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1 G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 1

2 BHCiG: TYPE 2 DIABETES MANAGEMENT PATHWAY MODEL INTRODUCTION What is the aim of the model? To improve the capacity of primary care health practitioners to better respond to the needs of people living with type 2 diabetes. What does the model describe? The model describes a continuum of care pathway from risk screening through to recall & review and ongoing risk assessment. Within the model clients would be screened/ assessed to determine need, priority of access & appropriate management pathways. It sets out a pathway which integrates risk prioritization at different steps along the way within the Annual Cycle of Care used by GP s. It will be supported by common Gippsland referral processes and feedback tools. What is the scope of the model? While the whole process from risk screening to ongoing assessment is described the BHCiG project is primarily concerned with the process from initial assessment onwards. This means that within the annual cycle of care if diabetes complications become present or increase then the response would become more intense until the risk was stabilised and patient would return to regular annual cycle of care visits. Who does it involve? The pathway reads with the GP as the central person the gateway who initiates the referrals. While this is true of a newly diagnosed client especially during initial assessment and diagnosis this may not be the case for someone already in the system especially when it comes to a change in the person s level of risk complications. Referral pathways will include other health professionals as they interact with the client with diabetes. How will it be tested? The BHCiG Chronic Disease Management Task Group has endorsed the final model. It will be the role of the local networks to establish how they implement it within agreed standards. The model is presented with best practice standards that underpin the model. However the local protocols, processes, procedures and systems that describe how these standards will be implemented will be developed at a local level where the model will be tested. These standard practices and processes would apply to each stage or component of the model. The first two stages of the model already have standards of practice used by GPs (NHMRC). G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 2

3 GLOSSARY Type 2 Diabetes: Previously known as non insulin dependent diabetes mellitus (NIDDM ) or mature onset diabetes BHCiG: Better Health Care in Gippsland is the name of the overall service coordination and chronic disease project jointly funded by the Commonwealth and State governments NHMRC: National Health and Medical Research Council DE: Diabetes Educator RACGP: Royal Australian College of General Practitioners WHO: World Health Organisation GP: General Practitioner DHS: Department of Human Services CVD: Cardio-vascular Disease ATSI: Aboriginal and Torres Strait Islander CALD: Culturally and Linguistic Diverse population. Previously the term Non English Speaking Background BMI: Body Mass Index HbA1c: Glycated Haemoglobin K10 tool: Kessler-10 is a self rating questionnaire which is used to measure psychosocial distress EPC Care Plan: for the purposes of this project it refers to a plan of action aimed at meeting the care needs of a high risk client with type 2 diabetes. It sets out the services to be provided by the clients GP and at least 2 other health or community care providers involved in their care. A date to review the care plan is also set at this time SC care plan: Multi-agency Service Coordination plan template designed by DHS to support shared care planning. Can be used as an alternative to EPC care plan EPC: Enhanced Primary Care Program BP: Blood Pressure BSL: Blood Sugar Levels RBSL: Random Blood Sugar Levels Case conference: A case conference is a meeting held between a client s GP and at least two other health or community care providers to jointly agree on the types of services the client needs. The meeting can be by phone, face to face or through video conferencing. It differs from a care plan in that it usually involves immediate management plans. However holding the case conference may identify the need for developing a care plan and visa versa. Care Coordinator: A nominated worker who has the responsibility of ensuring that the care plan is implemented, and that reviews and re-assessments are undertaken at the appropriate times by the relevant service providers Activities may include some or all of: Assessment Care plan development Referral and/or feedback Implementation of the care plan, including liaison with service providers Monitoring Review Reassessment Management of brokerage funds. G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 3

4 BHCiG: TYPE 2 DIABETES MANAGEMENT PATHWAY MODEL - SUMMARY PLEASE NOTE THIS IS A SUMMARY OF THE MODEL ONLY. YOU WILL NEED TO REFER TO THE MORE DETAILED DESRIPTION OF EACH STAGE OF THE MODEL AS DESCRIBED IN THE FOLLOWING PAGES STAGE COMPONENTS INITIAL SCREENING DIAGONSIS Risk screening of non diagnosed Type 2 Diabetes clients to identify those at high risk Clients identified as being at high risk of Type 2 Diabetes referred to and then by GP for diagnostic testing of blood glucose levels (measurement of venous plasma glucose) Follow up GP appointment made at time of GP ordering plasma glucose test Laboratory test undertaken(measurement of venous plasma glucose) Diagnosis of diabetes made according to Type 2 diabetes guidelines case detection and diagnosis information [ WHO guidelines, NHMRC INITIAL ASSESSMENT & ON-GOING REVIEW GP conducts initial detailed specialist assessment of patient, physical examination and orders further investigations [Diabetes Management in general practice 2004/5 Diabetes Australia & RACGP] GP develops with patient immediate care to relieve acute symptoms ONGOING REVIEW and ASSESSMENT of CARE REFERRALS AND IDENTIFICATION OF DIABETES TEAM CARE PLAN DEVELOPED RECALL & REVIEW and RISK COMPLICATIONS Based on assessment GP instigates referrals to appropriate health professionals using agreed referral cover sheet & Victorian Statewide Referral Form (once electronic) with priority access rating according to BHCiG Type 2 Diabetes risk map Referral feedback on assessment outcomes (via BHCiG Diabetes Management feedback forms) received by GP within maximum 6 weeks unless assessed as high risk Care Coordinator appointed for high risk clients Diabetes Management plan developed with client (and carer) and other nominated health professionals in diabetes care team (with case conference or other process as agreed) Cycle of care process established for all diabetes clients with agreed responsibilities of members of diabetes team and with agreed timelines & feedback processes Diabetes management plan documented in patient kept record [Diabetes Health Record] and client record Diabetes team members document visit outcomes in patient kept record and client medical record Diabetes team members continue to refer to appropriate health professionals where risk status has altered Ongoing risk assessment of diabetes complications of client by GP or other agreed health professional (ie: DE, practice nurse) using BHCiG Type 2 Diabetes risk map G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 4

5 STEP 1: SCREENING UN-DIAGNOSED DIABETES IDENTIFIED VIA A NUMBER OF POSSIBLE PATHWAY OPTIONS using DHS Community Based Risk Assessment Guide for CVD and Diabetes (see box below) GP CLIENT REGISTER SELF REFERRAL COMMUNITY BASED SCREENING OPPORTUNISTIC SCREENING OF HOSPITAL PATIENTS RISK SCREENING If client has one or more of these risk factors present then refer to GP Persons aged > 50 years Impaired glucose tolerance or impaired fasting glucose Women with history of gestational diabetes ATSI persons aged 35+ CALD background specifically people of pacific islander, indian subcontinent and of chinese origins People aged 45+ with one or more of the following: Obesity (BMI > 30mg/m 2 ) 1 st degree relative with diabetes hypertension All people with clinical CVD Women with polycystic ovarian syndrome who are obese Source: DHS Community Based Risk Assessment Guide for CVD and Diabetes IS THIS PERSON AT RISK OF DEVELOPING DIABETES? NO Provide advice on exercise and diet and early symptoms of diabetes Who: Provided by either GP, practice nurse, diabetes educator, community health nurse Resources: Provide client with local physical activity guide or consider using active script (GP) YES REFERRAL TO GP for PLASMA GLUCOSE TEST (see step 2) G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 5

6 STEP 2: DIAGNOSIS GP ORDERS PLASMA GLUCOSE FOR MORE DETAIL REFER TO: DIABETES MANAGEMENT in GENERAL PRACTICE 2004/5 GUIDELINES (RACGP DIABETES AUSTRALIA) < 5.5 Fasting: Random: Fasting :> 7.0 Random: >11.1 Diabetes unlikely Place on register and recall every 2 years Provide education & information on diet & exercise, CVD and diabetes risk; referral to lifestyle program as appropriate Diabetes unlikely Diabetes uncertain Oral glucose tolerance test 2 hour glucose levels < >11.1 Impaired glucose tolerance Diabetes likely Fasting blood glucose test annually Place on register and recall every 12 months Provide education & information on diet & exercise, CVD & diabetes risk; referral to lifestyle program as appropriate Diabetes likely Appointment with GP to begin comprehensive assessment and develop care plan (see step 3A) G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 6

7 STEP 3A: ASSESSMENT & ONGOING REVIEW DIAGNOSIS CONFIRMED and ASSESSMENT begins FOR MORE DETAIL REFER TO: DIABETES MANAGEMENT in GENERAL PRACTICE 2004/5 GUIDELINES pp7-8 (RACGP DIABETES AUSTRALIA) HISTORY: Specific symptoms: predisposition to diabetes, risk factors for complications, general symptoms review, lifestyle issues EXAMINATION: Weight and height measured, BMI, waist circumference, BP, CV system, eyes, feet, peripheral nerves, urinalysis INVESTIGATION: Establish baseline [renal, lipids, glycemia] PLUS consider others if one of the following: - ECG if >50years - Microurine if high risk group [women with neuropathy, vaginal pessary] - Thyroid function if family history or clinical suspicion BASED on this ASSESSMENT the GP can then make an initial determination of the clients risk of DIABETES COMPLICATIONS (see Step 3B) and begin a more comprehensive assessment process with initial referrals (see step 4) G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 7

8 STEP 3B: LEVEL OF DIABETES RISK ESTABLISHED USING RISK MAP The GP by using the risk map to refer to other practitioners can confidently ensure that their client is seen expediently according to the agreed risk rating. This priority of access can change at any time during the person s cycle of care if level of complications alters. URGENT RISK defined as patient with any of the following: Glycaemic Control: RBSL > 23 Uncontrolled hyper or hypo glycemia Foot: Ulcer with cellulitis requiring bed rest & IV antibiotics Ischaemic leg/foot with rest pain Gangrene Diabetic client with an urgent co-morbid condition Eye: sudden loss of vision RESPONSE: Immediate hospital admission and/or referral to specialist as part of continuum of care HIGH RISK defined as patient with any of the following Glycaemic Control: RBSL 15>23; HbA1c >9.0 Commencement of insulin therapy Self Management: Poor self management capacity Carer illness resulting in need for respite care Foot: Ulcer with cellulitis requiring IV antibiotics (but capacity for district nurses to monitor) Renal: Clinical proteinuria (macrobuminuria) dipstick reading > 500 mg/l Eye: visual impairment Hypertension: hypertension, particularly if proteinuria > 1g/d REFERRAL RESPONSE: GP contacts health practitioner (s) via phone, identifying patient as high priority for an appointment. Patient is given the referral letter along with the referral cover sheet to take to the appointment. Referral outcome received by GP within 1 week of contacting health practitioner. MEDIUM RISK defined as patient with any of the following Glycaemic Control: RBSL 12>15; HbA1c Dyslipidaemia: cholesterol > 6.5 mmol/l; triglyceride > 4.0 mmol/l (National Heart Foundation high risk group because of diabetes) Foot: Peripheral neuropathy REFERRAL RESPONSE: GP gives referral letter and referral cover sheet to patient and marks the referral as medium priority. GP instructs patient to identify the referral as being medium priority. Referral acknowledgement sent to GP by health practitioner within 5 working days of receipt. Referral outcome received by GP within 2 weeks of GP instigating referral. Patient rebooked to see GP 2 weeks from initial appointment. LOW RISK as defined as patient with any of the following Glycaemic Control: RBSL <12; HbA1c < 7.0 Microalbuminuria ( µg/min) Eye: Refractive errors blurred vision; cataracts; retinopathy Foot: Potential abnormal foot architecture Peripheral vascular disease: claudication REFERRAL RESPONSE: GP gives referral letter and referral cover sheet to patient and marks the referral as low priority. GP instructs patient to identify the referral as being low priority. Referral acknowledgement sent to GP by health practitioner within 5 working days of receipt. Referral outcome received by GP within 6 weeks of GP instigating referral. Patient rebooked to see GP 6 weeks from initial appointment. SOURCE: Based on DIABETES MANAGEMENT in GENERAL PRACTICE 2004/5 GUIDELINES G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 8

9 STEP 4: REFERRALS AND IDENTIFCATION OF DIABETES TEAM ACTIVITY TYPES IN RED FONT ARE MINIMUM initial REFERRALS. Commence COMPREHENSIVE ASSESSMENT FOR ALL NEWLY DIAGNOSED CLIENTS. Please see next page Referral sent within 1-7 days of diagnosis. Response as per risk level EYE CARE DIET EXERCISE SELF MANAGEMENT EDUCATION FOOT CARE Referral to ophthalmologist or suitably trained optometrist Diagnosed with eye disease? YES NO Review 12mthly Provide educatio n & info Referral to dietitian for all clients Review yearly or more often as per agreed workplan (ALL clients) Provide assessment, advice & individual plan Review every 2 years Provide education and information about early symptoms of eye disease Referral to DE Provide assessment, advice & individual plan (ALL clients) Consider assisted referral to community based exercise activities Referral to DE Review yearly or more often as agreed by DE client and according to risk rating Assess for self management capacity Develop individual plan (including individual & group activities) Consider referral for medium and high risk clients to self management programs REFERRAL FEEDBACK TO GP Referral to DE or GP for Assessment Assessed as high risk using CWGPCP tool Refer to podiatrist Assessed as low risk using CWGPCP tool Response Annual comprehensiv e assessment Assess/ recommendati on for appropriate foot wear Provide education for preventive self care Complete action plan G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 9

10 STEP 4: INITIAL REFERRALS AND IDENTIFCATION OF DIABETES TEAM (continued from previous page) Commence COMPREHENSIVE ASSESSMENT FOR ALL NEWLY DIAGNOSED CLIENTS GLYCAEMIC CONTROL MENTAL HEALTH ACTIVITIES IN BLUE FONT REFERRALS ONLY IF PROBLEMS PRESENTING AT TIME OF INITIAL ASSESSMENT Is this person experiencing uncontrolled hyper or hypoglycaemia OR experiencing significant level of complications? Is this person presenting with a mental health problem? YES NO YES Refer to Physician Response Assessment & clinical plan Refer to DE As per self management response Assessment for anxiety & depression using K10 tool Consider referral to primary mental health worker or appropriate mental health professional Liaise with clients case manager (if applicable) Referral to DE for self management support Continue to monitor REFERRAL FEEDBACK TO GP G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 10

11 STEP 5: MULTI-DISCIPLINARY CARE PLAN DEVELOPED & CARE COORDINATOR DETERMINED SHOULD THIS CLIENT HAVE A CARE COORDINATOR? YES if HIGH RISK (multi-agency involvement or complex needs) defined as patient with any of the following Glycaemic Control: RBSL 15>23; HbA1c >9.0 Commencement of insulin therapy Self Management: Poor self management capacity Carer illness resulting in need for respite care Foot: Ulcer with cellulitis requiring IV antibiotics (but capacity for district nurses to monitor) Renal: Clinical proteinuria (microalbuminuria) dipstick reading positive > 500 mg/l Eye: visual impairment Hypertension: hypertension, particularly if proteinuria > 1g/d Care coordinator identified Care coordinator initiates case conference if immediate management care needed Care coordinator develops care plan (EPC item) with relevant HP, client (and carer) Documented in Diabetes Patient Record Review date set NO if MEDIUM RISK defined as patient with any of the following Glycaemic Control: HbA1c ; RBSL 12>15 Dyslipidaemia: cholesterol > 6.5 mmol/l; triglyceride > 4.0 mmol/l (National Heart Foundation high risk group because of diabetes) Foot: Peripheral neuropathy Implement cycle of care with additional visits per referral feedback reports Documented in Diabetes Patient Record Send copy of care plan to all relevant HP professionals Implement recall & review process as agreed to by diabetes team NO if LOW RISK defined as patient with any of the following Glycaemic Control: HbA1c < 7.0; RBSL <12 Microalbuminuria ( µg/min) Eye: Refractive errors blurred vision; cataracts; retinopathy Foot: Potential abnormal foot architecture Peripheral vascular disease: claudication Implement annual cycle of care Document in client record and Diabetes Patient record G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 11

12 STEP 6: RECALL AND REVIEW PLUS IDENTFICATION OF DIABETES COMPLICATIONS Implement Annual Cycle of Care for newly diagnosed Type 2 diabetes first year Add additional visits based on referral outcomes from initial assessment OR if level of risk changes CYCLE OF CARE WHAT CLIENT TYPE High risk = HR; Medium risk = MR; Low risk = LR 3 MONTHS 6 MONTHS 12 MONTHS BP, BMI, weight, review symptoms, review self monitoring Check urine, check BSL record Y Y Y Y HbA1c, urine analysis Y Y Y lipids Y Y Y Foot examination, Y BP, BMI, review symptoms, review self monitoring, BP, lifestyle behaviour, foot review, waist circumference, Full assessment BP, lifestyle behaviour, review symptoms,, review lipids foot review, BMI, waist circumference, review self Y monitoring Eye exam Y Y 24 MONTHS Eye exam (if no eye damage diagnosed at initial assessment) Y Y Y Y Y Y Y Y Y HEALTH PROFESSIONAL To be determined by local networks Continue to document in PHR and client record; consider additional referrals; transfer information as agreed G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 12

13 RESOURCES TO SUPPORT REFERRALS HEALTH DOMAIN RESOURCES EYE CARE BHCiG eye exam summary assessment report DIET BHCiG dietitian summary assessment report EXERCISE Local recreation and sport directory SELF MANAGEMENT EDUCATION Diabetes health record patient held record BHCiG Diabetes Educator summary assessment report FOOT CARE BHCiG foot exam summary assessment report Best feet forward resource kit GLYCAEMIC CONTROL Diabetes Management in General Practice in General Practice 2004/2005 (RACGP Diabetes Australia) MENTAL HEALTH Anxiety & depression screening tool (K10) Community support groups OTHER RESOURCES CARE PLANNING EPC care plan tool EPC Standards and Guidelines MEDICARE Plus CASE CONFERENCING EPC case conference item GENERAL Diabetes Management in General Practice in General Practice 2004/2005 (RACGP Diabetes Australia) BHCiG Diabetes Resource Directory Victorian Statewide referral form G:\ CDM\BHCIG Diabetes Pathway FINAL September 05.doc 13

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