A Cycling Tour of Diabetes

Karen Booth RN

Leichhardt General Practice

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

• 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***

Equipment Tune-Up

Components of check up:-

• HT, Wt, BMI,

• Diet & exercise, education

• Feet

• Blood results

• Medication review

• ECG

You’re not Cycling on Your Own!!

Help Them Keep Their Balance• 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

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

Puncture Repair

• Regular review for maintenance & treatment adjustments

• May need new referrals

• Endocrinologist, Clinic review

• Diabetes educator, exercise phys referrals

• Motivation

THE LEICHHARDT GENERAL PRACTICE DIABETES MANAGMENT CHECKLIST

Activity Target Values

Frequency Date Date

Date

Date Date

Hb A1c < 7.0% 6mths

u/a Microalb < 20mg/L spot catch

12mths

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 mths

Examine feet 6 mths

Eye check 2 yr min

Selfcare 3-6 mths

Diet review 6 mths

Physical activity 6 mths

Smoking status 6 mths

Medication review

6 mths

ECG 12 mths

Cycling is a Team Sport

• Coach – GP

• P/T, Mx - Practice Nurse

• Support Crew – Clerical staff

• Specialist support – Endocrinologist, Diab Educ, Dietitian, Exercise Phys.

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

• 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

• 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.