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  • When Sherryn Streeter first asked me if I would do a cycling tour of diabetes I thought ‘Oh my God I can’t even ride a bike!” Then I thought well, I do know a bit about getting pts involved in the diabetes cycle of care. It was also a perfect excuse to use every cycling analogy I could think of in a short space of time.
  • Like cycling, our aim is to help our patients keep their diabetes in balance. These people are not yet fully enlightened. They haven’t got their helmets on, but with the right guidance & training we can help them get safely on track with their diabetes management.
  • When we first started looking at the wider picture of diabetes management & care at LGP We wanted to be involved with this new cycle of care. We needed a strategy. We knew where we wanted to go but how would we get there The practice principles & I worked out a plan where we looked at all the things that would be involved in implementing a large scale call in of our diabetic patients. Then we put the plan to the other doctors & clerical staff. Everyone had to know what was going on & everyone had to be involved. What worked best getting patients along for those first few cycles? A combination of everything, letters, coercing patients in the waiting room & direct GP referral.
  • We worked out that the nurse would do the majority of the physical assessment. We already were using that model for aged health assessments. It only took a bit of tweaking to adapt that framework to the diabetes annual health check.
  • Nurse can collect all this data ready to present to GP & report on any problems that are identified The patient would then ideally have the next timeslot with their GP to review the information collected by the nurse & complete any other more complex physical assessments that may be deemed necessary & review path results & treatments. Adjustments are then made & the patient referred back to the nurse for surveillance, lifestyle modification education, visits & care planning
  • We let our patients know that they are not on their own, that we are there to offer them as much support as they need to get the disease under control
  • Like cycling our aim is to help them keep their balance. We have all these CDM items to use as tools for our cycle maintenance 6 monthly check of HbA1c, BP, feet & general CDM maintenance, check on diet & exercise Recalls are built into the system. Those patients know that we will recall them for tune-up visits. Indeed many of them request to come back if they are encountering problems, need new referrals.
  • At each follow-up visit we discuss Mx, how are they going with their diet Mx, exercise program, what things do they feel are working best for them & how can we build on this. All new Dx pts get the Diab Aust fax back kit Yes we do meet a lot of resistance to diet & exercise but gradually we are wearing some of the more recalcitrant pts down. We have had some very good wins with pts lately including 2 older Mediterranean gents who have stopped smoking after 50 years, & Barbara who rang me back the day after her diabetes assessment. At the visit she said yes well I ve tried exercise & I don’t like walking & I think my diet is just fine ( that’s the AB Fab Edina model of dieting. She says to” Patsy Well darling I 've tried everything to lose weight except diet & exercise”. She said I have thought about what you said & I have discussed this with my sister. You are right. Can I come in & get that referral for the seniors gym.
  • Despite best efforts & the nature of the illness, sometimes the wheels fall off. That’s where bringing them back regularly for their maintenance checks pays off when you find problems in their early stages & begin / alter treatments management plan
  • Since starting the collabouratives we have looked at “ how can we be more innovative in our approach to Daib Mx” We have downloaded “The goals for optimum diabetes Mx from the RACGP website, & printed on bright yellow paper & laminated them. Each GP & nurse now has a flash card that they show to pts when they are discussing “targets’ or “Treatment goals’ We have also adapted our old paper based diab Mx Checklist to trial as a printed card that pts can bring to check-up & record their numbers & hopefully watch the numbers decrease as they meet their optimum targets
  • Just like Le Tour de France. Le Tour de Diabetes is a team sport LGP team strategies call them in for diabetes check up & HbA1c 2 per year Recall by letter, phone call or direct referral from GP Clinic booked in spare time slots when we can Tune up visits with the nurse 10997 & care plan & review with the nurse to streamline / slipstream Mx review by the GP Within a given team, you'll find specialists and key lieutenants whose jobs are help the team leader win the overall race… and they all benefit from high visibility and $ winnings if they succeed. This includes the patient & his health, The GP team sense of achievement & remunerated for good Mx & decreased burden on the health budget When we start the process the GP is the team leader but hopefully this role will change to one where the patient becomes the team leader & the GP team are the strategic partners that apply their strengths behind the scenes to help the ‘team leader’ gain competitive advantage.
  • And here is our cyclist well equipped ,& safely ready to tour


  • 1. A Cycling Tour of Diabetes Karen Booth RN Leichhardt General Practice
  • 2. Be Prepared! Are We in the Zone? How Will We Get There? The Strategic Plan!• What do you want to achieve? Target audience• Marketing (letter, phone, opportunistic, dr refer)• Space & Time / Appt schedule e.g. nurse then doctor• Budget e.g. cost of staff & room
  • 3. • Equipment, documents/templates• Division of labor/ teamwork/roles• PIP & SIP incentives• How do you bill??• Recalls & flow on services (referrals, HMR, care plan)• ***Establish a Model/Process that could be Easily Replicated***
  • 4. Equipment Tune-UpComponents of check up:-• HT, Wt, BMI,• Diet & exercise, education• Feet• Blood results• Medication review• ECG
  • 5. You’re not Cycling on Your Own!!
  • 6. Help Them Keep TheirBalance• Annual cycle of care• 6 month review• 10997 for CDM monitoring visits with the nurse• GPMP & TCA• Referral pathways for support (allied, Type II programs etc)• Build in the expectation of the return visits
  • 7. Remove the Training Wheels! Get Out on the Velodrome!• Give them information• Feel empowered to take control of their own health• Respond well to recalls, most pts are attending scheduled visits• Monitoring own BSL & weight• Regular exercise program
  • 8. Puncture Repair• Regular review for maintenance & treatment adjustments• May need new referrals• Endocrinologist, Clinic review• Diabetes educator, exercise phys referrals• Motivation
  • 9. THE LEICHHARDT GENERAL PRACTICE DIABETES MANAGMENT CHECKLIST Activity Target Frequency Date Date Date Date Date Values Hb A1c < 7.0% 6mths u/a Microalb < 20mg/L 12mths spot catch Cholesterol < 4.0 12mths Triglycerides < 1.5 12mths HDL > 1.0 12 mths LDL < 2.5 12 mths Weight 6 mths Height 12mths BMI 25 6 mths BP <130/80 6 mthsExamine feet 6 mths Eye check 2 yr min Selfcare 3-6 mths Diet review 6 mths Physical activity 6 mthsSmoking status 6 mths Medication 6 mths review EC G 12 mths
  • 10. Cycling is a Team Sport• Coach – GP• P/T, Mx - Practice Nurse• Support Crew – Clerical staff• Specialist support – Endocrinologist, Diab Educ, Dietitian, Exercise Phys.
  • 11. New Patient: Joan• A 66 year old female type II diabetic, Joan, has recently moved to your area to be nearer to her family. She would like to renew her prescriptions.• The receptionist books her 1st visit as a long consult
  • 12. • Triage by nurse: records BP, Wt, past medical history, medications & supplements?, vaccination status etc.• She has her current tablet packets with her.• She states she has been very happy with her current medication & would just like some repeats please!• Pt has been diabetic for past 9 Yrs• Has been taking tablets past 2 years• Discovered high BSL when having routine cholesterol check (which was also “a bit high” but pt has switched to low fat milk)• Moderately obese, BMI 30, BP 140/85, P 90 reg• (Hx diabetes & High cholesterol past 9 yrs) Mild hypertension not previously noted
  • 13. • Patient does not take own BSL• Joan likes to get her prescriptions with all her repeats “filled” at the same time. This saves her having to go back to the doctor or the chemist unless she feels unwell.• Patient does not have set exercise regime because she does enough running around when she visits the grandchildren & doing the housework.