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Diabetes Case Conference - enhancing diabetes care in SWS

Dr Chee L Khoo

We’ve read the management guidelines. We’ve attended some evening CPDs. We’ve read some articles in one of the medical journals. We have even attended a symposium on diabetes. We ought to know all we need to know about managing all manners of diabetic patients. Yet no one patient with diabetes is the same as another. They just don’t quite fit into the theoretical patient as described. Perhaps, the patients have too many other co-morbidities that makes their medical management just that much more tricky. Perhaps, we need a different perspective from another colleague with a little more experience.

DOMTRU in collaboration with SWS PHN and SSW GP Link is proud to roll out The Diabetes Case Conference program. Case conferencing involves a local diabetes specialist visiting you at your practice and discussing any patients who meet the criteria or who you feel you would like to discuss.  Practice time for case conferencing is well paid for by Medicare and can assist GPs to better manage patients with diabetes (Type 1 or Type 2). This will result in better care for diabetic patients, enhance the management skills of the GP and improve diabetes management capacity of the practice.

Aims of Case Conferencing

  • To allow efficient use of resources in diabetes management  by helping to manage more patients effectively in the primary care settings
  • To provide clinical support, advice and guidance for diabetes management in the primary care setting
  • To assist primary care with developing patient care plans for their more complicated patients
  • To provide interactive case based learning opportunities and increase primary care confidence in managing diabetes.
  • To identify complicated cases that might require more intensive multidisciplinary input in specialist or hospital clinics and generate a shared plan
  • To develop an integrated approach to diabetes management across primary care, hospital and  specialist services

What are the benefits to my practice?

  • Access to billing for MBS chronic disease items for case conferencing (see below), GP management plans, Team Care Arrangements and items of Diabetes Cycles of Care, as eligible.
  • Advice from specialists without extra cost to the patient
  • Reduced waiting time for some patients to access specialist care
  • Keep more patients within your practice
  • Increased patient satisfaction with a comprehensive, integrated and inter-disciplinary management approach in the one location

Who should we target first?  Diabetes with any of:

  • HbA1c≥9% (8-8.9% included once those ≥9% have been discussed)
  • Significant and frequent hypoglycaemia
  • Recent hospitalisation/CVD/Foot event in past 12 months
  • Nephropathy/ACR
  • Blood pressure over 160/100 mmHg
  • Triglycerides 10+mmol/l
  • Women planning/at risk of pregnancy
  • Other (Any other patient with diabetes you would like to discuss)

So, where do I sign?

The Steps:

  1. Identify patients that may benefit from further management intensification
  2. Obtain patient’s verbal consent and enter consent in clinical notes
  3. Fill patient’s clinical and laboratory details in referral form and forward to Admin Central by fax or email (see below)
  4. Referral triaged and case conference arranged for mutually agreed time
  5. Case conference between GP, endocrinologist and 3rd health professional (practice nurse, CDE) without patients present. For practices without a 3rd health professional available, an allied health professional may be sourced from the specialist team.
  6. For each patient, GP claims an item number for organising the case and a separate item number for participating at the case conference. Each case is anticipated to take about 15 mins each on average with some shorter while the complex cases a little bit longer.

How to refer for a (1-2 hours) case conference session:

Point of contact: Jodie Wilson

Number to call:  4634 3132


Fax referrals: 4634 3810


The views expressed are views of the authors and do not necessarily represent the views of the board of SSW GP Link