Pre-diabetes Referral Pathway

The Greater Newcastle Cluster Diabetes Service has developed a new referral pathway for patients diagnosed with pre-diabetes, providing improved care over an extended period. This has enhanced our capacity to provide education and clinical care for patients with diagnosed diabetes, with or without comorbidities, who generally have more complex management issues and are at a greater and more imminent risk of future diabetes complications than people with pre-diabetes.

In the new model, pre-diabetes referrals are triaged by a Diabetes Nurse Educator to confirm diagnosis and assess the support the patient needs to make and maintain required lifestyle changes. If appropriate, the patients are registered with Connecting Care which contacts the patient and offers one of two 6 month free health coaching services. The first is Healthways Australia, conducted by registered nurses and allied health professionals who deliver proactive and scheduled telephone calls and reinforce and support GP and health provider care. The second is Get Healthy, which also supports patients to reach their goals with up to 10 free calls. In both programs, coaches assist in developing personal health goals, creating action plans, maintaining motivation, identifying problem areas and creating solutions for successful change.

Connecting Care advise the referring GP that the patient is participating in Healthways or Get Healthy and the GP is provided with midpoint and final reports, if the patient agrees to this.

Other avenues for education are available to these patients, including community seminars conducted by the Australian Diabetes Council and individual education by general practice medical and nursing staff, Community Health or private dietitians.

Prior to establishing this new pre-diabetes pathway, GNC Diabetes offered resource intensive individual and group education programs. Channelling these lower risk patients along this pathway reallocates specialised diabetes resources that can be utilised for more complex, higher risk patients.