Diabetes management

Project OfficerSvetlana Serafimov     Phone: 9330 9979

Diabetes mellitus is a chronic disease that occurs when the body does not produce enough insulin or when the insulin that is produced does not work effectively. Diabetes is one of the top 10 causes of death in Australia.

Clinical guidelines

external link General practice management of type 2 diabetes 2016-18; RACGP Clinical Guidelines

external link Foot care in diabetes - Diabetes Australia

external link National evidence-based clinical care guidelines for type 1 diabetes

document-pdf-text HbA1c test for diagnosis of diabetes - CESPHN 

external link National Diabetes Service Scheme (NDSS):

People with type 2 diabetes who are not on insulin can purchase subsidised blood glucose testing strips for an initial period of six months. A doctor, credentialled diabetes educator or nurse practitioner can sign the form for  subsidised blood glucose test strips for a further six month period. The patient needs to bring this signed form to the pharmacy. Other NDSS products, such as needles, syringes, blood glucose test strips and urine test strips will be available from NDSS Access Points, usually your local community pharmacy.

  • To locate nearest NDSS community pharmacy call the NDSS Helpline on 1300 136 588.
  • The form for the test step approval
  • Search the Online Services Directory for NDSS Access points in the local area
  • Details about recent changes can be found here

General Practice support

CESPHN primary care support team provides General Practice to improve co-ordination of care with regards to diabetes prevention and management, specifically on:

  • Medicare billing – Diabetes Program Incentives (PIP) and Service Incentives (SIP) Diabetes incentive guidelines
  • Chronic Disease Clinical Management Quality Improvement support – mapping practice profile, identifying high risk patients and offering support and referral options
  • Upskilling Practice Nurses in diabetes education and management
  • Supporting the establishment of a Diabetes Clinic within a General Practice
  • Providing updates on latest diabetes management policies and guidelines, including diabetes annual cycle of care 

document-pdf-text Assessing CVD risk (see also Cardiovascular disease)

external link Guidelines for modifiable risk factors

Diabetes Annual Cycle of Care

external link Diabetes incentive guidelines - Department of Human Services

Diabetes Integrated Care and Referral Pathways

CESPHN has been working in partnership with the Local Health Districts on the Diabetes Integrated Care project to improve access, communication and coordination of diabetes care and services between the primary and tertiary sector.

Prince of Wales Diabetes Centre 

The Prince of Wales Diabetes Centre is a multidisciplinary clinical and education service that assists with the management and education of patients with complex diabetes mellitus. The centre provides diabetes clinics, podiatry:  high level and complex diabetes foot  care, dietetics and diabetes education for patients who live in the Prince of Wales hospital catchment area. A new referral process requires a referral form to be completed. The referral criteria will assist to triage patients and ensures patients are seen in an appropriate length of time. 

document-pdf-text New diabetes referral guidelines to POW Diabetes Centre

document-pdf-text POW Diabetes Centre referral form; GP referral template for Best Practice, GP referral template for Medical Director

document-pdf-text POW Diabetes Centre - Podiatry: High level and complex Diabetic foot care referral pdf; GP referral template for Best Practice, GP referral template for Medical Director

St George and Sutherland Hospitals

document-pdf-text  Diabetes referral guidelines

document-pdf-text  Diabetes Education Centres referral form to St George and Sutherland Hospitals:Best Practice templateMedical Director template

document-pdf-text St George Outpatient Clinics - pdf referral form; GP referral template for Best Practice, GP referral template for Medical Director 

Multidisciplinary care


document-pdf-text Diabetes Prevention and Management - CESPHN Toolkit for General Practice


Basic Foot Assessment Checklist: Best PracticeMedical Director

Patient education