Diabetes self-management - Guidelines for providing services to people newly diagnosed with Type 2 diabetes
Care for people with chronic disease, such as Type 2 diabetes, usually involves multiple health care providers in multiple settings. To provide this care within an integrated system, health care providers must work collaboratively to coordinate and plan care and services. This requires a commitment from health care providers and agencies to work together to achieve shared goals.
People with Type 2 diabetes need a responsive person-centred and effective system of care. These diabetes self-management guidelines aim to support member agencies of Primary Care Partnerships (PCPs), in particular Community Health Services (CHSs), Rural Health Services (RHSs) where applicable, and Divisions of General Practice (DGP), to implement new diabetes self-management funding in the context of a chronic disease management (CDM) approach across the service system. The guidelines also provide support for CHSs, PCPs and DGP as part of the broader integrated chronic disease management (ICDM) work. They should be used in conjunction with the Chronic Disease Management Program Guidelines.
Self-management is about people being actively involved in their health care. The approach is underpinned by a number of principles 1 and has been recognised by the Commonwealth Government and the Victorian Government as a key component of diabetes management and CDM more broadly.
Diabetes self-management funding supports work already being undertaken by CHSs and PCPs. For example:
All PCPs now receive recurrent funding for ICDM which builds on the established PCP role in facilitating service system integration and change management across member agencies.
Core business for CHSs includes providing services to people in the community who have chronic disease. Many CHSs, particularly those in receipt of Early Intervention in Chronic Disease funding, are working on internal systems changes to ensure services are delivered within a CDM model of care.
While these guidelines are targeted at CHSs (or RHSs where applicable) and PCPs that receive direct funding (recurrent for CHSs/RHSs and one-off funding for PCPs), they are also intended to support agencies in their work with people who have chronic disease.
The diabetes self-management guidelines should be used in conjunction with:
- Chronic Disease Management Program Guidelines
- Primary Care Partnership Planning and Reporting 2006–2009 guidelines