Regional Diabetes Pathways

Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes

Developed by Department of Health - Loddon Mallee Region

Department

of Health

Pathways for prediabetes, type 1, type 2 and gestational diabetes were developed by Department of Health, Loddon Mallee Region.

The pathways were prepared by Collaborative Health Education and Research Centre (CHERC), a business unit of Bendigo Health.

© DH Loddon Mallee 2009This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Department of Health, Loddon Mallee Region.

Graphic Design - www.youngbloodink.com.au

These evidence - based pathways have been developed to help guide clinicians in the Loddon Mallee region in the appropriate care and management of people with prediabetes and diabetes.

The pathways provide guidelines for the identification and management of prediabetes, type 1, type 2 and gestational diabetes, and are not intended to replace professional judgement or clinical expertise.

National and international guidelines have informed the development of these pathways and it is anticipated that they will be reviewed and updated as changes to national guidelines arise.

These pathways are endorsed by Diabetes Australia - Victoria.

Pathways for Prediabetes, Type 1, Type 2 and Gestational Diabetes

Acknowledgements ................................................................................................. 4

Glossary of Acronyms & Abbreviations ......................................................... 5

Explanatory Notes.................................................................................................... 6

Prediabetes:

- Prediabetes Clinical Pathway .................................................................................... 8

- Prediabetes Ongoing Self-Management Pathway ................................................. 9

Type 1 Diabetes:

- Type 1 Diabetes Clinical Pathway ........................................................................... 10

- Type 1 Ongoing Self-Management Pathway ......................................................... 11

Type 2 Diabetes:

- Type 2 Diabetes Clinical Pathway ........................................................................... 12

- Type 2 Diabetes Ongoing Self-Management Pathway ........................................ 13

Gestational Diabetes:

- Gestational Diabetes Clinical Pathway .................................................................. 14

- Gestational Diabetes Ongoing Self-Management Pathway ............................... 15

References .................................................................................................................. 16

Table of Contents

August, 2009 PAGE 3

Design of the Loddon Mallee Regional Diabetes Pathways has been based on the collective contribution of all members of the working party. The working party consisted of clinical experts from within the region, who have freely given of their time to guide and direct the development of these four pathways. Their enthusiasm, expertise and willingness to participate has ensured successful development of the pathways.

Members of the LMR Regional Diabetes Model Pathway project working party:

Professor Frank Alford .................Endocrinologist St. Vincent’s Hospital, Melbourne

Jacqui Cesco .................................Diabetes Educator/Care Co-ordinator, Sunraysia Community Health Services, Mildura

Michelle Chappel ..........................Practice Nurse, Central Victorian General Practice Network, Bendigo

Fran Degrandi ................................Pharmacist, Central Highlands General Pratice Network, Gisborne

Kate Edwards ................................Dietitian, Bendigo Community Health Services, Bendigo

Lyn Flavell ......................................CDE, Sunraysia Community Health Services, Mildura

Raelene Gibson .............................Diabetes Educator, Mildura Base Hospital, Mildura

Linley Grylls ...................................CDE, Diabetes Team Leader, Bendigo Health, Bendigo

Dr. Greg Harris ..............................Physician, Bendigo

Ange Jewson ................................Community Health Nurse / CDE, Swan Hill District Health, Swan Hill

Tracy Kemp ....................................Podiatrist, Sunraysia Community Health Services, Mildura

Susan Kennett ...............................Podiatrist, Bendigo Community Health Services, Bendigo

Claire Kerslake ..............................Diabetes Educator, Deniliquin

Elizabeth Lacey .............................Diabetes Educator, Kyneton District Health Service, Kyneton

Robyn Lindsay ...............................Physiotherapist, Bendigo Health, Bendigo

Jane McCaig .................................Exercise Physiologist, Bendigo Health, Bendigo

Dr. Sydney Paul .............................General Practitioner, Deniliquin

Wendy Pogue ................................CDE, Kyabram and District Health Service, Kyabram

Angela Roney ................................Diabetes Educator, Northern District Community Health Service, Kerang

Christine Schaller .........................Dietitian, Bendigo Health, Bendigo

Catherine Shultz ............................Diabetes Educator (acute) Swan Hill District Health, Swan Hill

Katrina Sparrow ............................Registered Nurse Div 1, Bendigo Health, Bendigo

Fiona Williams ...............................Practice Nurse/Diabetes Educator, Maldon Medical Clinic, Maldon

Janette Woolley ............................CDE, Bendigo Community Health Services, Bendigo

Acknowledgements

August, 2009 PAGE 4

ADEA ......................Australian Diabetes Educators Association

ADIPS .....................The Australasian Diabetes in Pregnancy Society

ATSI .........................Aboriginal and Torres Strait Islander

AUSDRISK .............The Australian type 2 diabetes risk assessment tool

BGL ..........................Blood glucose level

BMI .........................Body mass index

BP ............................Blood pressure

CDE ..........................Credentialled diabetes educator

CHO .........................Carbohydrate

CVD .........................Cardiovascular disease

DAA .........................Dietitians Association of Australia

DAFNE ....................Dose adjustment for normal eating

DA Ltd .....................Diabetes Australia (national organization)

DAV .........................Diabetes Australia (Victoria)

DE ............................Diabetes educator

DMMR ....................Domiciliary medication management review

EPC ..........................Enhanced primary care

FBG ..........................Fasting blood glucose

GAD .........................Glutamic acid decarboxylase

GCT ..........................Glucose challenge test

GDM ........................Gestational diabetes mellitus

GP ............................General practitioner

HbA1c .....................Glycated haemoglobin

HDL ..........................High density lipoprotein

HMR ........................Home medicines review

Ht ..............................Height

Hx .............................History

ICU ...........................Intensive care unit

IFG ...........................Impaired fasting glucose/glycaemia

IGT ...........................Impaired glucose tolerance

K10 ...........................Kessler psychological distress scale

Kg/m2 ......................Kilograms/metres2

LDL ...........................Low density lipoprotein

LSMP ......................Lifestyle modification program

MBS ........................Medical benefits schedule

mmol/L ....................Millimoles per litre

NCCCC ....................National Collaborating Centre for Chronic Conditions

NCCWCH ...............National Collaborating Centre for Women’s and Children’s Health

NDSS ......................National Diabetes Services Scheme

NHMRC ..................National Health and Medical Research Council

NHPAC ...................National Health Priority Action Council

NICE ........................National Institute for Health and Clinical Excellence

OGTT .......................Oral glucose tolerance test

OHA .........................Oral hypoglycaemic agent

PD ............................Prediabetes

PG ............................Plasma glucose

PWD ........................Person with diabetes

RACGP ....................Royal Australian College of General Practitioners

RBG .........................Random blood glucose

SBGM .....................Self blood glucose monitoring

T1DM ......................Type 1 diabetes mellitus

T2DM ......................Type 2 diabetes mellitus

TCA ..........................Team care arrangement

WHO .......................World Health Organisation

Wt ............................Weight

2hrG .........................2 hour OGTT

Glossary of Acronyms & Abbreviations

August, 2009 PAGE 5

= Decision = Action

PREDIABETES

TYPE 1 DIABETES

TYPE 2 DIABETES

GESTATIONAL DIABETES

Annual Cycle of CareThe Annual Cycle of Care (Diabetes) provides minimum guidelines of care for a person with diabetes. General practitioners working in an accredited practice, can apply for the Practice Incentive Program (PIP) with Medicare Australia and receive a Service Incentive Payment (SIP) for each cycle of care completed for a person with diabetes, within an 11 to 13 month period. It would be anticipated that most people with T1DM and T2DM require more frequent monitoring and review. 7 24

The minimum requirements include:

Activity Frequency / Description

Assess diabetes control by measuring HbA1c At least once every cycle

Ensure that a dilated fundus examination and visual acuity assessment is carried out by an ophthalmologist or optometrist

At least every two years

Measure weight, height & calculate BMI At least twice every cycle

Measure blood pressure At least twice every cycle

Examine feet At least twice every cycle

Measure total cholesterol, triglycerides and HDL At least once a cycle

Test for microalbuminuria At least once a cycle

Provide self-care education Assess self-management practices ( at least once a year) & review feedback from diabetes educator

Review diet Reinforce key messages from dietitian and review nutrition (at least once a year)

Review levels of physical activity Reinforce importance of regular and appropriate levels of physical activity (at least once a year)

Review smoking status At least once a year

Review medication At least once a year and consider referral for DMMR / HMR

Diabetes Educators Credentialled Diabetes Educators’ (CDE) are nationally accepted as providing quality assured provision of diabetes self-management education. An ADEA CDE is recognised as having met the following criteria:• Authorisationtopracticeinaneligiblehealthdiscipline• CompletionofanADEAaccreditedgraduatecertificatecourseofstudyindiabeteseducationandcare• 1800hoursofexperienceinprovidingdiabetesself-managementeducationasdefinedbyADEAandinaccordwiththeStandardsofPracticeidentifiedbyADEA• SubmissionofarefereedreportbyaCDE• Completionofamentoringprogram• EvidenceofcontinuingeducationacrossalldomainsofpracticeforCDEs• CommitmenttotheADEACodeofConductforDiabetesEducators40

The following disciplines are eligible for recognition as a CDE• Registerednurse(inVictoriathisappliestodivisiononeregisterednursesonly)• Accreditedpractisingdietitian(APD)• Registeredmedicalpractitioner• RegisteredpharmacistwhoisalsoaccreditedbyeithertheAustralianAssociationof Consultant pharmacy (AACP) or the Society of Hospital Pharmacists Australia (SHPA) While recognising Credentialled Diabetes Educators (CDE) as the ‘gold standard’ in the provision of diabetes self-management education, the term diabetes educator forthepurposeofthesepathwaysistakentomeanapersonwhohassuccessfullycompletedanADEAaccreditedgraduatecertificateindiabeteseducationandmanagement.

The term diabetes resource nurse and Aboriginal health worker, applies to a person employed within a health care service who has undertaken an appropriate and recognisedleveloftrainingindiabetes.Anumberofdiabetescoursesareavailable,including2daydiabetesworkshopsconductedbyDiabetesAustralia(Victoria)and an online training course Diabetes Management in the General Care Setting, developed by the National Association of Diabetes Centres (NADC) a joint initiative between the Australian Diabetes Educators Association (ADEA) and the Australian Diabetes Society (ADS). Neither of these courses, on completion, entitles a person to use the title Diabetes Educator.

KesslerPsychologicalDistressScale(K10)A simple screening tool, which can be used during a consultation to assess the mental health state of a person with diabetes18

Explanatory Notes

August,2009PAGE6

PrediabetesImpaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are conditions in which blood glucose levels are elevated but not high enough for a diagnosis of diabetes to be made. People with prediabetes are at increased risk of developing diabetes, cardiovascular and other macrovascular disease12

Self-ManagementSelf-management is the cornerstone of diabetes care. Actively encouraging, supporting and involving people with diabetes in their self-management, promotes healthandwellbeing,improvesqualityoflife,reducesdepressionandanxiety,significantlyincreasessatisfactionwiththeirtreatmentandreducesutilisationofhealth services 6 Optimal and effective self-management of diabetes is best supported by an evidence-based and collaborative approach to care involving ongoing feedback and communication between all parties.

Systems for CarePeople with diabetes require a systematic approach to their management, particularly annual review, from all members of a multi-disciplinary team. A systematic approach for GPs is facilitated by the use of:• Adiseaseregister• Anactiverecallsystemtofacilitatetimelyrecallofallpeoplewhenaspectsofdiabetes• managementrequirereview(pathology,complicationscreening,monitoring,reviewsandcareplanning).• Flowcharts• Reviewcharts

The RACGP and General Practice networks have resources to assist practices in establishing such systematic approaches to the care of their patients with diabetes 6 7

Explanatory Notes

August,2009PAGE7

AUSDRISK scoreLow risk < 5

Intermediate risk 6 – 14High risk > 15 4

People at risk of developing T2DM and PD- A family history of T2DM- Aged 55 years and over- Aged 45 years and over with 1 or more associated CVD risk factor- Aboriginal and Torres Strait Islanders (ATSI)- From culturally and linguistically diverse backgrounds aged 35 years and

over – Pacific Islanders, Maltese, people from the Middle East, North Africa, Indian sub-continent, China, Vietnam

- Overweight or obese (BMI > 25kg/m2). Waist circumference is an indicator of abdominal fat which increases risk of T2DM and CVD

- Women who have had GDM- Women with Polycystic Ovarian Syndrome who are overweight- Smokers- Physical inactivity- Those taking certain medications, antipsychotic medication & steroids

Everyone can be screened using AUSDRISK tool but people identified at high risk of T2DM should be screened 1 2

Prediabetes Clinical Pathway

The Australian Type 2 Diabetes Risk Assessment (AUSDRISK) is a questionnaire screening tool which accurately predicts a person’s risk of

developingT2DM within the next five years 2 3 5

Person performs self-assessment of T2DM risk using AUSDRISK tool3

GP/health professional confirms AUSDRISK score 4

diabetes uncertain

diabetes likely

diabetes unlikely*

Promote importance of healthy lifestyle choices for prevention of T2DM, PD and CVD. Provide information on local community based

LSMP/self-management interventions. Encourage continued good health5

Person diagnosed with prediabetes. Refer to - LSMP- Diabetes educator- Dietitian LINK TO REVERSE Link to Type 2 Diabetes

Clinical Pathway

Are symptoms of diabetes present?

Recheck FBG > 24 hours. In the presence of illness wait

until well *2

Result of FBG

Perform FBG (laboratory tested) if not done in last 12 months. Results indicate:

< 5.5 (diabetes unlikely) 5.5 – 6.9 (diabetes uncertain)

> 7.0 (diabetes likely)*2

Perform OGTT Results indicate:FBG < 6.1 or 2hrG < 7.8 (diabetes unlikely)

FBG 6.1 – 6.9 or 2hrG < 7.8 (IFG)FBG < 7.0 or 2hrG 7.8 – 11.0 (IGT)

FBG > 7.0 or 2hrG > 11.1 (diabetes)*2

* People with AUSDRISK score of 15 or more with a FBG of < 5.5 are eligible for Life! Program

YES

NO

< 7.0

5.5 - 6.9

Low Risk

F. > 7.0

< 5

< 5.5

> 7.0

6 - 14> 15

Are there identified risk factors for T2DM & PD?

Recheck FBG 3

yearly 2

No

Yes

August, 2009 PAGE 8

A person with PD understands T2DM may be prevented

or delayed by adopting

healthier lifestyle modifications

T2DM has been excluded with recent FBG 3

Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with prediabetes 6

Prediabetes Ongoing Self-Management Pathway

Consider referral to appropriate and locally agreed allied health professional:- dietitian- diabetes educator- exercise physiologist/physiotherapist

Lifestyle Modification Program- if aged 40 years & over, eligible for

subsidised LSMP eg. Life! Program.- an ATSI adult person aged 15 –

54 years is also eligible for Life! Program

- a person of any age is also eligible for Life! Program, under WorkHealth initiative

- consider referral to other locally available self-management interventions & LSMPs

REFERENCES:1Diabetes Australia Victoria 2009 2 NHMRC 2001. 3 Diabetes Australia 2009 4 Diabetes Australia Victoria 2009 5 Royal Australian College of General Practitioners 2009 6 National Health Priority Action Council 2006 7 Royal Australian College of General Practitioners 2008 8 9 10 Department of Health and Ageing 2009. 11 Department of Health (WA) Diabetes Australia (WA) 2005 12 Twigg et al 2007

Reassess AUSDRISK score – Prediabetes adds 6 points to

initial AUSDRISK score 4

Role of GP:- provide a systematic approach to PD management

with systems for care - annual review of modifiable lifestyle risk factors for

T2DM and CVD- annually perform a clinical CVD risk assessment

including BMI, waist circumference, BP, FBG & fasting lipids

- consider referral to other allied health professionals based on local community availability and person’s need

- psychosocial stress may increase individual risk of developing T2DM. Screening with K10 tool can identify people with depression and anxiety

- support and promote self-management practices

People with Prediabetes should receive same target goals of BP and lipid management as people with T2DM.

consider using these MBS Item numbers

Item 710 ATSI adult health check if person is aged 15 - 54 years (inclusive)Item 713 T2DM Risk Evaluation if aged 40 - 49 years (inclusive).Item 717 45 year old health check

Refer to MBS for full item descriptor and explanatory notes on all these item numbers 5 6 7 8 9 10 11 12

Role of LMP FACILITATOR/DIABETES EDUCATOR Provide evidence-based interventions which promote and support healthier lifestyle change & choices in prevention of T2DM. LSMPs promote self-management and self-determination by addressing modifiable lifestyle risk factors for T2DM using behaviour change techniques, counselling and goal setting. eg. - The Life! Program - diabetes educators (based on local agreement) - other community based diabetes self-management groups and LSMP’s available in the Loddon Mallee region

Contact local Division of General Practice and Community Health Centres for available programs in your area

Role of ABORIGINAL HEALTH WORKERProvide culturally appropriate support and counselling to promote understanding of PD and T2DM prevention 7

Role of PRACTICE NURSE, COMMUNITY HEALTH NURSE & DIABETES RESOURCE NURSE

- Establish and maintain systems for care and identify people who may be at risk of T2DM and PD and access for aged-related health checks.

- promote healthy lifestyle modification with high emphasis placed on T2DM being preventable

- consistent with Dietary Guidelines for Australian Adults & Physical Activity Guidelines for Australian Adults

- support ongoing self-management practices with advice and information which is current & appropriate.

- reinforce feedback key messages from LSMP facilitators and other members of the multi-disciplinary team. 7 12

Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPISTProvide individual assessment, exercise prescription and behaviour-change counselling

- regular physical activity is a key message, and should be provided by all members of the multi-disciplinary team.

- exploring individual preference for physical activity and providing information about local exercise interventions, and advise appropriate to the person’s age and level of fitness. 5

Role of DIETITIAN Assess nutritional needs, develop personalised eating plans, offer nutritional counselling, support, weight management and specific nutritional advice for people with PD, dyslipidaemia & hypertension 21

Score 15 & over

A person with prediabetes requires referral for intensive LSMP by GP

DESIRED OUTCOMES- identify and screen for T2DM & PD- diagnosis and early intervention for people

diagnosed with PD - prevent and delay progression to T2DM with

intensive, evidence based lifestyle modification interventions

- annual screening for T2DM and CVD

Score 14 & less

Lifestyle Modification ProgramNot eligible for Life! Program. Consider referral to other locally available LSMPs- Consider ‘Life on Line’ or telephone coaching

August, 2009 PAGE 9

Type 1 Diabetes Clinical Pathway

Person with initial diagnosis of T1DM requires immediate referral to medical

practitioner

Refer to diabetes educatorPerson seen 1-2 hrs daily

over 4-5 days

Refer to endocrinologist/physician (adults) and

paediatric endocrinologist/paediatric physician (children

and adolescents)

Refer to mental health worker/social worker

If assessed at high priority, to be seen within one week. If at low priority,

within one month of diagnosis. Up to 1 hr consultations several sessions over first month and then annually unless

indicated more frequently 32

Refer to dietitianInitial contact within first

week then 4-6 sessions over first month 32

All people with T1DM, family & carers should receive immediate referral for survival skills education and self-management support

Following survival skills phase and initial management, GP to refer all people with T1DM, family and carers for assessment, education and treatment within the first 12 months. Feedback between GP, PWD, carers and multi-disciplinary team

Refer to: - podiatrist - ophthalmologist/optometrist - exercise physiologist/physiotherapist - community Health/Sexual Health worker(adults only)

Paediatric clients-emergency department admissionCriteria includes:- all children under 5

years of age to be admitted to a paediatric acute setting or consider ICU 31

Person well – ambulatory service provisionCriteria include:- BGL elevated- no acute illness- no signs of ketoacidosis- 24 hr access to clinical advice 31 33

Person well – acute hospital admissionCriteria includes:- geographically isolated- physical/mental disability which may impede

self-management- no telephone available in the home- language or communication difficulties- profound grief reaction in family- individual dependant on a carer who is unable to take

responsibility for safe insulin administration 32 33 37

Person acutely unwell –emergency department admission

Person presents with:- hyperglycaemia (RBG

> 11.1 mmol/L)- polyuria- polydipsia 31

Link to Type 2 Diabetes Clinical Pathway

Options

Criteria includes:- BGL >11.1mmol/L- ketoacidosis - admission to ICU/acute

settingClinical findings- polyuria- polydipsia- weight loss- abdominal pain- weakness- vomiting- confusion

Clinical signs- dehydration- deep sighing (kussmaul)

respirations- smell of ketones- lethargy, drowsinessBiochemical signs- ketones in urine or blood- acidaemia pH<7.3 13 14 31

Link to Type 1 Diabetes Ongoing Self-Management Pathway

Does person have? - non-fasting ketonuria - marked weight loss *30

YES

YES

NO

August, 2009 PAGE 10

Ignoring age & BGL, are there symptoms of:• ketonuria (may be absent)• polyuria, polydipsia & weight loss• no other features of the metabolic

syndrome & BMI < 25• family hx of autoimmune disease• in 80% of people GAD & IA2

antiibodies will be present 13 14

NO

Type 1 Diabetes Ongoing Self-Management Pathway

TYPE 2 DIABETES ONGOING MANAGEMENT PATHWAY

DESIRED OUTCOMES:- achieve optimal target management goals of BGL’s,

BP and lipid control - support optimal psychosocial adjustment to diabetes- monitor growth and development (children and

adolescents)- prevent / early detection of macrovascular and

microvascular complications with screening- promote self-management practices- quality of life 6 7 14 15 18 21 26 27

REFERENCES:6. NHPAC (2006) 7. DA & RACGP (2008) 13. NCCCC adult (2004) 26. NHMRC 2008 30. Bristol, North Somerset and South Gloucestershire (2009). 32. National Institute for Clinical Excellence (NICE) 2004 33. ADEA 2004 31. NHMRC 2005 38. ADEA (2006)

Optimal adjustment to living for a

person with T1DM, their family and

carers *18

Role of DIABETES EDUCATORInitial contact – survival education - describing the diabetes disease process

and treatment options - monitoring blood glucose, urine/blood

ketones (when appropriate) discuss and demonstrate

- insulin initiation and skill acquisition - preventing, detecting and treating

acute complications eg.hypoglycaemia/hyperglycaemia

- VicRoads notification- NDSS registration - on-going self-management plan - peer support - sick day managementOngoing contact – minimum of annual review- pathophysiology of diabetes- agreed self-management plan- insulin adjustment- long term complications- glycaemic control- effects of physical activity- hypoglycaemia- travel and diabetes- promoting pre-conception care and

management during pregnancy (if appropriate)

- children & carers (discuss childcare, preschool and school sick day management)

- age-appropriate education on sexuality, smoking, alcohol and drugs, employment, fitness to drive

- re-assess education requirements - establish and maintain a system of recall

and review 6 31 38

Role of DIETITIANInitial contact- survival education- family Hx, including beliefs about T1DM- medical Hx, conditions that may impact on diet- social situation, family structure, cultural issues- diet Hx (establish usual diet, energy intake, total and saturated fat, CHO

intake and distribution, appetite and food preferences)- usual routine and activity- motivation and ability to ensure appropriate nutritional intervention such

as hypoglycaemic measuresOngoing contact- minimum of annual review- height, weight, BMI- usual nutritional intake and appetite- meal planning/carb counting/DAFNE- self management- management of life activities and growth- method of treatment of hypoglycaemia- CHO intake & adjustment pre and post exercise- alcohol intake and advice- consideration of new medical conditions- re-educate where required- establish and maintain a system of recall and review 6 31 32

Role of MENTAL HEALTH WORKERInitial contact- assess for client adjustment issues, limited social supports, needle

phobia, depression, anger, anxiety.- assess the typical range of emotional reactions to the diagnosis of T1DM- guilt and grief- marital/personal stress- treatment adherence- anxiety and depression assessment and increased risk factors- children and adolescents need age-related assessment

- establish and maintain a system of recall and review- provide support for family & carers 6 30 31

Role of GP- annual cycle of care - systems for care- management planning, TCA & mental health care plan (as

needed)- ensure recommended annual screening completed- assess sexual health, discuss contraception and

provide pre-conception advice as needed- support for family & carers- ATSI people should receive culturally appropriate

interventions - assess oral health & refer to oral health professional

under available Medicare Australia dental items 7 31

Role of PHARMACIST- conduct an annual DMMR/HMR 22

Role of OPHTHALMOLOGIST/OPTOMETRIST- on diagnosis and yearly assessment for adults.

adolescents after 2 years of diabetes and 5 years for children

- assess visual acuity, new vessel formation- urgent referral to ophthamologist if sudden changes

occur 13

Role of PODIATRIST- annual structured foot surveillance as minimum for

adults, children and adolescents- check for skin conditions, shape and deformity, shoes,

impaired sensory nerve function and vascular supply- establish and maintain a system of recall and review 6 13

Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPISTEducate on - the link between physical activity and arterial risk- exercise in relation to insulin, nutritional needs pre and

post exercise - establish and maintain a system of recall and review 6 13

Role of ENDOCRINOLOGIST/PHYSICIAN/PAEDIATRICIANReview - 3 monthly for children and adolescents & minimum of annually for adults.

Initial contact-assessment of client including medical history, complications, recent diabetes history, family history, vascular risk factors, foot/eye/vision examination, urine albumin excretion, urine protein, serum creatinine, BP & fasting lipids- insulin initiation and adjustment as required

Ongoing contact- HbA1c measurements based on individual

need. - screening for microvascular and macrovascular

complications.- assess sexual health, discuss contraception and provide pre-conception advice as needed 13 31

Mircrovascular complications screening is critical for person with T1DM.


Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T1DM, their family and carers. 6

Type 2 Diabetes Clinical Pathway

Agreed individualised target goals of weight management, BGL’s, BP and lipid management. Identify individual health priority and needs.

Information resources should be current, consistent and consider culture, language, literacy, age and special learning needs.

Person with initial diagnosis of T2DM

First visit to GP

Assess modifiable lifestyle risk factors 5

Clinical assessment & screening for CVD risk factors 5 6 1 4

Explore and identify psychosocial issues, reaction to diagnosis, factors

affecting coping, adjustment & barriers to learning. Screen for depression

Assess individual needs Annual Cycle of Care

GP management planning Refer to multi-disciplinary team members using TCA & allied healthgroup services

to promote and support self-management practices 7 16 17

Refer to diabetes educator within one month of diagnosis. Based on priority of need should be

seen within 6 weeks. May require earlier

appointment

Ongoing multi-disciplinary review based on clinical assessment and individual need, with feedback between PWD, GP & multi-disciplinary team. 19

Refer to dietitian within one month of diagnosis 21

Refer to exercise

physiologist / physiotherapist

Refer to podiatrist 27

Refer to ophthalmologist

/optometrist 26

Review by GP following 3 months trial of lifestyle modification. Recheck HbA1c,BMI, waist circumference and other investigations based on clinical assessment and individual need.

Review medication management - consider referral for DMMR/HMR

Refer toMental health worker

Social workerSmoking cessation program

Aboriginal health workerOral health professional

(based on individual need assessment)

Ignoring age & BGL, are there symptoms of:• ketonuria (may be absent)• polyuria, polydipsia & weight loss• no other features of the metabolic

syndrome & BMI < 25• family hx of autoimmune disease• in 80% of people GAD & IA2

antiibodies will be present 13 14

Link to Type 1 Diabetes Clinical Pathway

Provide information and registration / notification forms for NDSS & VicRoads

Children & adolescents with T2DM need referral to paediatric endocrinologist / physician.CONSIDER

YESYES

Assess for 3 month trial of lifestyle modification only, with assistance from multi-disciplinary team. Are there symptoms of hyperglycaemia with BGL >

20mmol/L? 7

Does person have T2DM?

Consider commencing Metformin as first line OHA of choice 7

Are individualised, agreed goals of management being achieved?

Link to reverse for Type 2 Diabetes Ongoing Self-

Management Pathway

YES NO

YES

NO


Type 2 Diabetes Ongoing Self-Management Pathway

REFERENCES:6 NHPAC 2006 7 RACGP 2008 14 Cohen,M 2007 15 NHMRC 2004 16, 17 Department of Health and Ageing 2009 18 Eigenmann C & Colagiuri R 2007 19 ADEA 2004 20 ADEA & ADA 2005 21 ADA 2006 22 23 Department of Health and Ageing 2009 24 Medicare Australia 2009 25 MIMS Australia 2008 26 NHMRC 2008 27 NHMRC 2005 28 AAESS 2008

Optimal adjustment

to living for a person with

T2DM 18

Role of DIETITIAN- provide nutritional assessment and nutrition prescription,

education, goal setting and ongoing reviews- annual review is part of care- establish and maintain a system of recall and review * 6 20 21

Role of OPHTHALMOLOGIST / OPTOMETRIST - ensure all PWD receive a dilated fundus examination

and visual acuity assessment at initial diagnosis and at least every 2 years 7 22

Role of ENDOCRINOLOGIST / PHYSICIAN- ensure all people with complicated problems related

to their diabetes receive expert clinical advice and management

- reviews are based on clinical judgment and individual need.

Role of GP- provide continuity and coordination of care - annual cycle of care- management planning & TCA - multi-disciplinary referrals using allied health service MBS

items- review metabolic control (HbA1c, self-monitoring of BGLs) - surveillance and screening for macrovascular &

microvascular complications, annual fasting lipids, U&E’s & microalbuminuria

- explore psychosocial issues, particularly depression, social isolation, sexual health, family stress. Screen using K10 screening tool and refer to appropriate allied mental health professional

- people with an HbA1c > 8% for 6 months should be referred to an endocrinologist /physician for assesment and management

Role of PRACTICE NURSE- establish & maintain systems for care, and under direction

from GP assist with GP management planning, TCA and annual cycle of care.

- conduct annual nursing review 6 7 8 14 15 16 17 19 23 24 26

Role of PHARMACIST - conduct an annual Domiciliary Medication Management

Review (DMMR) for people with diabetes living at home, who meet eligible criteria, using MBS Item 990 22

Role of ABORIGINAL HEALTH WORKER- provide culturally appropriate practical support and

counselling to promote understanding of T2DM amongst Indigenous people

- establish and maintain a system of recall and review * 6 7

Role of COMMUNITY HEALTH NURSE- promote and support optimal health and well being and

assist with optimal adjustment to living with diabetes- establish and maintain a system of recall and review * 6

Role of EXERCISE PHYSIOLOGIST/PHYSIOTHERAPIST- provide individual assessment, physical activity

advice, exercise prescription and behaviour-change counselling

- annual review is part of care- establish and maintain a system of recall and review

6 7 28

Role of PODIATRIST - perform initial foot assessment, at diagnosis- following initial assessment, a podiatrist may consider

a PWD at “low risk” of foot complications and able to receive ongoing foot screening from an appropriately trained health professional

- people with ‘high risk’ feet should be managed and assessed by a podiatrist

- annual foot assessment should be conducted by a podiatrist, and is part of ongoing care

- establish and maintain a system of recall and review 6 27

Role of DIABETES EDUCATOR- provide & consolidate knowledge and understanding of diabetes. - identify and address gaps in learning and provide ongoing support and counselling, facilitating optimal

adjustment to living with diabetes. - annual review is part of care and a minimum requirement. - establish and maintain a system of recall and review. 6 18 19 20

Role of ORAL HEALTH PROFESSIONAL- provide optimal dental care for people

with chronic and complex care needs who require assistance with oral health.. Medicare dental items (85011 – 87777) are currently available for people with diabetes using the EPC program

Role of SOCIAL WORKER- assist a person with T2DM address

social, emotional, financial and practical issues that may affect daily living.

- establish and maintain a system of recall and review 6

Role of ALLIED MENTAL HEALTH PROFESSIONAL- provide psychological assessment and therapy from

eligible clinicians using Medicare GP mental health care items and better outcomes in mental health care program.

- establish and maintain a system of recall and review 2 3 6

DESIRED OUTCOMES:- achieve optimal target management goals of

BGL’s, BP and lipid control - support optimal psychosocial adjustment to

diabetes- prevent / early detection of macrovascular and

microvascular complications with screening- promote self-management practices- quality of life 6 7 14 15 18 21 26 27


Feedback and communication between all parties is crucial to achieving optimal health and well being for a person with T2DM 6

Gestational Diabetes Clinical Pathway

A woman with GDM is considered a high risk pregnancy *14

Woman requires BGL monitoring in the first 24 hrs post delivery and an appointment with GP at 6 weeks.Essential part of hospital discharge plan - provide woman with OGTT pathology request form with results to

be followed up with GP at first postnatal appointment

If FBG <5.5 and 2 hrs postprandial <7.0

Woman to continue with diet and exercise management 35

Woman requires OGTT (75g glucose load) at 26-28 weeks gestation, or if persistent glycosuria during pregnancy. F >5.5 2hrs or PG >8.0, confirms diagnosis 35

Follow up with GP/obstetrician for

routine care during pregnancy.

Persistant hyperglycaemia (on more than 2 occasions) FBG>5.5 or

2 hour postprandial >7.0Woman referred to obstetrician/endocrinologist

for initiation of insulin 35

At 26-28 weeks gestation woman requires GCT (50g oral glucose load) if PG > 7.8 at 1 hr

indicates an elevated result 35

At 12 - 16 weeks gestation woman requires OGTT (75g

glucose load) if F>5.5 or 2hr PG>8.0, confirms diagnosis 35

Refer to diabetes educator

Clinically uncomplicatedUsual pregnancy care

with close BGL and clinical monitoring 35

Good controland no mccrosomia or complications -

consider delivery full term 35

Clinically complicatedObstetric

management and consider delivery <38

weeks 35

- GDM in previous pregnancy- Previous baby > 4.5kg- Previous unexplained stillbirth- BMI > 30kg/m2

- Over 30 years- Indigenous Australians- Certain high risk ethnic groups

– Chinese, Vietnamese,

North African, women from Indian sub-continent, Polynesian & Middle Eastern

- Prediabetes (IFG & IGT) 35 36

Poor controlmacrosomia or complications -

consider delivery <38 weeks 35

Refer to dietitian Refer to obstetrician

Elevated SBGM

Risk factorsidentified *2

Review SBGM

ReviewSBGM

This pathway is not designed for women with pre existing T1DM or T2DM

YES

NO YES NO NO

YES

NO

YES

NO

Is diagnosisconfirmed?

Is GCTelevated?

Is diagnosisconfirmed?

Woman has Pregnancy Confirmed

YESNO

Perform Risk Screening for GDM


Gestational Diabetes Ongoing Self-Management Pathway

Role of DIETITIANDietary therapy is the primary therapeutic strategy for the achievement of acceptable glycaemic control in GDM and should :- conform with the principles of dietary

management of diabetes in general- meet the nutritional requirements of

pregnancy- be individualised for each person

depending on maternal weight and BMI- be culturally appropriate - moderate exercise is an adjunct therapy

with benefits, when used with dietary modifications and / or insulin 35

Role of DIABETES EDUCATORProvide information, advice, support and assist with diabetes management. Important aspects of education for the woman and her partner include:- the implications of GDM to herself and her baby- the dietary and exercise recommendations - SBGM is the optimal choice of monitoring glycaemic

control with one fasting and one postprandial BGL obtained daily as a minimum.

- the frequency of testing can be increased or decreased depending on results and progress of pregnancy

- insulin initiation and skill acquisition - survival skills and sick day management- contraception and pre-conception advice for future

pregnancy- peer support 35

Minimum goals of SBGM:- fasting capillary BGL < 5.5- 1hr postprandial capillary BGL< 8.0- 2 hr postprandial capillary BGL < 7.0 35

Role of GP & PRACTICE NURSE- establish & maintain systems for care to ensure

recommended ongoing follow up & screening. - at first postnatal visit ensure OGTT has been

performed and results reviewed. If OGTT normal, rescreen with FBG in 3 years. If OGTT abnormal rescreen FBG annually and link to appropriate pathway

- screen with AUSDRISK tool to determine risk of T2DM. Link to appropriate pathway

- provide contraception advice and pre-conception counselling and consider OGTT prior to future conceptions 7 35

Optimal adjustment for a women with Gestational

Diabetes *18

Role of OBSTETRICIAN & MIDWIFEAll women with GDM are considered to have a high risk pregnancyManage and monitor a woman through pregnancy. Timing and frequency of foetal monitoring depends on other complications such as pre-eclampsia, hypertension, ante-partum haemorrhage, intrauterine growth retardation. Ultrasonography should be considered at around 34 weeks gestation to detect abnormalities of foetal growth and polyhydramnios. Encourage breast feeding. Consider referral to a lactation consultant 35

Role of PAEDIATRICIAN- BGL should be checked 1 hour post delivery then before

the first 4 feeds for up to 24 hours. - a paediatrician should be present at delivery if significant

neonatal morbidity is suspected 35

Role of ENDOCRINOLOGIST / PHYSICIAN- Medically manage and monitor diabetes during

pregnancy. Initiate insulin if blood glucose goals are exceeded on 2 or more occasions within a 1 – 2 week period, particularly in association with clinical or investigational suspicion of macrosomia 35

Role of LSMP/SELF-MANAGEMENT INTERVENTION- address modifiable lifestyle risk factors using

behaviour change techniques, counselling and goal settings to prevent T2DM

- refer to locally available community health self management and LSMP’s 6

Role of ABORIGINAL HEALTH WORKER - provide culturally appropriate practical support

and counselling to promote understanding of GDM and long term prevention of T2DM amongst indigenous people 7

REFERENCES:7 RACGP 2008 35 Australasian Diabetes in Pregancy Society (ADIPS) 2003.

DESIRED OUTCOMES:- achieves optimal glycaemic control through

pregnancy- delivers a healthy baby- provision of ongoing advice, information and

screening for prevention of T2DM *35


Feedback and communication between all parties is crucial to achieving optimal health and well being for a woman with gestational diabetes 6

References used for Prediabetes, Type 1, Type 2 and Gestational Diabetes Pathway Design

1. Diabetes Australia Victoria 2009, Who is at risk of type 2 diabetes?, Diabetes Australia, Melbourne, viewed 20 July 2009, www.diabetesvic.org.au

2. NHMRC 2001, National evidenced based guidelines for the management of type 2 diabetes mellitus part 3 case detection and diagnosis of type 2 diabetes, National Health and Medical Research Council, Canberra, viewed 20 July 2009, <www.nhmrc.gov.au/publications/synopses/_files/di9.pdf>

3. Diabetes Australia Victoria 2009, The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), Diabetes Australia, Melbourne, viewed 20 July 2009 www.diabeteslife.org.au/Portals/0/Risk-test.pdf>

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5. RACGP 2009, Guidelines for preventive activities in general practice 7thedn, Royal Australian College of General Practitioners, South Melbourne, viewed 20 July 2009 <www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheRedBook/redbook_7th_edition_May_2009.pdf>

6. NHPAC 2006, National service improvement framework for diabetes, National Health Priority Action Council, Australian Government Department of Health and Ageing, Canberra, viewed 20 July 2009 www.health.gov.au/chronicdiseasestrategy

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8. Department of Health and Ageing 2009, Medicare benefits schedule – item 710 aboriginal and torres strait islander adult health check,Canberra, viewed 20 July 2009 http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A27&qt=noteID&criteria=item%20710

9. Department of Health and Ageing 2009, Medicare benefits schedule – item713 type 2 diabetes risk evaluation, Canberra,viewed20July2009 <http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A29&qt=noteID&criteria=item%20713>

10. Department of Health and Ageing 2009. Medicare Benefits Schedule – item 717 45 year old health check , Canberra, viewed20July2009 http://www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=A31&qt=noteID&criteria=item%20717

11. Department of Health (WA) and Diabetes Australia (WA) 2005. Western Australian Impaired Fasting Glucose and ImpairedGlucoseToleranceConsensusGuidelines,viewed20July2009 http://www.diabetes.health.wa.gov.au/policy/docs/Western%20Australian%20IFG%20IGT%20Consensus%20Guidelines.pdf

12. Twigg,SM, Kamp, MC, Davis, TM, Neylon, EK and Flack, JR 2007, Prediabetes: a position statement from the Australian Diabetes Society and Australian Diabetes Educators Association. MJA 166 : 9 7 May 2007.

13. National Collaborating Centre for Chronic Conditions, 2004, Type 1 diabetes in adults: national clinical guideline for diagnosis and management in primary and secondary care. Royal College of Physicians, London, viewed 20 July 2009 http://www.nice.org.uk/nicemedia/pdf/G015_fullguideline_adults_development_section.pdf

14. Cohen, M. 2007. Handbook of diabetes management 8th edn. International Diabetes Institute, Caulfield.

15. NHMRC 2004. National evidence based guidelines for the management of type 2 diabetes mellitus (part 5) prevention and detection of macrovascular disease in type 2 diabetes. Approved by the National Health and Medical Research Council 18 March 2004, viewed 20 July 2009 www.health.gov.au/internet/main/Publishing.nsf/Content/pq-diabetes-guide

16. Department of Health and Ageing 2009. Medicare benefits schedule item 721 GP management plan, viewed 20 July 2009 http://www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=A29&qt=noteID&criteria=721

17. Department of Health and Ageing. Allied health group services under medicare people with type 2 diabetes items 81100 – 81125 information for GPs, viewed 20 July 2009 .http://www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=M3.1&qt=noteID&criteria=allied%20health%20group%20services%20under%20medicare

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19. Australian Diabetes Educators Association 2004, The rationale for commonwealth government funding of diabetes self-management education. Prepared by Ann Nosworthy Consulting April 2004. View 20 July 2009 <www.adea.com.au/public/content/ViewCategory.aspx?id=39>

20. Australian Diabetes Educators Association and Dietitians Association of Australia 2005, Joint statement on the role of accredited practicing dieticians and diabetes educators in the delivery of nutrition and diabetes self management education services for people with diabetes www.adea.com.au/public/content/ViewCategory.aspx?id=40

21. Dietitians Association of Australia (2006). Evidence based practice guidelines for the nutritional management of type 2 diabetes mellitus for adults, viewed 21 July 2009, www.daa.asn.au

22. Department of Health and Ageing 2009. Medicare benefits schedule – items 900 and 903, domiciliary medication management review, viewed 21 July 2009 http://www9.health.gov.au//mbs/search.cfm?q=item+900&sopt=S

23. Department of Health and Ageing 2009. Medicare benefits schedule –items 2710 to 2713 GP mental health treatment items, viewed 21 July 2009 http://www9.health.gov.au//mbs/search.cfm?q=item+2710&sopt=S

24. Medicare Australia (2009). Practice incentive program (PIP) diabetes incentive. Last updated 18February2009, viewed 21 July 2009 http://www9.health.gov.au/mbs/search.cfm?q=+PIP+diabetes&sopt=S

25. MIMS Australia 2008

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28. Australian Association for Exercise and Sports Science and Dietitians Association of Australia 2008. The collaboration of exercise physiologists and dietitians in chronic disease management, viewed 21 July 2009 http://www.daa.asn.au/files/Info%20for%20Professionals/Publications_and_Resources/PUB_AAESS_A4_Brochures_FINAL_for_website.pdf

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33. ADEA 2004. National standards for the development and quality assessment of services initiating insulin therapy in the ambulatory setting. Australian Diabetes Educators Association, Holder , viewed on 21 July 2009 www.adea.com.au/public/content/ViewCategory.aspx?id=39

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References


Regional Diabetes Pathways

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