Diabetes Integrated Case Conferencing in South Western Sydney

8th November 2018

SWSPHN and the South Western Sydney Local Health District’s Diabetes Obesity and Metabolism and Translational Research Unit (DOMTRU) are working together to support and enhance diabetes management in primary care.

An integrated case conferencing program is in place whereby endocrinologists are available to provide clinical support for the management of type 1 and type 2 diabetes in the general practice setting.

The GP is asked to provide a referral to one of the participating endocrinologists for each individual patient after obtaining a verbal consent from the patient. GPs are being asked to prioritise complex cases where the HbA1c is > 9 per cent or diabetes complications (e.g. nephropathy, post hospital discharge) are present.

Essentially, one of the program’s endocrinologists attends the GP practice at a scheduled time that suits the GP. The patient’s case is discussed without the patient being physically present. A third party such as a practice nurse or diabetes educator (which we can arrange if necessary) is also required to attend.

Ultimately a diabetes management plan is documented and conveyed to the GP in writing which they can later implement with their patient. A follow up conference is then arranged three to six months later to check on the patient’s progress.

DOMTRU recognises the increasing prevalence of type 2 diabetes in South Western Sydney and the strain it places on resources in both general practice and the public hospital system. As such many patients with complicated diabetes miss out on access to timely specialist and multidisciplinary care.

The aim of this case conferencing program is to support general practitioners provide comprehensive care for patients with diabetes, including improvement in their glycaemic, blood pressure and lipid control (where needed) and avoiding hospital admissions and hospital clinic referrals (where possible).

The program facilitates timely access for patients to specialist services that are bulk billed. 

Additionally, the case conference is an excellent forum for sharing knowledge and learning opportunities to equip GPs with the confidence and tools to manage complex diabetes patients.

It is hoped this will reduce the number of patients needing specialist review.

There is also the added incentive of remuneration for the GP’s time through case conferencing booking and attendance MBS items. This will vary according to the complexity of the case and the time spent on the discussion.

GPs are encouraged to the use case conferencing program to improve the management of diabetes.

For more information, contact DOMTRU administration on 4634 2192 or 4634 2065, via email at swslhd-campbeltownidc@health.nsw.gov.au or visit the SWSPHN website http://www.swsphn.com.au/diabetesinsws.


Article by Dr Shamani Mendis, Dr Eddy Tabet, Dr Rohit Rajagopal, Dr Bobby Chan and Professor David Simmons

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