This month’s LIFE changes

Easy entry for patients with Ischemic Heart Disease or a past history of Gestational Diabetes.

• Age: 18+
• Exclude Diabetes: OGTT
• AusDrisk: no longer required

There are some restrictions regarding timing of entry to LIFE with these diagnoses – contact me for more information.

Referral by BDDGP Referral Gateway (fax: 5331 5754 or send via ARGUS), or self referral via Diabetes Australia Vic.

How does self-referral work?

Patients can obtain a referral from DA-Vic, send it to DA-Vic central intake and be referred to a LIFE facilitator.

While the facilitator can manage the referral/enrolment process, the patient must nominate a “usual GP” to be eligible for this process.

The facilitator will organise an individual consultation with the patient where they gather biometric information, organise pathology (Fasting Glucose and Lipids), and explain the LIFE program. Assuming the patient wishes to continue with the program, they are then enrolled in a course.

Can anyone else self-refer?

Yes, self-referral is meant as a conduit to improve the ease (and speed) of entry into a program NOT to exclude the normal GP.

Others who can self-refer include people who have scored above 12 on the AusDrisk and are either:

• Aged 50+ years, or
• Have attended a WorkHealth Check.

Inclusion into the program requires that diabetes be excluded BUT as stated above, this can be organised by the LIFE facilitator.

Next Month: Information on WorkHealth Checks

Want to know more? Interested in a visit about setting systems in your practice to identify patients who would benefit from a LIFE program?

Contact me on 5331 6303 or email tanyag@bddgp.org.au.

DETA also provides diabetes and pre-pregnancy planning, diabetes and pregnancy managment for women with Polycystic Ovarian Syndrome (PCOS), Gestational Diabetes and type 1 and 2 diabetes.

Service details

Eligible patients: all patients with or at risk of diabetes, including pregnancy
Medicare registered: yes
Cost: Bulk billed where a CDM referral is made, some Private Health Insurance coverage and out of pocket expense depending on circumstance
Bulk bill: yes
Require same day payment: no
Gap: n/a

Referrals

Argus: no
VSRF: no
Phone: 0408 394 156
Fax #: 5332 8939
Address: 526 Macarthur Street, Ballarat Vic 3350
Reports returned by: fax

Hours

Monday to Friday, weekends and after hours by appointment

About Sheree Rennie

Credentials: Credentialled Diabetes Educator RN Div 1 (Hon)

http://www.detadiabetes.com.au

Monash University are conducting a community-based research study to measure clinical and emotional benefits of regular participation in a peer-led support group for people with type 2 diabetes.

Two support groups will be established in the Ballarat and Wendouree/Sebastapol areas.  Participants will receive education, have pathology and anthropometric measurements taken and discuss the importance of the clinical care team in their disease management during the group meetings. They will be encouraged to discuss their results with you.

If you would like to find out more about this study, please contact the project team via one of these methods;

• Phone: 03 9903 0512
• Email: peersforprogress.depm@med.monash.edu.au
• Web: www.peersforprogress.monash.edu.au

1. More time is needed for practice nurses, managers and GPs to:

• Talk to patients
• Learn new processes and plan how to go about things
• Find things (resources, websites, templates etc.) quickly
• Do things properly with patients without being under constant pressure

2. Insufficient staffing impacts on new initiatives, dependent on:

• The number of staff available within a practice
• The space available within a practice environment either for extra staff and/or extra activities
• Availability of skilled practice staff
• Interest areas of practice staff – including GPs and practice nurses. This can impact on the type of care patients receive.
• How often practice nurses are pulled away to do other things on an ad-hoc basis which are not on the list for the day

There are constant demands placed on practice nurses. This was not evident in the survey results, but came through very strongly in verbal discussions.

3. The referral pathways for diabetes prevention programs are not clear

• There is much confusion about referral pathways from all GPs, practice nurses and practice managers, but in particular within the GP group.
• GPs would like the steps clearly identified, easily found & promoted, and the profile of the diabetes program raised.
• Everybody would like the referral process to be as simple as possible.
• There is confusion about the rules for MBS items, for referral to groups & the necessity of doing an OGTT.
• Practice staff would like to see the profile raised of both diabetes prevention programs

4. All practice staff wanted to know who and what is out there

• More information about providers; who are they, what do they do?
• More information about diabetes prevention
• More information about care plans
• More stats on diabetes and costs to community and what is happening locally
• More resources for practices – posters, brochures, patient information kits
• What are the local supports available for GPs to refer to?
• How do practices get on to these supports?

5. Need help to identify patients at risk

• Some would like practice nurses to use the PEN cat tool
• Some would make a designated person responsible for identifying patients in the practice who are at risk, and for that person to drive the approach
• Some would like to identify a trigger for GPs to remember to screen patients at risk
• There was a suggestion to align diabetes week with practice activities in identifying at risk patients

6. Please BDDGP … simplify, tailor and change the way information is provided

• Practices want simple, fast, small chunks of information
• Keep the information coming
• Raise the profile of new programs and initiatives
• Practice nurses in particular want to know about the software requirements
• Suggestions for BDDGP to provide information packages for staff and for patients (about diabetes prevention programs)
• From this small survey, it appears that GPs prefer to use the website, practice nurses may favour the mid-week news and practice managers might like email best because “it’s in your face!”

7. Division practice visits don’t suit everybody

• Practice visits from the division – great, but difficult to fit into a normal day
• Practice visits were seen as a good way to build relationships and to keep in touch, for input and updates and education (selected), but only in the way the practice finds it useful
• Face-to-face and 1:1 visits were preferred by some, while others liked group sessions.
• 3 respondents talked about how much time Division visits can take and the impact this has on their own planning and meeting times, even though the Division visits are generally considered useful.

8. Ambivalence about education on new programs, new government stuff

• Education was considered highly important by practice managers (5/6)
• GPs were half and half in how they saw this (4/9)
• Practice nurses did not see education as a highly desirable way to get information about new initiatives (2/8)
• Suggestions were to have education sessions on site; after hours in different venues; coupled with other events and for the Division to consider different ways of learning such as “walking through something (with practice staff so they had the opportunity) to see and hear it.”

Stay tuned for the next article where we tackle these issues.

As part of reviewing how we deliver information on the diabetes prevention program, we’ve been developing a web-based tool. This links in with a survey on diabetes prevention that some practices have been participating in over the past few weeks.

The interview-style survey aims to find out what practices need, and how they would like information and support about diabetes prevention (and possibly other programs) delivered by the division.

We need to know if this web-based tool has value to GPs.

Diabetes prevention decision tool

If it proves useful, there is tremendous potential for guiding GPs safely through any number of complex referral pathways.

I know you have many concerns competing for your attention. Please, please take 2 mintues to check it out and send some feedback. I think we might be onto something good here.

You can email me directly at julianl@bddgp.org.au, or leave a message below.

What is it?

Through practical learning, the DAFNE program encourages individuals to become activated self managers, building on their own experience and expertise within the skills and guidance that the DAFNE principles provide. The program is designed for adults with Type 1 diabetes and involves attending a 5 day structured training course facilitated by DAFNE trained diabetes educators and dietitians. Topics include:

• carbohydrate estimation
• insulin adjustment
• blood glucose monitoring
• hypos
• illness and exercise under the supervision of DAFNE trained diabetes educators and dietitians

Who should attend?

To participate in DAFNE you need to:

• Have had type 1 diabetes for at least six months (and/or post your ‘honeymoon’ period)
• Be over 17 years of age
• Not on a pump
• Motivated to improve your diabetes control
• Willing to inject and test blood glucose levels up to five times per day
• Able to attend all five days of the program from 9am to 5pm
• Take one or two injections of long acting insulin each day and quick acting insulin each time you eat
• Able to speak/understand/read English

Where and when?

The next course will be run from Monday Oct 26th until Friday Oct 30th. BCH is the only accredited provider in Ballarat, call them on 5338 4500. Kerri Gordon and Marg Neale are the accredited trainers.

The cost is $50, but can be reduced for patients in financial difficulty.

History

DAFNE originated in the UK and is based on a course run in Germany since the 1980s. Results from the thousands of people in the UK, Republic of Ireland and Australia who have attended a DAFNE program show

• better blood glucose control
• fewer severe hypos
• improved quality of life
• fewer days off work
• less chance of diabetes complications

Since courses commenced in Australia in 2005, over 600 people have been trained in DAFNE principles including members of Ballarat Community Health. In Australia we call it OzDAFNE.

They will also be aware of discount options, company promotions and the availability of free meters. Alternatively meters can be purchased from NDSS outlets or local pharmacies. If you have private health insurance with ancillary cover you may be able to claim a rebate.

A letter from your doctor stating that you require a blood glucose meter for monitoring your diabetes is required when making a claim.

The Department of Veterans’ Affairs will supply a meter free of charge to gold card holders and to white card holders where diabetes is accepted as caused by their service.

Please note that meters have a lifetime warranty and your meter company will provide you with a free replacement meter should yours be faulty or out of date. Batteries and record books are usually provided by the meter company free of charge. To obtain these phone the company on their toll free number.

All meter companies provide a 24 hour toll free number to assist with meter problems or enquiries (number can be found on the back of the meter).

GPs and PNs please note this information has come from the Diabetes information resource for the Central Highlands Region which was launched by the Central Highlands Primary Care Partnership Diabetes Steering Group in July 2009.

You can access this resource at http://bddgp.org.au/diabetes#booklet.

The expo highlighted diabetes services available to the Ballarat community; including diabetes prevention. Heather Campbell and myself were on hand to discuss Diabetes risk assessment and the lifestyle modification programs offered in Ballarat.

Practice Nurse Gail Schuler also represented BDDGP and discussed the merits of GP Management Plans.

The Expo and Diabetes Information Resource for the Central Highlands Region were developed by the CHPCP Diabetes Steering Group, which comprises representatives from:

• Ballarat Community Health
• Ballarat District Nursing and Health Care
• Ballarat & District Division of General Practice
• Ballarat Health Services
• Central Highlands Primary Care Partnership
• Djerriwarrh Health Services
• Hepburn Health Services
• Hesse Rural Health Services
• St John of God Health Care Ballarat
• Consumers
• Diabetes Australia (National & State) and The Royal Australian College of General Practitioners – Victoria
• Australian Diabetes Educators Association

Tim Stewart (CHPCP)

Kerri Gordon, Dietitian (BCH)

Gail Schuler, Practice Nurse

Marg Neal, Diabetes Educator (BCH)

News From Diabetes Victoria

Getting Started – type 2 diabetes information sessions

Diabetes Australia – Vic offers people with newly diagnosed type 2 diabetes or those who have not had diabetes education in the past, the opportunity to participate in a Getting Started – type 2 diabetes information session.

The one-off 2.5 hour session is run by a diabetes educator and a dietitian and provides patients with valuable information to get them started with managing their diabetes. Carers and family members are also welcome.

There are a number of sessions throughout the year and all are held at the Diabetes Australia – Vic office.

• Address: 570 Elizabeth Street, Melbourne.
• Cost: $10 for Diabetes Australia – Vic members, or $15 for non members.
• Dates: 3 and 13 August 2009.
• Bookings: No referral required but bookings essential.

To book phone the Diabetes Information and Advice Line on 1300 136 588.

Cultural Diversity Program

DA-Vic delivers diabetes awareness and prevention sessions within multicultural communities in Melbourne. The peer led program employs bilingual health workers who are trained to deliver diabetes prevention sessions in their first language.

The nine language groups available are:

• Arabic
• Chinese (Cantonese and Mandarin)
• Greek
• Italian
• Macedonian
• Spanish
• Turkish
• Vietnamese

The bilingual educators are trained in diabetes prevention and awareness messages which include the promotion of physical activity, and maintaining a healthy weight and healthy diet in order to lower the risk of developing type 2 diabetes.

While therapeutic options such as physical activity, nutrition and medication are available and enable the achievement of optimal glycemic control in the majority, co-morbidities, cognitive and functional disability, depression, frailty and social issues are common in the elderly person with diabetes and may impact adversely on efforts to optimise diabetes care.

Where diabetes is under treated or under managed due to such barriers elderly people are more likely to experience increased morbidity, disability and mortality.

New guidelines

The Guidelines for the Management and Care of Diabetes in the Elderly focus specifically on the ‘healthy’ person with diabetes over the age of 65 years. This includes the elderly person who despite a decline in physical or cognitive function is able to actively participate in their diabetes care. The application of the Guidelines in the frail elderly person with diabetes should be determined on an individual basis with special consideration of the physical and mental health status of the person.

It is anticipated that the Guidelines will assist in decision making by providers and consumers, assure quality of care and offer the opportunity for significant health gain and improvement to quality of life in older people with diabetes.

The Guidelines for the Management and Care of Diabetes in the Elderly provide readily accessible information about diabetes prevention, diagnosis, treatment and long term management options for elderly people at risk of or living with diabetes today.

They provide guidance about what is broadly appropriate rather than a prescriptive set of rules and it is important that their application relies on an individual medical assessment of the elderly person’s health status, attitudes, self care beliefs and physical environment.

Evidence

This information is a summary of the best knowledge and research available at the time of their development.

The Guidelines for the Management and Care of Diabetes in the Elderly were formulated using the NHMRC development process, the recognised standard for evidence based guideline development.

Where there was a lack of evidence of sufficient research rigour to meet NHMRC standards, other types of evidence such as position statements and expert consensus were used to augment the available evidence.

Level of Evidence

1. Evidence obtained from a systematic review of all relevant population-based studies.
2. Evidence obtained from a well-designed population-based study or representative cohort study
3. Evidence obtained from less well-designed population study, non representative cohort study or well-designed case-control study.
4. Evidence obtained from case series.

The search for evidence also identified issues requiring further research – these include the impact of the disease, the special problems faced by elderly people with diabetes in accessing a range of appropriate services and care, choice of treatment, treatment options and cost effectiveness and the consumer view.

Importantly, identifying the gaps in our knowledge offers the opportunity to focus and motivate our research efforts in this special group of people.

Download

Guidelines for the Management and Care of Diabetes in the Elderly are available at the bottom of this page.

A recent study in the MJA (Volume 190 Number 4, 16 February 2009) shows that approximately 30% of children with newly diagnosed diabetes were not sent to hospital within 24 hours of GP presentation, and that 50% of children admitted to hospital in DKA were seen by a GP in the previous week.

Some children are either misdiagnosed with other conditions, or are not being referred speedily enough to an emergency department. As a consequence, DKA is the most common cause of death in newly diagnosed type 1 diabetes albeit the most preventable, if detected early.

All children suspected of having diabetes, or who have an elevated glucose from a finger prick, should be referred immediately to a hospital.

Performing a full urine test on children who present unwell is another simple and easy test to identify young children and adolescents with type 1 diabetes.

All children (including those who are overweight or normal weight) should be assumed to have type 1 diabetes until proven otherwise.

No child with symptoms should be made to wait another day for confirmation of hyperglycaemia or diagnosis. It is important to note that approximately 25% of children with type 2 diabetes also present in DKA.

A child or adolescent does not need an oral glucose tolerance test (OGTT) for the diagnosis of type 1 diabetes. A urine test can give valuable information about the presence of glucose and ketones.

Misdiagnosis occurs because some of the symptoms of DKA can mimic other conditions. For instance: nausea, vomiting and weight loss can be confused with gastro enteritis; abdominal pain and an acute abdomen can be misdiagnosed for appendicitis; and Kussmaul respirations can be mistaken for a chest infection, pneumonia or asthma.

Doctors or nurses in general practice must send a child or adolescent with glucose present in either the urine or blood above the normal BGL range to the closest emergency department for assessment and prompt management. It is important to notify the Endocrinology Registrar to alert them of your patient’s arrival.

Refer to the Clinical Practice Guidelines: Type 1 diabetes in children and adolescents for further information.