends the referring GP a letter to advise that their patient will be offered telephone coaching, if suitable

• Connecting Care advise the referring GP that the patient is participating in Heathways or Get Healthy.

• If the patient consents, the GP is also provided with midpoint and final reports.

Patient numbers before and after the new pathway:

• BEFORE new referral pathway established, from Jan 2011 to Mar 2012 (14 month period):– 192 patients were seen individually and/or attended group

education – resource intensive! – 1 hour individual consults + two 3 hour group sessions with a DNE and a dietitian

• AFTER new referral pathway established, from Mar 2012 to July 2013: (16 months)– 295 patients were referred to Connecting Care for

telephone coaching– 24 patients only were seen individually (face to face) by the

Diabetes Service clinicians