Prediabetes and Diabetes affects 25% of Australians and a recent inpatient audits have shown ~26% of inpatients are affected by diabetes, mandating that all clinicians need to be familiar with diabetes management. Monash Health (MH), one of Australia’s largest health care services (1.6 million catchment) has major inpatient and ambulatory service demand. MH Diabetes Unit has taken a strategic and collaborative approach to service development.

MH now runs one of the largest diabetes services nationally, providing ~42,000 episodes of care per year across 10 hospital, community and outreach sites, we provide inpatient and 23 ambulatory care services and integrate and support primary care management of diabetes across paediatric, adolescent, preconception, pregnancy, adult chronic disease, primary care support services, oncology and mental health liaison, pump services and inpatient and ambulatory services and nurse practitioner led services. Our strategic plan is developed with a stakeholder steering group including Medicare Locals, local government, community health and other key representatives. Our focus is on supporting both patients and other community based services to manage diabetes with education, support and rapid access services to develop care plans and return the majority of patients to primary care or for a minority to limited public chronic disease management or private endocrinology services. These services also support transitional care pre and post admission.

The unit is structured as a multidisciplinary team with all craft groups represented and reporting through a single reporting line/ head of unit. We support 6 clinical advanced trainees and currently train 13 PhD students, through the integrated Monash University Centre for Health Research and Implementation, located at Monash Health and run by MH Diabetes staff.

Funding sources are innovative and diverse, but most services are funded by MBS funding. This has been possible through considered planning with health administrators, strong clinical leadership and a committed multidisciplinary team, streamlined models of care and strong primary care engagement. A business manager and dedicated administrative team has been  key success factors and the model of care, enablers and barriers will be explored.