Outreaching Diabetes Management: from patient to practice nurse – a holistic and sustainable approach to managing diabetes within rural communities.

Shellie Burgess1, Lesley Wilcox2

1Marathon Health, PO Box 175 BATHURST, NSW, 2795, shellie.burgess@marathonhealth.com.au
2Marathon Health, PO Box 175 BATHURST, NSW, 2795,  lesley.wilcox@marathonhealth.com.au

Background: Marathon Health provides many services within rural NSW and among the greatest in demand is diabetes education. The primary health services team recognised that a more sustainable and effective service delivery model was needed to manage the ever increasing demand and a strategic plan was developed that incorporated a wraparound service for the consumer while at the same time building capacity within the area to provide diabetes education services into the future.

 Models:

A more efficient mode of service delivery was developed incorporating a combination of face-to-face and telehealth sessions with both the Diabetes Educator and Dietitian. This enabled an increased frequency of service delivery and continuity of support for the consumer, while reducing expenditure. The inter-program referral between the Diabetes Educators and Dietitians enhanced the care for the consumer which was further improved by linking with the Marathon Health Connecting Care and Supplementary Services team for care coordination and specialist interventions.

To build workforce capacity, a Diabetes Management for Practice Nurses education package was developed and delivered by Credentialed Diabetes Educators (CDE) throughout the region to not only enhance clinical knowledge but also provide the opportunity to develop a network of clinicians to support each other, particularly those working in isolation. A Diabetes Support Network was established and with regular tele and videoconferencing an opportunity for ongoing education, support and interagency liaison has been sustained.  An expansion of both the education package and the support network to target Aboriginal Health Workers occurred during 2016.