General practice management of type 2 diabetes

Models of high-quality healthcare
☰ Table of contents

The medical home

Quality and safety in diabetes care start with coordinated, ongoing and comprehensive primary healthcare. Primary care is the central component of care across the spectrum of patients with diabetes: those dealing with a new diagnosis, managing (often multiple) medications, with complications of diabetes and multimorbidity, through to patients at the end of life.

A general practice chosen by a patient to provide ongoing, comprehensive, patientcentred care is known as a ‘medical home’. The medical home is responsible for the patient’s healthcare across their entire health journey, and this approach results in better health outcomes for patients and their families.6 Australian general practice encapsulates the medical home model.7

This model has measurable benefits, including improved continuity of patient care,8 and improved quality and cost effectiveness of care for patients with a chronic disease.9 Medical homes reduce disparities in access to quality care among traditionally difficult to reach groups,10,11 which leads to improved overall population health 12 and lower overall healthcare spending.13–15 The RACGP’s Vision for general practice and a sustainable healthcare system  is based on the patient-centred medical home model and is informed by RACGP’s definition of quality general practice.

A model for chronic disease management

For patients with type 2 diabetes across the spectrum, structured care programs that are easy to implement, well supported and meet the needs of the individual are required. These programs bring together healthcare teams, evidence-based guidelines, useful support tools and good systems to support patients throughout their journey.

Refer to Chapter 5. Structured care and patient education for more information.

The Chronic Care Model (CCM), developed by the MacColl Institute identifies the fundamental elements of a healthcare system that supports high-quality chronic disease care:

  • health system (organisation and mechanisms)
  • delivery system design
  • decision support
  • clinical information systems
  • self-management support
  • the community.

The CCM has been shown to be an effective framework for improving the quality of diabetes care.16

In practice

Health system

GPs can help create a health system that facilitates easy and appropriate access to care for people with diabetes by reducing barriers associated with accessing, and maintaining healthcare across primary care and other health tiers.

General practices can access the Australian Government system level incentives to support diabetes care. This support is provided through Medicare Benefits Schedule (MBS) payments to GPs, nurses, allied health professionals and general practices. These include the Chronic Disease Management (CDM) items (formerly known as Enhanced Primary Care), which provide support for developing management plans and organising team care.

Patients have experienced improvements in process and clinical outcomes with these management plans and team care arrangements.17


It is recommended that all practices identify patients of Aboriginal or Torres Strait Islander descent.
Registering patients also allows access to the Closing the Gap Pharmaceutical Benefits Scheme (PBS) co-payment, earlier interventions (as determined by PBS criteria) and access to specific MBS item numbers.

Refer to Appendix A in the PDF version. Accessing government support for diabetes care in general practice.

Delivery system design

Diabetes care requires a proactive preventive approach to keeping patients as healthy as possible rather than episodic or reactive intervention when complications arise. An effective system to achieve this will engage patients with a range of healthcare providers using good communication and information technology.17

Collaborative multidisciplinary teams are best suited to provide diabetes care, facilitate patient self management, identify those patients who require individualised support and coordinated case management.18,19 Using multidisciplinary care and engaging the wider team have been shown to improve outcomes for people with diabetes.20

A team approach provides flexible and comprehensive care to meet individual patient needs. Roles within a general practice team are not mutually exclusive, and clear guidance is required to identify the team member primarily responsible for key activities. Teamwork success may be supported by workflow coordination and management of structured care programs (care planning).

Decision support

Accessible guidelines for diabetes management and associated issues (eg management and prevention guidelines for all types of diabetes; refer to Austroads and National Transport Commission, Therapeutic Guidelines Limited [TGL] antibiotic guidelines) are required for GPs to make decisions about diabetes care that is consistent with evidence and meets regulations.

Having electronic records also facilitates decision to support this goal by ensuring prescription error checking against medication allergy, and drug–drug and drug– disease interactions, creating diabetes clinical measures and databases, facilitating risk assessment such as cardiovascular disease (CVD) risk scoring and thus providing a basis for data collection linked to quality improvement processes.

Clinical information and recall and reminder systems

Structured diabetes care programs are based upon good information management systems (eg registers, recalls and reminders) combined with risk factor, complication assessment management and comorbidity strategies. Management plans are most effective when they involve a team care arrangement and are reviewed regularly.17 Structured recall systems ensure a patient receives formal reviews at regular intervals. Several studies have shown that computerised recall systems, monitoring and reminding patients and practice team members about appointments, investigations and referrals, improve diabetes care.21–24 Computerised systems can also provide automated reminders, generate mailing lists of those overdue for preventive activities and help minimise repeat data entries.

Combining a reminder system with a practice register ensures that the reminder system is systematic and targeted. This can prevent patients with diabetes missing out on basic care such as screening for retinopathy and foot care. Depending on the complexity of individual patient needs, structured recall may occur on a three-month to 12-month basis.

For example, during a consultation, the GP and patient make key management decisions or team care changes dependent on care plan progress. A recall is added in a time frame suited to the patient’s needs. This cycle then repeats. Another example is where a structured recall may ensure that all necessary investigations are completed before the next practice visit by the patient.

Self-management support

The aim of self-management support is to facilitate skills-based learning and patient empowerment. Diabetes self-management, education and support programs improve understanding of, and belief in, the importance of those factors that influence diabetes (eg goals, complications, living with a chronic illness), and thus might be able to be modified by patients’ behaviours and actions (eg self-monitoring of blood glucose [SMBG], dietary choices and physical activity). Other factors, such as medication(s), foot care, individual complication risk assessment and understanding of laboratory results, may need engagement with a health professional team.

The community

Community resources and policies can be harnessed to improve the quality of the practice service including:

  • National Diabetes Services Scheme (NDSS)
  • Diabetes Australia resources
  • Primary Health Network (PHN) collaborations
  • local endocrinology specialist services – private and tertiary-level care
  • allied health support teams including CDEs, Accredited Practising Dietitians (APDs) and Accredited Exercise Physiologists (AEPs)
  • partnerships with universities or hospitals in providing diabetes care
  • medication advice at pharmacies
  • diabetes support groups, diabetes support applications and online support groups
  • community health centres.

Translated diabetes resources are available from the NDSS diabetes portal, which includes resources from Diabetes Australia, Diabetes Australia state and territory agents, and non-government organisations.


Some PHNs run chronic care coordination programs for Aboriginal and Torres Strait Islander patients that can help access practical help in attending a range of specialist and allied health appointments.

Diabetes Australian and RACGP logo's
  1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. Leawood, KS: AAFP, 2007. 
  2. The Royal Australian College of General Practitioners. What is general practice? East Melbourne, Vic: RACGP, 2012.[Accessed 1 September 2013].
  3. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: A critical review. Ann Fam Med 2004;2(5):445–51.
  4. Grumbach K, Grundy P. Outcomes of implementing patient centred medical home interventions: A review of the evidence from prospective studies in the United States. Washington, DC: Patient-Centred Primary Care Collaborative, 2010.
  5. Geisinger Health System. Presentation at White House Roundtable on advanced models of primary care. 10 August, 2009. Washington, DC: Geisinger Health System, 2009.
  6. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA Jr. Community care of North Carolina: Improving care through community health networks. Ann Fam Med 2008;6(4):361–67.
  7. Scholle SH. Developing and testing measures of patient centred care. Washington, DC: The Commonwealth Fund Health Care Quality Survey, 2006.
  8. Beal A. Closing the divide: How medical homes promote equity in health care. New York: Commonwealth Fund, 2007.
  9. MacKee N. Medical home potential. MJA Insight;Issue 21, 8 June 2015 [Accessed 15 February 2016].
  10. Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care. JAMA Intern Med 2015;175(8):1362–68.
  11. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: A systematic review. Prev Chronic Dis 2013;10:E26.
  12. Wickramasinghe LK, Schattner P, Hibbert ME, Enticott JC, Georgeff MP, Russell GM. Impact on diabetes management of general practice management plans, team care arrangements and reviews. Med J Aust 2013;199(4):261–65.
  13. The Royal Australian College of General Practitioners. A systems approach to the management of diabetes: A guide for general practice networks. South Melbourne, Vic: RACGP, 2010.
  14. American Diabetes Association. Standards of medical care in diabetes – 2015. Diabetes Care 2015;38 Suppl 1:S1–94.
  15. Harris MF, Jayasinghe UW, Taggart JR, et al. Multidisciplinary team care arrangements in the management of patients with chronic disease in Australian general practice. Med J Aust 2011;194(5):236–39.
  16. Bellazzi R, Arcelloni M, Bensa G, et al. Design, methods, and evaluation directions of a multiaccess service for the management of diabetes mellitus patients. Diabetes Technol Ther 2003;5(4):621–29.