| Programs and Services - Diabetes |
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Diabetes Services:
 Diabetes Co-management
Diabetes Foot Program (Community)
Diabetes Foot Unit (Acute)
Services provided by HARP PIH Program
The following services are provided for clients referred into the Program:
- Initial and review assessments
- Key worker to coordinate interventions
- Care planning and care coordination
- Client action plans
- Liaison with regular GP
- Education and self management support
- Specialist consultation as appropriate and available
Service duration and hours of operation
Services are offered from 8.30am to 5.00pm Monday to Friday (excluding public holidays).
The service duration depends on the client’s needs and the service component area. HARP PIH aims to provide interim services to address client’s needs and to transition clients into more sustainable services as available and appropriate.
Services are provided on the campuses of the partnership agencies, in client’s homes and general practices.
Diabetes Co-management Service
Diabetes Co-management Service (DCS)
The Diabetes Co-management team consists of Registered Nurses who are Credentialled Diabetes Nurse Educators (RN-CDE), a dietitian and an endocrinologist. The DCS work in collaboration with GPs to provide ongoing clinical management, education and support for people with diabetes who are at high risk of hospitalisation. The overall aim of the DCS is to reduce the incidence of diabetes related hospital admissions.
The RN CDEs provide services in general practice and community health setting
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Education and self management support to people with complex diabetes issues.
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Appropriate monitoring , review of treatment and clinical management
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Coordination of clinical review to other allied health professionals including the capacity for internal dietetic and Endocrinology review
Eligibility Criteria to the program:
Adults with Type 1 or Type 2 Diabetes who attend one of the participating GP clinics, or who live within the catchment areas of Merri Community Health Service (City of Moreland and some northern suburbs) or Doutta Galla Community Health Service (City of Melbourne & City of Moonee Ponds).
Eligible clients must also present with one or more of the following:
· - previous 12 month history of RMH hospitalisation because of their diabetes
· - at risk of hospitalization because of complex needs
· - HbA1C ≥ 9%
· - 2+ high risk foot factors
· - microalbuminuria
· - diagnosis of Diabetes for 15 +years
· - cardiovascular disease
· - proliferative retinopathy
Location:
Participating general practices within the catchment area.
Merri Community Health Service (Coburg).
Doutta Galla Community Health Service (Niddrie)
For further information contact:
Melbourne General Practice Network: 9347 1188
DCS Team Leader: 0450 908 223
Diabetes Foot Program
The program aims to provide evidence-based, best practice management, across the care continuum for people with diabetes-related foot complications. To reduce the need for hospitalisation, Emergency Department presentations for Diabetes-Related Foot Illness, the incidence of amputations, to improve wound healing, to prevent or restrict the progression of diabetes-related foot disease and to improve clients’ quality of life. The service maintains close links with Diabetes Nurse Educators, GPs and other allied health treatment sites at Merri and Doutta Galla Community Health Services.
Eligibility: Diagnosed diabetes plus one, or more of the following:
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Peripheral Neuropathy in the presence of gross foot deformity (Hx Amputation, Charcot’s)
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Significant Peripheral Vascular Disease
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Active foot wound/ Recent past history
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Hospital admission with a foot related problem in past 12 months.
Locations: Doutta Galla Community Health Service (Moonee Ponds and Kensington), Merri Community Health Service (Brunswick, Coburg and Fawkner) and client homes where possible.
Diabetes Foot Unit
The Diabetes Foot Unit (DFU) offers specialised podiatry for people with active wound complications and/or as a result of advanced diabetes, within an acute setting. The DFU implements evidence-based assessment and management of patients with diabetes-related foot problems, aiming to reduce amputation rates, reduce length of stay, and ensure cost effective and appropriate use of hospital investigations and resources for this patient group. The DFU is staffed by a multidisciplinary team (Endocrinologist, Podiatrist, Vascular Surgeon, Rehabilitation Consultant, Clinical Psychologist, Diabetes Nurse Educator, Dietitian).
Eligibility:
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History of significant diabetic foot related problem
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Current foot ulcer
OR
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Peripheral neuropathy (as determined by 10g monofilament) in the presence of gross deformity
OR
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Peripheral vascular disease (with or without wound)
Location: The Diabetes Foot Unit operates from The Royal Melbourne Hospital.
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