Diabetes self-management - Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Page created by Rafael White
Diabetes self-management
Guidelines for providing services to people
newly diagnosed with Type 2 diabetes
March 2007
Improving Victoria’s oral health
May 2007
ii Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Published by the Victorian Government Department
of Human Services
Melbourne, Victoria
© Copyright State of Victoria 2007
This publication is copyright, no part may be reproduced by
any process except in accordance with the provisions of the
Copyright Act 1968.
This document may also be downloaded from the
Department of Human Services website at:
Authorised by the State Government of Victoria,
50 Lonsdale Street Melbourne.
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� iii

In Australia, the burden of chronic disease is increasing
rapidly. In Victoria, approximately 70 per cent of the total
burden of disease is attributed to six groups: cardiovascular
disease, cancers, injuries, mental health conditions,
asthma and diabetes. As of 2001, approximately one million
Australians were diagnosed with Type 2 diabetes. A few
decades ago Type 2 diabetes was known as adult-onset
diabetes, mainly affecting older people. The prevalence of
Type 2 diabetes in younger people, including children and
adolescents, is increasing at an alarming rate and is linked
to increasing rates of obesity.
Victoria’s primary health care system must be able to
respond in an appropriate and cost-effective way to
this challenge. Self-management is about people being
actively involved in their health care. The approach has
been recognised by the Commonwealth Government and
the Victorian Government as a key component of chronic
disease management including diabetes.
The diabetes self-management funding is a component of
Victoria’s commitment under the Australian Better Health
Initiative (ABHI): a joint Australian, State and Territory
Government initiative. The funding will support early
intervention for people with high risk and newly diagnosed
with Type 2 diabetes to assist them to become an active
partner in the management of their health.
The diabetes self-management guidelines are aimed at
Primary Care Partnerships and their member agencies (in
particular community health services, rural health services
and Divisions of General Practice) to support the provision
of planned, managed, integrated and proactive care for
people with chronic disease. I encourage you to use the
guidelines to improve the health outcomes for people with
chronic disease.

Janet Laverick
Director Primary Health Branch
iv Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Foreword                                                                         iiii

1. Introduction                                                                     1
1.1   About the guidelines                                                          1
1.2   The impact of diabetes                                                        2
1.3   A coordinated approach to chronic disease                                     4
1.4   Overview of diabetes self-management funding                                  5

2. Chronic disease management                                                       7
   model for primary care

3. Diabetes self-management                                                         9
   service delivery
3.1 Client assessment and care planning                                             9
3.2 Self-management                                                                11
3.3 Client monitoring                                                              14

4. Diabetes self-management –                                                    16
   supporting systems
4.1 GP liaison                                                                    16
4.2 Client recruitment and referral pathways                                      17
4.3 Clients with multiple chronic conditions
    or complex needs                                                              17
4.4 Decision support tools                                                        18
4.5 Flexibility in service provision                                              18
4.6 Addressing health inequalities                                                19

5. Funding and reporting                                                          21
5.1 Funding and reporting for CHSs                                                 21
5.2 Funding and reporting for PCPs                                                 21
5.3 Funding for workforce development                                              21

Appendix 1
A summary model of community
care through community health
services for people with
Type 2 diabetes                                                                  22
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 

1. Introduction
1.1 About the guidelines                                                       While these guidelines are targeted at CHSs (or RHSs where
                                                                               applicable) and PCPs that receive direct funding (recurrent
Care for people with chronic disease, such as Type 2
                                                                               for CHSs/RHSs and one-off funding for PCPs), they are also
diabetes, usually involves multiple health care providers in
                                                                               intended to support agencies in their work with people who
multiple settings. To provide this care within an integrated
                                                                               have chronic disease.
system, health care providers must work collaboratively
to coordinate and plan care and services. This requires a                      The diabetes self-management guidelines should be used in
commitment from health care providers and agencies to                          conjunction with:
work together to achieve shared goals.                                         • Chronic Disease Management Program Guidelines
People with Type 2 diabetes need a responsive person-                          • Primary Care Partnership Planning and Reporting
centred and effective system of care. These diabetes                             2006–2009 guidelines
self-management guidelines aim to support member                               Audiences
agencies of Primary Care Partnerships (PCPs), in particular
Community Health Services (CHSs), Rural Health Services                        Community Health Services
(RHSs) where applicable, and Divisions of General Practice                     funded under diabetes self-management
(DGP), to implement new diabetes self-management                               Funding provided to CHSs (or RHSs where applicable)
funding in the context of a chronic disease management                         for diabetes self-management has been made available
(CDM) approach across the service system. The guidelines                       to CHSs that are not in receipt of Early Intervention in
also provide support for CHSs, PCPs and DGP as part of the                     Chronic Disease funding. However, as stated in the Early
broader integrated chronic disease management (ICDM)                           Intervention in Chronic Disease guidelines, the diabetes
work. They should be used in conjunction with the Chronic                      self-management funding also builds on the work already
Disease Management Program Guidelines.                                         being done by CHSs and PCPs to support people in the
Self-management is about people being actively involved                        community who have chronic disease. Specifically, it
in their health care. The approach is underpinned by a                         provides CHSs with additional funding to increase service
number of principles and has been recognised by the                           delivery to people with Type 2 diabetes, but also expects
Commonwealth Government and the Victorian Government                           that CHSs will work on internal systems changes to deliver
as a key component of diabetes management and CDM                              services that are consistent with evidence-based chronic
more broadly.                                                                  care. Refer section 5.1.
Diabetes self-management funding supports work already                         PCPs
being undertaken by CHSs and PCPs. For example:                                PCPs have been provided with one-off funding to facilitate
• All PCPs now receive recurrent funding for ICDM which                        service system integration and change management across
  builds on the established PCP role in facilitating service                   member agencies. In particular, general practice (through
  system integration and change management across                              DGP) and CHSs will need to be involved. Refer section 5.2.
  member agencies.
                                                                               Other agencies
• Core business for CHSs includes providing services to
                                                                               Although funding for this initiative has been targeted to
  people in the community who have chronic disease.
                                                                               CHSs, all CHSs see significant numbers of people with
  Many CHSs, particularly those in receipt of Early
                                                                               chronic disease who would benefit from self-management
  Intervention in Chronic Disease funding, are working
                                                                               interventions and approaches. These guidelines could be
  on internal systems changes to ensure services are
                                                                               applied to other agencies wanting to develop and/or embed
  delivered within a CDM model of care.
                                                                               self-management into practice.

	   National Health Priority Action Council (NHPAC) 2006, National
     ������������������������������������������������������                    	   http://www.health.vic.gov.au/communityhealth/downloads/
     Chronic Disease Strategy, Australian Government Department of                  cdm_program_guidelines.pdf
     Health and Ageing, Canberra                                               	 http://www.health.vic.gov.au/pcps/strategy/index.htm#reporting
 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Rationale for self-management                                                            Diabetes – the facts
There is a strong evidence base internationally for self-                                Diabetes is a disease in which the body does not produce or
management and a growing evidence base within the                                        properly use insulin. Insulin is a hormone that is needed to
Australian context. The most recent and largest initiative to                            convert sugar, starches and other food into energy needed
test self-management models within the Australian health                                 for daily life. The cause of diabetes is unknown. Both family
care system was the Australian Government funded Sharing                                 history and lifestyle factors, such as obesity, poor diet and
Health Care Initiative. The initiative included a series of eight                        lack of exercise, are risk factors. The major types of diabetes
demonstration projects conducted over three years using                                  are gestational diabetes, prediabetes, Type 1 diabetes and
a range of models including the Stanford Model, Flinders                                 Type 2 diabetes.
Model and Telephone Coaching. All eight projects found
                                                                                         Gestational diabetes
that people reported improved health outcomes, a better
                                                                                         • Occurs during pregnancy and usually goes away after the
quality of life and reduced use of health services. These
                                                                                           baby is born.
trends were also found in Indigenous and culturally and
linguistically diverse (CALD) client groups, which were part                             • Affects 3–8 per cent of pregnant females.
of most projects.                                                                        • Increases the risk of developing Type 2 diabetes later in
                                                                                           life with a 30–50 per cent chance of developing Type 2
The National Chronic Disease Strategy outlines a number
                                                                                           diabetes within 15 years of pregnancy.
of key directions for self-management which have been
built into these guidelines. Embedding self-management                                   Prediabetes5
principles has been identified as a key to maximising the                                • Occurs when a person's blood glucose levels are higher
quality of life of people with a chronic disease and reducing                              than normal but not high enough for a diagnosis of Type 2
the risk of complications.                                                                 diabetes.
                                                                                         • Many people live with prediabetes unaware of the
1.2 The impact of diabetes                                                                 condition and its impact on their health.
Diabetes has an enormous impact on people, their families,                               Type 1 Diabetes5
the community and the health system. It has been proven
                                                                                         • Affects 10-15 per cent of Australians with diabetes.
that people with Type 2 diabetes have significantly lower
                                                                                         • Is an autoimmune condition.
productivity and participation rates. The costs for Type 2
diabetes have been rising rapidly over recent years. The                                 • Results from the body's failure to produce insulin.
Australian Institute of Health and Welfare projects that                                Type 2 Diabetes6
government expenditure on Type 2 diabetes will increase                                  • In 2001, approximately one million Australians were
by over 600 per cent between 2001 and 2031.                                                diagnosed as having Type 2 diabetes.
The facts on diabetes means the government must act                                      • Up to 50 per cent of all cases remain undiagnosed.
to ensure a strong focus on:                                                             • Is largely a preventable chronic disease.
• prevention of diabetes                                                                 • By 2031, it is projected 3.3 million will have Type 2
• early detection and intervention                                                         diabetes.
• quality service provision, including self-management                                   • Increases two to five times the risk of having a heart
  to prevent complications.                                                                attack or stroke.

	National Evaluation of the Sharing Health Care Initiative: http://
	National Health Priority Action Council (NHPAC) 2006, National                         	   National Reform Agenda, 2006: Victoria’s plan to address the growing
  Chronic Disease Strategy, Australian Government Department of                               impact of obesity and type 2 diabetes, Consultation Draft, Council of
  Health and Ageing, Canberra                                                                 Australian Governments
    Australian Institute of Health and Welfare 2006, Australia’s Health
	�������������������������������������������������                                      	����������������������������������������������������������������
                                                                                             Diabetes Australia, Diabetes Fact Sheets, viewed February 2007,
    2006, Canberra                                                                           International Diabetes Institute – Diabetes Research, Education and Care
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 

• Without adequate management a person with Type 2                                • poor housing
  diabetes is likely to develop complications such as renal                       • exposure to violence
  impairment and peripheral vascular disease.                                     • extent of control and perceptions of mastery in the
• Insulin is still produced by the pancreas, but is less                            workplace and wider society
  effective than normal. This is known as insulin resistance.                     • higher exposure to ‘life stressors’ such as the death of
The prevalence of Type 2 diabetes in younger people,                                a family member or close friend, overcrowding at home,
including children and adolescents, is increasing at an                             alcohol and other drug problems, serious illness or
alarming rate. A few decades ago Type 2 diabetes was                                disability, and not being able to get a job
known as adult-onset diabetes, mainly affecting older                             • food insecurity.
people. The prevalence of Type 2 diabetes in children
                                                                                  Rural and regional communities
and adolescents is linked to the increasing rates of obesity
                                                                                  People living in rural and remote areas of Australia have
in this group. Obesity rates for children aged 7–15 years,
                                                                                  poorer health and higher levels of health risk factors
based on studies conducted in 1985 and 1995, grew for
                                                                                  compared with those living in urban areas. This is despite
boys from 1.4 per cent to 4.5 per cent and grew for girls
                                                                                  the perceived health advantages of living in rural areas
from 1.2 to 5.3 per cent. It has been estimated that in
                                                                                  (clean air, less traffic, more relaxed lifestyle)11. Rurality itself
2004, 20–25 per cent of children and adolescents were
                                                                                  is not the main factor leading to poorer health among people
overweight or obese.
                                                                                  outside major cities. Factors associated with rurality are the
Diabetes and chronic disease                                                      causes of comparative health disadvantage in those areas.
in disadvantaged subgroups                                                        Such factors include:
The link between diabetes and an ageing population                                • socioeconomic disadvantage (including lower incomes
and various subgroups within the population has been                                 and education levels)
recognised.8                                                                      • geographic isolation and difficulties with access to
                                                                                     health care
Subgroups include (but are not limited to):
                                                                                  • shortage of health care providers and services
• Aboriginal and Torres Strait Islander communities
                                                                                  • greater exposure to injury
• people from CALD backgrounds
                                                                                  • greater difficulties in transport and communications
• rural and regional communities
                                                                                  • sparsely distributed populations leading to diseconomies
• people from lower socioeconomic groups.
                                                                                     of scale
These subgroups warrant attention to minimise the impact                          • insufficient supply of affordable and quality fresh food
of chronic disease on the individual, their family and the
                                                                                  • unsupportive environment for physical activity.
broader community.
                                                                                  Lower socioeconomic groups
Aboriginal and Torres Strait Islander communities
                                                                                  Socioeconomic status (SES) is a strong predictor of
Aboriginal and Torres Strait Islander communities have
                                                                                  health. The lower a person’s SES, the shorter his or her life
particularly high rates of diabetes, with up to 30 per cent of
                                                                                  expectancy and the more prone he or she is to a wide range
some communities being affected by diabetes. High levels
                                                                                  of chronic diseases and conditions. Diabetes prevalence
of ill health among Indigenous Australians10,9 have been
                                                                                  is almost 2.5 times higher for the lowest SES groups. The
linked to:
                                                                                  link between SES and health begins at birth and continues
• adverse socioeconomic conditions compared with general                          through life. There is a strong, but indirect, association in
   Australian standards including lower incomes, poorer
   educational outcomes and lower rates of home ownership

    Australian Institute of Health and Welfare 2006, Australia’s Health
    2006, Canberra
10 National Public Health Partnership 2001, Eat Well Australia: An
   Agenda for Action for Public Health Nutrition 2000–2010, Strategic             11 Australian Institute of Health and Welfare 2006, Chronic Diseases and
   Inter-Governmental Nutrition Alliance, Canberra                                   Associated Risk Factors in Australia, 2006, AIHW, Canberra, http://
   http://www.nphp.gov.au/publications/signal/eatwell1.pdf                           www.aihw.gov.au/publications/phe/cdarfa06/cdarfa06.pdf
 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

which SES affects health and health affects SES. Some                                    The diabetes self-management funding is for the provision
factors that can lead to SES effects on health12,11 include:                             of self-management interventions to high risk people newly
• differential access to high quality health care                                        diagnosed with Type 2 diabetes. The services provided under
• individual factors such as smoking, exercise, nutrition,                               this funding should:
  stress and depression                                                                  • operate within a broader CHS CDM model
• social environments such as neighbourhood, work,                                       • be linked to an ICDM approach across the local PCP.
  interpersonal support or conflict                                                      Under the ICDM funding, PCPs have an important role in
• violence and discrimination                                                            bringing agencies together to develop systems that support
• long-term effects of prenatal and early childhood                                      a coordinated approach to the planning and delivery of
  environmental factors                                                                  services for people with chronic disease. PCPs are focusing
• structural factors that affect equitable access to food.                               on service system integration over the next three years for
                                                                                         this client group by strengthening their service coordination
1.3 A coordinated approach                                                               work. In particular, ICDM activities include:
to chronic disease                                                                       • strengthening referral systems to include regular feedback
                                                                                           and communication mechanisms that share service
A coordinated statewide response to diabetes is being                                      outcomes between agencies, and between agencies and
developed (currently out in draft for public comment)13                                    general practice or between agencies and/or providers
and will be part of the National Reform Agenda to address
                                                                                         • developing clinical pathways for certain chronic diseases,
the growing impact of chronic disease. Diabetes self-
                                                                                           such as diabetes
management funding is one of many strategies that will
                                                                                         • supporting a self-management mapping process and
make up this statewide response. Strategies will be based
                                                                                           developing a plan to address gaps and facilitate workforce
on evidence of what works and have a strong focus on
prevention, early detection and early intervention. Already
this focus has been given impetus by packages such as                                    • developing inter-agency care planning models that
the COAG Australian Better Health Initiative, of which this                                include and promote the participation of GPs, private
funding is a part.                                                                         allied health practitioners and state-funded health
                                                                                           practitioners in multidisciplinary care through the Medical
People with Type 2 diabetes require services from a broad                                  Benefits Scheme (MBS) CDM items, such as Team Care
range of health care providers, are likely also to live with                               Arrangements.
other chronic conditions, and will use health services
throughout their life. Managing the burden of disease into                               These service system activities are essential in supporting
the future requires a robust health system that integrates                               and helping to inform service delivery initiatives and
prevention and care over time and different stages of                                    change management processes, such as diabetes self-
disease, integrates the care of different conditions, and                                management.
integrates care across different services and service

12	National Public Health Partnership 2001, Eat Well Australia: An
   Agenda for Action for Public Health Nutrition 2000-2010, Strategic
   Inter-Governmental Nutrition Alliance, Canberra http://www.nphp.
11 Australian Institute of Health and Welfare 2006, Chronic Diseases and
   Associated Risk Factors in Australia, 2006, AIHW, Canberra, http://
13 National Reform Agenda: Victoria’s plan to address the growing
   impact of obesity and type 2 diabetes, Consultation draft,
   December 2006
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 

Self-management mapping                                                  It is important that people newly diagnosed with Type 2
                                                                         diabetes have access to a range of services that are
The self-management mapping process is a PCP activity
                                                                         well coordinated between health care providers. Early
that has strong links to diabetes self-management funding
                                                                         intervention services should aim to provide:
and will inform future systems development for the initiative.
The information from the self-management mapping will be                 • information about diabetes and managing diabetes
invaluable to planning and developing the initiative.                    • assistance with monitoring and maintaining healthy
                                                                             blood glucose levels
Mapping data will assist PCPs and members to identify:
                                                                         • support for self-management (at an organisational and
• current gaps in the provision of self-management
                                                                             clinical level)
                                                                         • information and assistance to manage lifestyle risks
• workforce capacity and gaps
                                                                         • links to community groups and programs that will support
• capacity vs. demand issues
                                                                             lifestyle change
• referral pathways into self-management interventions.
                                                                         • assistance to cope with the impacts of a long term
This data will be key to PCP and members planning around                     health condition
workforce development, coordinating the delivery of                      • effective communication and referral between service
self-management interventions across their catchment,                        providers.
ensuring that interventions target high risk subgroups,
                                                                         Early intervention services are best provided in the
defining agency and general practice roles in providing self-
                                                                         primary care setting and delivered by a range of health
management interventions and support.
                                                                         care providers, including GPs. The GP is the primary health
PCPs should prepare for this mapping process by identifying              professional involved in detection and diagnosis and has
agencies to be involved (state and Commonwealth funded,                  a central role in the ongoing medical management of the
public and private), conducting planning to ensure maximum               disease. Allied health and nursing professionals have an
agency participation, and planning how the process can be                important role in providing education, self-management
used for capacity building.                                              support, foot care, lifestyle support (including dietary
                                                                         management) and referral. The development of care plans
1.4 Overview of diabetes self-management                                 may be appropriate, through use of the MBS care planning
funding                                                                  items, if the relevant criteria are met.
The diabetes self-management funding is a component of                   The diabetes self-management funding provides:
our commitment under the Australian Better Health Initiative             • Non-recurrent PCP funding in 2006–07 for work with
(ABHI): a joint Australian, State and Territory government                 general practice (through DGP) to build on current activity
initiative. The initiative will provide early intervention to              at the local level, focusing on people with chronic disease
people with high risk and newly diagnosed Type 2 diabetes                  and complex needs. While these funds need to be used to
to support them to become good self managers of their                      ensure people newly diagnosed with Type 2 diabetes are
health. High risk includes subgroups of the community                      referred into self-management programs, they should also
that experience higher levels of chronic disease and find it               support a broader approach to working with DGP, building
more difficult to access services. High risk groups include                on existing effort as part of service coordination and ICDM.
Indigenous Australians, people from CALD backgrounds,                    • Non-recurrent funding in 2006–07 for staff training and
regional and rural communities, and those who experience                   development, which will be managed by Department of
socio economic disadvantage.                                               Human Services regions.
                                                                         • Recurrent CHS (or RHS where applicable) funding for
                                                                           delivery of self-management interventions. Fourth quarter
                                                                           targets only for 2006–07 and full year targets from 2007–08.
 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

The funding has an emphasis on providing people with self-
management support that assists them and their families
(and/or carers) to gain the skills and resources to actively
manage their health. Effective client self-management is:14
• enhanced if started early
• a key component of successful chronic disease
• leads to improved health and wellbeing outcomes.
Self-management support goes beyond traditional
knowledge-based client education to include processes that
develop client problem-solving skills, improve self-efficacy,
and support application of knowledge in real-life situations
that matter to clients. Self-management is the ability of the
client to deal with all that a chronic disease entails, including
symptoms, treatment, physical and social consequences,
and lifestyle changes.13
The funding for service delivery, in summary, should provide:
1. Client assessment.
2. Care planning (where this does not meet criteria for MBS
   related care planning).
3. Self-management intervention.
4. Client monitoring.
These guidelines provide specific advice about service
delivery within each of these areas. This should build
on existing capacity to provide services to people with
diabetes. Funding should be used to address the gaps in
providing the services described in these guidelines.
Refer to section 5 for more funding information.

14 National Health Priority Action Council (NHPAC) 2006, National
   Chronic Disease Strategy, Australian Government Department of
   Health and Ageing, Canberra
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 

2. Chronic disease management model for primary care
Core ‘business’ for CHSs includes integrated population-                         Self-management is a key element in the model. The
based health promotion initiatives and providing services                        elements are interdependent components, building upon
and programs to people with chronic disease, including                           one another. Evidence-based principles under each
those with diabetes. Therefore, this funding and the                             element, in combination, foster productive interactions
supporting diabetes self-management guidelines should add                        between informed clients and health care providers. As
value to existing services and programs involved in ICDM.                        its ultimate goal, the Chronic Care Model envisions an
The diabetes self-management funding should operate                              informed, activated client interacting with a prepared,
within a broader CHS CDM model that includes recognising                         proactive practice team, resulting in high quality, satisfying
the importance of the interrelationships among individuals                       encounters and improved outcomes. The Chronic Disease
and the social, cultural, environmental, behavioural and                         Management Program Guidelines provide details of the
biological factors that influence their health.                                  model in the context of CHS and PCP functions.
PCPs core activities include strengthening service                               Table 1 provides examples of how diabetes self-
coordination systems across agencies for people with                             management can operate within a broader chronic care
chronic disease, with a focus on self-management, care                           model. This list is not exhaustive; it is provided to illustrate
planning, and referral and communication mechanisms.                             the links and interdependence between the six elements
Key agencies involved in ICDM include CHSs and DGP.                              of the models. Local capacity, resources and requirements
Therefore, this funding should be integrated with and add                        will need to be considered in developing diabetes self-
value to existing service system development across these                        management services.
agencies and with general practice. Service coordination
work should align with the new Victorian Service
Coordination Practice Manual15 which describes practice
standards for initial contact, initial needs identification,
assessment, care planning and referral.
To achieve this, the Primary Health Branch of the
Department of Human Services has adopted the Wagner
Chronic Care Model16,17 for managing chronic disease in
the primary care setting. Wagner proposes that managing
chronic disease requires nothing less than a transformation
of health care, from a system that is essentially reactive
– responding mainly when a person is sick – to one that is
proactive and focused on keeping a person as healthy as
possible. The Chronic Care Model is a systems-based model
that summarises the essential elements for improving care in
health systems at the community, organisation, practice and
client levels. The model can be applied to a variety of chronic
diseases, health care settings and target populations.

15 http://www.health.vic.gov.au/pcps/publications/sc_pracmanual.htm
16	��������������������������������
    Improving chronic illness care:
17	�����������������������������������������
    Wagner E, Glasgow R, Davis C et al, 2001 �����������������������
                                              Quality Improvement in
    Chronic Illness Care: A collaborative Approach, Journal of Quality
    Improvement, Volume 27 Number 2, February
 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Table 1: Chronic Care Model examples18

                                                                       The Chronic Care Model

                                               Community                                              Health System
                                                                              Self-               Delivery                    Clinical
                                                                           Management             System                    Information
                                                                             Support              Design                      Systems

                                                          Informed,              Productive              Prepared,
                                                          Activated             Interactions             Proactive
                                                            Patient                                    Practice Team


                                                                           Improved Outcomes

  Source: Wagner E, Glasgow et al 2001
  The six elements of the model
  Community – Examples
  − All staff have been trained and have access to Internet-based service directories which include community information.
  − Linkage to community programs (as appropriate) for people with diabetes and recorded on the care plan.
  − Self-management programs (including diabetes education program) include exercise sessions conducted at local leisure centres.
  Health system – Examples
  − CHS strategic plan articulates a commitment and describes a plan to integrate funding (including diabetes self-management funding)
    and provide a seamless and integrated chronic disease management (CDM) program.
  − Identification of clinical leaders to support staff.
  − Management and staff roles for planning, implementing and monitoring CDM are clearly defined.
  − Policies and procedure are in place that clearly support multidisciplinary teamwork and the diabetes team meets regularly.
  Self-management support – Examples
  − Self-management needs are routinely assessed for all clients with chronic disease including diabetes, using the Flinders Partners in
    Health Scale (PIH)18 or other identified tool.
  − All clients with sub optimal self-management skills are referred to self-management interventions (a range of interventions are available
    depending on client need), clients with diabetes are offered a diabetes education group program or individual sessions (including face to
    face and telephone contact).
  Delivery system design – Examples
  − A referral pathway to the CHS for diabetes care exists and is well known and used by GPs.
  − CHS nursing staff conduct assessment clinics every fortnight within two large local general practices; assessment clinics take referrals
    for a range of programs.
  − GPs are available for case conferencing with CHS nurses (and other CHS staff via teleconference) for complex clients.
  − Follow up appointments between the GP and CHS for clients with chronic disease are coordinated.
  Decision support – Examples
  − Clients with chronic disease referred to the CHS are provided with a pocket size booklet to record their own health information
    (developed through the CHS and DGP).
  − Diabetes guidelines and client handouts are evidence-based and sourced from Diabetes Australia.
  − Interagency care planning occurs for all clients with more than two chronic conditions (including diabetes) using the Service Coordination Plan,
    coordinated by a key worker.
  Clinical management systems – Examples
  − Clinical indicator data collected by the GP is shared with the CHS following client consent.
  − Reports about CHS diabetes care are generated every 12 months and shared with GP practices, reports include no. of people: referred for service,
     completing diabetes program, having a written care plan (with GP input), meeting lifestyle goals etc.

18 http://som.flinders.edu.au/FUSA/CCTU/Hand%20out%20Flinders%20Model%20June%202006.pdf
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 

3. Diabetes self-management – service delivery
Given the emphasis on an integrated approach to                         •   managing blood glucose levels
delivering health services, CHSs in receipt of diabetes self-           •   assessing lifestyle risk factors
management funding should use the funding to add value                  •   assessing coping skills and social supports
to existing CDM programs by prioritising high risk clients              •   screening for mental health issues.
newly diagnosed with Type 2 diabetes. The initiative provides
CHSs with an opportunity to review their broader CDM                    Taking anthropometric measurements
program and workforce capacity (in which the diabetes self-             Includes:
management initiative should be embedded) to ensure it is:              • weight
• based on evidence of what works                                       • body mass index (BMI)
• supported by systems (based on the Wagner Chronic Care                • waist circumference.
  Model elements) that ensure best practice is routine                  This provides the client and health professional with
• targeted at high risk clients who experience poorer health            baseline data from which changes over time can be
  and have difficulty accessing services.                               measured. Being overweight or obese is a leading risk factor
The diabetes self-management funding builds on the                      for Type 2 diabetes and most people diagnosed with the
components of care that should be part of all CDM                       disease are overweight. An American trial, The Diabetes
programs, that is:                                                      Prevention Program, studied people with prediabetes and
• assessment                                                            found that those who increased their physical activity most
• care planning                                                         days of the week and lost 5 to 7 per cent of their body
                                                                        weight reduced their risk of developing diabetes by 58 per
• self-management interventions
                                                                        cent. The Shape-Up test on the Diabetes Australia website19
• linkage to community programs
                                                                        combines BMI and waist circumference to give clients an
• client monitoring or follow-up.
                                                                        idea of their risk for Type 2 diabetes. Although the tool is only
Aspects of service delivery within these components will                a guide aimed at healthy adults it can assist clients gain an
vary depending on the chronic disease and on local service              awareness of this risk factor.
                                                                        The CHS and DGP should work together to establish a
Therefore, the following describes the service delivery                 process that ensures measurements are only taken by one
requirements for high risk clients newly diagnosed with                 health professional and shared with the team (with client
Type 2 diabetes, without prescribing a model in which it is             consent). Often GPs collect this information, so CHSs
to be implemented. The model should be determined at the                should not duplicate this assessment.
local level, to meet the needs of the local community and fit
within the local service system.                                        Assessing knowledge of diabetes
Agencies receiving diabetes self-management funding under
                                                                        • assessing clients’ confidence and skills to manage
this initiative need to ensure the following service delivery
                                                                          diabetes (self-efficacy).
components are provided. A summary model of care is
provided at Appendix 1.                                                 Simply assessing knowledge is not enough because
                                                                        knowledge does not necessarily equal behaviour change.
3.1 Client assessment and care planning                                 A client with a lot of knowledge may not put this knowledge
                                                                        into practice. Assessment (that includes self-efficacy)
Assessment                                                              may be undertaken using a tool (such as the Flinders tools
All clients referred for a diabetes self-management service             – Partners in Health Scale, Cue and Response) or through
must have access to a client assessment conducted by                    a structured interview process. Self-efficacy has a greater
an appropriately qualified health professional. A diabetes              correlation with behaviour change. Clients should be asked
assessment should include:                                              to rate how confidant they are to make changes based on
• routine assessment procedures                                         their knowledge.
• taking anthropometric measurements
• assessing knowledge and providing information
  on diabetes
                                                                        19 http://www.diabetesnsw.com.au/diabetes_prevention_pages/
10 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Managing blood glucose levels                                                           Disease21, states that people with chronic medical diseases
Managing blood glucose levels is a very important                                       commonly experience depression and anxiety. Because of
component of managing diabetes and should be done                                       this association, an awareness of and screening for mental
together by the client, GP and other health professionals.                              health issues is important. Studies show that undiagnosed
The GP may have started this process so the role of other                               depression will make it harder for people to self-manage, for
health professionals may be to assist the client to:                                    example, take medications, eat properly and keep health
• gain and use a home meter                                                             care appointments22. CHS staff should be aware that clients
• understand hyperglycaemia and hypoglycaemia                                           with depression may be able to access private counsellors
                                                                                        under new MBS items for mental health, through GP referral.
• understand use of insulin (if appropriate) and other
  medication                                                                            Care planning
• access the National Diabetes Services Scheme.
                                                                                        All clients referred for a diabetes self-management service
Assessing lifestyle risks                                                               will require a care plan. Assessment outcomes identified
There is often a causal link between lifestyle risk factors                             areas where further support is required. This will assist the
and Type 2 diabetes. Assessment of lifestyle risks can be                               client and health professionals determine the plan of care.
done through the use of a tool such as the GP lifestyle                                 Practice standards for care planning are described in the
script screening, based on the SNAPW framework                                          new Victorian Service Coordination Practice Manual 23.
(smoking, nutrition, alcohol consumption, physical activity,                            The manual identifies three levels of care planning: service
weight management)20. Where lifestyle risks are identified                              specific care planning, intra-agency care planning and inter-
clients should be encouraged to set goals around                                        agency care planning. Care planning under this funding may
managing these risks.                                                                   occur at all three levels. Service specific plans may include
                                                                                        a GP management plan, a self-management plan, and a
Assessing coping skills
                                                                                        foot care plan. However, it will also be important to develop
A person’s support network and their ability to deal with
                                                                                        models for intra-agency and inter-agency care planning
the emotional impacts of diabetes is important and will
                                                                                        because medical management, allied health management
impact on their ability to self-manage. We know that
                                                                                        and self-management should be coordinated.
effective self-management occurs in the context of strong
social connectedness. Good self-managers receive                                        Clients with complex needs may also be eligible for a Team
support from their family, friends and/or community. It is                              Care Arrangement under the MBS-CDM items. For these
often psychosocial issues that limit self-management.                                   clients, it will be important that CHS staff provide input
With training, health professionals without a professional                              into the care planning and coordination of services, with
background in counselling can and should provide basic                                  the GP and, potentially, specialists and private allied health
psychosocial support. It is imperative that mechanisms are                              professionals.
in place to support health professionals in this role. This                             The care planning process should be a dynamic,
is important as sadness, a sense of loss and other similar                              consultative process that includes the client (and family/
emotions (that is not depression) are a normal experience                               carers as appropriate) and health care providers, and meets
with chronic disease.                                                                   the client’s health needs in a holistic way. Treatment options
Although depression is not a recognised side effect of                                  should be provided so clients can make informed decisions
diabetes, people with diabetes have a higher incidence of                               about their care. Goals and actions should be measurable
depression. Certainly literature, such as the National Survey                           and articulate who is responsible, so that review and
on Mental Health and Wellbeing and the Victorian Burden of                              reflection is possible.

                                                                                        21 http://www.health.vic.gov.au/healthstatus/bodvic/bod_current.
                                                                                        22 University of Arkansas for Medical Sciences (UAMS), Depression
                                                                                           makes chronic diseases harder to handle, http://www.uams.edu/
20 http://www.health.gov.au/internet/wcms/publishing.nsf/                                  today/2003/021003/chronic.htm
   Content/health-pubhlth-strateg-lifescripts-index.htm                                 23 http://www.health.vic.gov.au/pcps/publications/sc_pracmanual.htm
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 11

Care plans should include the following elements:                          achieve their goals, identify barriers to reaching their goals,
• issues/problems                                                          and plan for overcoming these barriers, including obtaining
• goals, actions, target dates, responsible agents                         needed resources.Goals for self-management should
• regular review dates                                                     include:
• participants                                                             • managing blood glucose levels
• checklist – evidence of need                                             • managing lifestyle risks
• method of planning.                                                      • engaging in normal activities of daily life that are
                                                                             important to the client.
Goal setting
                                                                           Goals should be documented on the care plan.
Goal setting is an essential component of care planning
for people with chronic disease. It should follow a health
professional and client interaction that identifies problems               3.2 Self-management
from the client’s perspective, and barriers to making                      Self-management is described as26:
change. Goal setting should involve the client setting short               The client (and their family/carers as appropriate) working
term and long term goals. The goals should be realistic,                   in partnership with their health care provider to:
proposing behaviours that clients are confident they can                   • know their condition and various treatment options
achieve. Confidence can be measured by asking the client                   • negotiate a plan of care
to estimate their confidence — on a 0 to 10 scale — that they
                                                                           • engage in activities that protect and promote health
can achieve their goals. Experience shows that if the answer
                                                                           • monitor and manage the symptoms and signs of the
is 7 or higher, the goals are likely to be achieved. If the
answer is below 7, the goals should be made more realistic
in order to avoid failure.                                                 • manage the impact of the condition on physical
                                                                              functioning, emotions and interpersonal relationships.
It is important that goals are client-centred, that is, they are
developed by the client and are relevant to the client. The                Self-management is the ability of the client to deal with all
purpose of clients setting their own goals is to increase their            that a chronic disease entails, including symptoms, treatment,
confidence in managing diabetes. Confidence fuels internal                 physical and social consequences, and lifestyle changes.
motivation. Health professionals need to support clients to                Self-management support
do this initially. The Commonwealth Sharing Health Care
                                                                           Self-management support is the care and encouragement
Initiatives 2001–2004, found that health professionals had
                                                                           provided to people (and their family/carers as appropriate)
difficulty shifting their practice from a traditional medical
                                                                           with chronic disease to help them understand their
model of care to a client self-management focus which
                                                                           central role in managing their conditions, making informed
included care planning where clients set personal goals
                                                                           decisions about care, and engaging in healthy behaviours.
rather than health professionals setting clinical goals.24
                                                                           Self-management support goes beyond traditional
Goal setting support tools — Flinders self-management                      knowledge-based client education to include processes that
care plan and ACIC self-management support tool25                          develop client problem-solving skills, improve self-efficacy,
— are examples to guide discussion between the health                      and support application of knowledge in real-life situations
professional and client. The tools assist the health                       that matter to clients.
professional and client to determine goals, identify steps to

24	National Evaluation of the Sharing Health Care Initiative
   Demonstration Projects 2005 http://www.health.gov.au/internet/
25 http://www.improvingchroniccare.org/tools/PDFs/self_mngmt_              26 http://som.flinders.edu.au/FUSA/CCTU/Hand%20out%20Flinders
   support.pdf                                                                %20Model%20June%202006.pdf
12 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

Good self-management support involves collaboration                                     Table 2: Examples of self-management interventions27
between client and health care provider, where the                                                         Type of intervention     Examples
provider is coach as well as clinician and the client
                                                                                          Individual       Face-to-face             Flinders University model
and family are managers of daily care. It also includes
                                                                                                           consultation             of clinician-administered
helping clients (and their family/carers as appropriate)                                                                            support
identify and achieve appropriate behavioural and lifestyle
                                                                                                           Telephone coaching       Coaching patients On
changes. This often means identifying the attitudes and                                                                             Achieving Cardiovascular
beliefs that clients hold about their health, and addressing                                                                        Health (COACH) program
the barriers to behaviour change.
                                                                                                           Internet individual      New South Wales Arthritis
As identified, self-management support should include family                                               course                   Foundation course
and/or carers. Supporting behaviour change for individuals                                                 Internet group course    UK National Health
may include supporting changes being made within a family.                                                                          Service’s
For example, an individual who wants to make changes to                                                                             Expert Patients Program
their diet may need support from family members who do the
food shopping and/or meal preparation.                                                                     Group: ongoing cycle     Rehabilitation programs

                                                                                                           Group: formal/           Stanford University
Self-management interventions
                                                                                                           structured               program
Self-management interventions support and cover all
                                                                                                           Written information      Non-government
aspects of self-management as described above. While the                                                                            organisation publications
diabetes self-management funding should provide a range of
                                                                                                           Television/multimedia,   Back pain beliefs
interventions that are flexible in content and delivery to suit                                            social marketing         campaign;
individual client needs and preferences, it is important that                                                                       Quit anti-smoking
interventions aim at achieving the following client outcomes:                             Population                                campaign
• engagement or re-engagement in life-fulfilling activities                             Source: Joanne Jordan and Richard Osborne January 2007
• engagement in health promoting behaviours and
                                                                                        Generic evidence-based self-management interventions
   reduction of lifestyle risks
• learned skills and techniques to manage symptoms and
   overcome health problems                                                             • Stanford Model
• a positive attitude to life and being able to live with the                           • Flinders Model
   disease without it ‘controlling life’                                                • motivational interviewing for behaviour change.
• self-monitoring of clinical indicators, insight into living with                      The most common behavioural models that underpin self-
   a health problem and setting realistic limitations                                   management interventions28 are the:
• ability to confidently interact with health professionals and                         • social learning theory that includes problem solving and
   use the health system appropriately                                                    goal setting to improve self-efficacy
• social engagement and the ability to seek support from                                • cognitive behavioural approach which aims to motivate
   interpersonal relationships and community organisations                                clients to adjust thought distortions that impact behaviour.
• improved general emotional wellbeing
• support client sustaining the lifestyle changes over the
   longer term.
Table 2 illustrates the broad range of self-management
interventions that have been developed from one-on-
one interventions to group-based programs. This enables
interventions to be provided to suit the local capacity and
the needs of the client.                                                                27 Jordan J and Osborne R 2007, ‘Chronic Disease self-management
                                                                                           education programs: challenges ahead’, Medical Journal of Australia,
                                                                                           Volume 186 Number 1, p. 1
                                                                                        28 Joanne Jordan, Joan Nankervis, Caroline Brand and Richard Osborne
                                                                                           Chronic Disease self-management education programs: where should
                                                                                           Victoria go?, Final Technical Report 2005–06
Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes� 13

Generic self-management models are appropriate for people                     This style of interview, asking the patient provocative
with diabetes; however, they need to be provided by an                        questions and discussing the responses, can often help
appropriately qualified allied health professional (such as                   uncover important behaviour change issues.
a dietitian or physiotherapist) and combined with diabetes
education. The advantage of self-management interventions                                          Stages of Change Model
that combine education with behavioural models is that they
build client knowledge as well as self-efficacy.

Stanford Model
Developed by Stanford University,29 the model is a                                                     Relapse         Precontemplation
structured group program that runs over six sessions for
people with arthritis or osteoporosis, or any chronic health
problem. Sessions are facilitated by two trained leaders                                          Maintenance               Contemplation
and cover:
• techniques to deal with problems such as frustration,
  fatigue, pain and isolation                                                                             Action       Determination/
• appropriate exercise for maintaining and improving
  strength, flexibility, and endurance
• appropriate use of medications
• communicating effectively with family, friends, and health
  professionals                                                                    The Stages of Change Model identifies the stages
• nutrition                                                                        through which clients pass. The model is based on
                                                                                   the premise that behaviour change is a process, not
• how to evaluate new and alternative treatments.
                                                                                   an event, and that individuals have varying degrees
Flinders Model                                                                     of motivation or readiness to change. Motivational
Developed by the Flinders Human Behaviour and Health                               interviewing has been proven effective in assisting
Research Unit,30 the model is a generic set of tools and                           clients move through stages of change and preventing
processes. It enables clinicians and clients to undertake                          relapse. Research has found that providing motivation is
a structured process that allows for assessment of self-                           much more successful31 than simply providing clients
management behaviours, collaborative identification of                             with knowledge.
problems and goal setting, leading to the development of
individualised care plans. The tools include the Partners in                  Disease specific evidence based self-management
Health Scale, Cue and Response Interview, Problem and                         interventions
Goals Assessment and Self-Management Care Plan.                               These interventions have been proven to be effective
                                                                              through rigorous evaluation (for example, control group,
Motivational interviewing
                                                                              before and after time series) and have demonstrated
Based on the Prochaska and Declemente Model, a cognitive
                                                                              improved client outcomes.
behavioural approach, motivational interviewing is a
counselling approach that prepares clients for behaviour                      In 2002, the Department of Human Services funded the
change. Using the technique, health professionals                             Hume Moreland PCP, through the Diabetes Prevention
encourage clients to identify lifestyle behaviours that they                  and Management Initiative, to develop a lifestyle group
would like to change and to articulate the benefits and                       program for people with diabetes. The program, called One
difficulties of making that change. The interviewer uses                      Step Ahead, combines self-management support, exercise
directive questions and reflective listening to help clients                  and diabetes education. The program was implemented
come to their own decisions by exploring their uncertainties.                 in four health services and evaluated by The University of
                                                                              Melbourne. Evaluation results showed that participants were

29 http://patienteducation.stanford.edu/programs/                             31 Bodenheimer T and Lorig K, ‘Patient Self-management of Chronic
30 http://som.flinders.edu.au/FUSA/CCTU/Hand%20out%20Flinders                    Disease in Primary Care’, http://jama.ama-assn.org/cgi/content/
   %20Model%20June%202006.pdf                                                    full/288/19/2469
14 Diabetes self-management: Guidelines for providing services to people newly diagnosed with Type 2 diabetes

highly satisfied with the program and client health outcomes                            Communication agreements should be part of broader
included improved self-reported physical activity levels and                            ICDM inter-agency care planning models. Models may
statistical improvements in blood glucose control at six and                            vary in sophistication but should always be underpinned
12 months post-program completion. A program manual                                     by processes for sharing information and coordinating
was developed out of the initiative along with a workforce                              care. For example, a basic level care planning model may
development strategy. The program manual describes:                                     simply include sharing service specific care plans between
• the structure and content of the six session program                                  agencies. At a more sophisticated level, the model may
• all necessary resources                                                               include discussion between health care providers from
• information about conducting the program.                                             different agencies around client goals which leads to
                                                                                        the development of one new coordinated care plan that
It is anticipated that both the program manual and                                      synthesises all information from service specific plans.
workforce development strategy will be available on the
Department of Human Services website in early 2007.                                     Following the package of services and self-management
                                                                                        support provided to clients, the CHS should take a step
Under the diabetes self-management funding, it is expected                              down approach and communicate with the GP regarding
that self-management interventions will be provided to                                  ongoing management. A step down approach may include
clients over the period of approximately 12 months. This                                one or more of the following options:
may include a period of service intensity, for example, a
                                                                                        • The client exiting from service with an opportunity for
group program. However, intensity should step up or down
                                                                                          re-contact should other issues arise or through invitation
to regular but infrequent contact as clients’ support needs
                                                                                          to additional or refresher diabetes self-management
change, for example, telephone contact every three months.
                                                                                        • Annual podiatry appointments.
3.3 Client monitoring
                                                                                        • Ongoing but infrequent telephone coaching.
A team approach to diabetes management starts with
the client and their GP, and adds allied health, specialist                             Ongoing management
and education services as required, particularly following                              As well as self-management interventions, clients may
diagnosis. The diabetes self-management funding is aimed                                require allied health (for example, podiatry, dietetics),
at CHSs providing a range of services to people following                               nursing and/or counselling services. Clients should be
diagnosis and ensuring they have adequate supports in                                   assisted to access these services via appropriate referral.
place for long-term management. Therefore, it is important                              These services may or may not be funded directly by the
that people with Type 2 diabetes have a regular GP. If not,                             diabetes self-management funding, and may or may not be
they should be supported to find a GP they trust. It is also                            provided by the CHS, depending on how funding is used
important that communication occurs between the CHS                                     and what services outside the CHS are more appropriate
and GPs of clients receiving services.                                                  (such as MBS funded allied health and dental).
GP communication                                                                        Clients should also be educated about, and linked to, other
                                                                                        health and community services that can provide routine
Communication between the GP and other health care
                                                                                        ongoing care and support. Ideally, as part of an annual cycle
providers is important to maintain the team approach to
                                                                                        of care (sourced from the Australian Government Health and
care. Agreements and protocols around communication
                                                                                        Ageing website – Medicare online), the GP will facilitate the
between the GP and CHS should be established (if not
already in place) to ensure this occurs and should be
consistent with the practices, processes, protocols and
systems described in the Victorian Service Coordination
Practice Manual. Referral32 and communication pathways
are also discussed in section 4. It is recommended that
the diabetes self-management guidelines be used in
conjunction with the manual.

32 http://www.health.vic.gov.au/pcps/coordination/ppps.htm
You can also read