Getting your Patients on Board: The Annual Diabetes Cycle of Care

Early interventions targeting multiple risk factors can significantly reduce the complications of diabetes.1-4 Refer your patient early to a diabetes educator so they are informed fully about their diabetes, its management and what they can do to reduce complications; informed patients who are actively engaged in their own care are more likely to have beneficial outcomes.2, 5

The annual diabetes cycle of care can be a useful framework for people with diabetes.1 This therapeutic brief focuses on veterans who have been recently diagnosed with diabetes; it advocates the provision of support, resources and education to veterans.

Analysis of the DVA health claims dataset identified 10,187 veterans diagnosed with diabetes within the previous four years.6

Very few veterans with newly diagnosed diabetes receive recommended care. Ten percent or less have a claim for a Home Medicines Review, a diabetes educator or an exercise physiologist.


Implement the Diabetes Cycle of Care

Consider establishing or using your ‘practice diabetes patient register’ to routinely recall your patients for regular check-ups. Set the recall program so your patients receive check-ups as outlined in the diabetes cycle of care. Include a pathology form for relevant blood tests with each recall letter. This can be managed by the practice nurse.


Diagram 1: The Cycle of Care as recommended by The general practice management of type 2 diabetes 2014/15 guidelines.

There are a number of elements in the diabetes annual cycle of care. The general practice management of type 2 diabetes 2014/15 guidelines outlines recommended care (Diagram 1).1 Provision of the recommended services fulfils the requirements for the Annual Cycle of Care Medicare Benefits Scheme rebate. Consider a General Practice Management Plan (GPMP) (Medicare item 721) as part of this process.1 Refer to the Insert for DVA funded services available for veterans with diabetes.

Provide patient self-management education

Evidence suggests informed and engaged patients who are actively involved in their health care achieve significantly better health outcomes.5

Provide self-management education to your patients on diagnosis and continue to review their self-care skills frequently during the first year. Refer your patients with recently diagnosed diabetes to a diabetes educator initially, and then as considered necessary.1 Improving your patient’s skills, knowledge and confidence to manage their own condition will help reduce complications and is the foundation of diabetes care.

This may include:

  • establishing a healthy eating plan
  • encouraging daily physical activity that they enjoy
  • self-monitoring, such as home blood glucose monitoring
  • safe medication usage
  • managing high and low blood glucose levels
  • establishing good foot-care and hygiene habits
  • interacting with the multidisciplinary health care team and support services.

Refer to the Insert for DVA funded services.

Diabetes education is ongoing and needs to continue for the rest of your patient’s life.

Address cardiovascular risk

Optimal blood pressure and lipid control are as important as optimal glucose control in reducing cardiovascular complications. Check your patients’ blood pressure and blood lipids on diagnosis and then every three and twelve months respectively.1 Assessment of absolute cardiovascular risk (Australian absolute CVD risk calculator) will help identify people who need active intervention such as drug therapy and risk factor monitoring. Assessment of combined risk factors is considered more accurate than the use of individual risk factors.1 A cardiovascular risk calculator can be accessed at

Individualise targets for blood pressure, lipid and HbA1c levels according to patient and treatment factors. As a general guide, encourage your patients with diabetes to achieve the goals for optimum diabetes management listed in Box 1.1

Box 1: Goals for optimum diabetes management1


Equal to or less than 53 mmol/mol (7%) where this doesn’t precipitate hypoglycaemic events

Blood pressure

130/80 mmHg

Total cholesterol

Less than 4.0 mmol/L


Equal to or more than 1.0 mmol/L


Less than 2.0 mmol/L


Less than 2.5 mmol/L


Less than 2.0 mmol/L

Address glycaemic control

For every one percent decrease in HbA1c, the risk of microvascular complications is reduced by 37%.7 There is no one glycaemic goal that fits all, however, selected patients may benefit from more intensive glycaemic control than is generally recommended.1 Consider a more stringent HbA1c target (42 to 48 mmol/mol or 6% to 6.5%) in patients with a recent diagnosis, low risk of hypoglycaemia, long life expectancy, a good self-care capacity and no significant cardiovascular disease, if it can be easily and safely achieved without adverse effects.1, 8, 9 A less intensive HbA1c target of 58 to 64 mmol/mol (7.5% to 8%) may be appropriate in patients with recurrent or severe hypoglycaemia, extensive co-morbidities, limited support systems and poor self-care capacity or a limited life expectancy. Always individualise HbA1c targets as stringent glycaemic goals may increase the risk of hypoglycaemia and mortality, especially in older people.1, 8, 9

Perform a baseline HbA1c level at the time of diabetes diagnosis and every three months in patients who are not achieving HbA1c goals or whose diabetes treatment has altered. Otherwise review HbA1c levels six monthly.2 Note; some chronic medical conditions including anaemia or abnormalities of red blood cell structure may affect HbA1c results.10

Using the HbA1c test to diagnose diabetes

An early diagnosis of type 2 diabetes in asymptomatic high-risk patients can now be made based on a raised HbA1c test alone with the introduction of a new MBS item (66841). The new MBS item is restricted to one per patient per year. A result of equal to or greater than 48 mmol/mol (6.5%) is accepted as a diagnosis for diabetes. A follow-up test before beginning treatment to confirm diagnosis is recommended in most cases.10, 11

Address self-monitoring of blood glucose levels

Routine self-monitoring of blood glucose levels in low-risk patients taking oral glycaemic-lowering medicines (except for those taking sulphonylureas) is not recommended.1 There are limited clinical benefits and no improvement in quality of life for patients with type 2 diabetes not using insulin and self-monitoring their blood glucose levels.12, 13

Self-monitoring of blood glucose levels is recommended in patients:

  • using insulin or taking an oral hypoglycaemic medicine that can cause hypoglycaemia, for example sulphonylureas
  • with hyperglycaemia arising from illness or changes in treatment or lifestyle
  • when HbA1c values are unreliable, for example in patients with abnormalities of red blood cell structure.1, 10

Preprandial blood glucose levels of 6 to 8 mmol/L and postprandial blood glucose levels of 8 to 10 mmol/L are recommended as a general guide.1

Address immunisation

Review immunisation status and consider vaccinating your patient against influenza annually, pneumococcal disease and tetanus.1

Address nephropathy/microalbuminuria

Microalbuminuria is a marker of early renal damage, an independent predictor of end-stage renal disease and a strong predictor of cardiovascular disease.1

Screen all patients for microalbuminuria and calculate glomerular filtration rate (eGFR) at the time of diabetes diagnosis and at least twelve monthly thereafter. The automatic calculation of eGFR is now implemented on measurement of serum creatinine. Monitor three to six monthly if microalbuminuria is confirmed.1

Address eye complications

Eye complications associated with diabetes include refractive errors, glaucoma, cataracts, retinopathy and maculopathy which can lead to major vision impairment and blindness.1, 14

Refer to an optometrist or ophthalmologist for a comprehensive eye examination at the time of diagnosis and at least two yearly intervals or more frequently if problems exist.1

Educate your patients about the importance of daily foot care and appropriate footwear. Refer your patients at the time of diagnosis to a podiatrist to assess potential abnormal foot architecture, peripheral neuropathy, vascular disease or deformity due to poor hygiene and foot-care or inappropriate footwear as part of a foot protection plan. This can be followed by three to six monthly reviews with yourself or a practice nurse. Consider referral for a detailed assessment with a podiatrist every twelve months or earlier if required.1 Refer to the Insert for DVA funded services.

Review medicines

Consider a review of your patient’s medicines at least twelve monthly.1

Patients with diabetes may receive an in-pharmacy review of medicines with a focus on diabetes medicines management. For more information on the Diabetes MedsCheck services refer to

Home Medicines Reviews undertaken by pharmacists can enhance patient compliance and understanding of their medicines. See Module 29: Home Medicines Review - The benefits for you and your patient.

Monitor emotional wellbeing

Living with diabetes may have a profound effect on the emotional and psychological wellbeing of your patient. Studies indicate up to 13% of patients with diabetes are diagnosed with depression and one in five report experiencing depressive or anxiety-related symptoms.15 Monitor your patient’s emotional wellbeing during routine visits.16 Patients experiencing difficulty accepting the diagnosis of diabetes or who experience emotional or psychological distress may benefit from the support of a psychologist, social worker or counsellor.1 Refer to the Insert for DVA funded services.

Promote lifestyle interventions

Adopting a healthy lifestyle is the essential component of diabetes management.

A healthy diet and a moderate amount of physical activity may result in near normal glycaemic control, blood pressure and lipid profiles.1

The Royal Australian College of General Practitioners’ SNAP (Smoking, Nutrition, Alcohol and Physical Activity) guide 2nd edition, provides recommendations for implementing healthy lifestyle choices.17


Check smoking status, advise your patient of the risks of smoking and encourage cessation frequently. Referring your patients to the QUIT help line or website may be useful.17

Nutrition and Alcohol

Review and reinforce information about appropriate dietary choices frequently. Consider recommending the National Health and Medical Research Council’s ‘Healthy Eating for Adults’ or the Mediterranean diet for your patients.1 Refer your patient to a dietician initially for comprehensive education, and thereafter as necessary.1 Refer to the Insert for DVA funded services. Advise your patients to restrict their alcohol intake to no more than two standard drinks (20 g) per day.17

Physical activity

Lifestyle modifications, including a nutritious diet together with at least 150 minutes of moderate physical activity per week can help to improve glycaemic control in the majority of patients with recently diagnosed diabetes.1 Some of your patients may struggle to exercise for the recommended time each week or to lose weight, but significant improvements in outcomes can still be seen even with less than the recommended amount of physical activity. Encourage your patients to be physically active every day and review at three to six monthly intervals.17 Referral to an exercise physiologist may be beneficial for your patient.1 Refer to the Insert for DVA funded services.

Further information:

INSERT: How DVA supports a comprehensive cycle of care for veterans with diabetes

The Department of Veterans’ Affairs supports high quality care for veterans with diabetes and recognises the key role allied health professionals play in providing treatment. The information below summarises the treatment services available to entitled members of the veteran community which allied health professionals are eligible to claim through DVA. A Team Care Arrangement (TCA) can be organised but is not a requirement to access these services. If you are unsure of a person’s eligibility for treatment, DVA can be contacted on 1800 550 457.

In most cases the provider of the service determines the type, number and frequency of the treatments for services. Some services have treatment thresholds and prior financial authorisation requirements (details for the respective health care provider are available via the links included in the table below).

A referral is generally required and is valid for 12 months, unless the referring provider has indicated on the referral that treatment is necessary for a chronic condition and that the referral is open-ended and ongoing. It is important to check that the service provider you refer an entitled person to accepts DVA arrangements.

General information about DVA supported services and an explanation of the procedures to be followed when providing health care services to entitled persons can be accessed at:

The Department of Veterans’ Affairs also provides funded services and consumables to support wound management for eligible veterans with diabetes, along with aids and appliances designed to help veterans with diabetes maintain functional independence in their homes.

What to discuss with your veteran patient with recently diagnosed diabetes

  • Encourage your patients to become active members in their health care team and to be familiar with the information, support and resources available for self-management. Engaged patients achieve better health outcomes.1, 5
  • Highlight diabetes as a chronic disease which can damage blood vessels and cause problems with the heart, kidneys, feet and eyes. Achieving early control in the cycle of care by establishing good management patterns can help prevent problems associated with elevated HbA1c levels, hypertension and dyslipidaemia.
  • Develop a comprehensive care plan with your patient that is based on their needs, values and choices.
  • Ensure your patient understands the need for a range of regular tests and examinations, including foot care. Advise your patient to make an appointment for review if they notice any foot problems.
  • Encourage healthy lifestyle choices which can assist your patient’s wellbeing. Quitting smoking is the most important action to prevent cardiovascular disease.17 Eating a balanced and nutritious diet, limiting alcohol intake, maintaining a healthy body weight, having an adequate non-alcoholic fluid intake and engaging in regular moderate physical activity can make a significant difference to achieving good health outcomes.
  • Explain that for those living with a chronic illness such as diabetes, depression or anxiety may be a problem. But like other diseases, they can be treated. Encourage your patients to talk with you, their family, friends and health care team if they are feeling isolated or depressed.1 Treatment can help to lift their depression or anxiety, which in turn can improve the management of their diabetes.
  • Explain to your low-risk diabetic patients not using insulin that routine self-monitoring of blood glucose levels is generally not needed.

DVA funded services to support diabetes management include:

Diabetes Educator

Diabetes educators can enhance knowledge about diabetes and self-management of the condition.

A claim for diabetes education services cannot be provided to veterans receiving community nursing services from a DVA-contracted community nursing provider.

Further information

For health professionals and veterans:

Referral required: Yes


Dietetic and nutritional services can help veterans with diabetes to manage their health through dietary and nutritional support.

Further information

For health professionals and veterans:

Referral required: Yes


Podiatry services assess potential abnormal foot architecture and review peripheral neuropathy, vascular disease or deformity.

Further information

For health professionals and veterans:

Referral required: Yes

Optometry services

Optometrists can check for eye complications associated with diabetes including refractive errors, glaucoma, cataracts, retinopathy and maculopathy.

One initial consultation and one subsequent optometric consultation can be claimed in a two-year period, unless the entitled person has a significant change in visual function or develops a new condition.

Further information

For health professionals and veterans:

Referral required: No

Exercise Physiologist

Exercise physiologists are university trained with knowledge and skills to design and deliver clinical exercise to manage chronic diseases such as diabetes.

DVA does not provide exercise physiology services for generalised and ongoing exercise regimes or gym programs.

Further information

For health professionals and veterans:

Referral required: Yes

Psychologist and Mental Health Social Worker

Psychologists and mental health social workers help prevent, assess, diagnose and treat a wide range of emotional problems that interfere with the normal functioning of daily life. Psychologists provide a range of psychological therapies and strategies including cognitive-behavioural therapy which helps to change negative patterns of thinking and behaviour.

Further information

For health professionals and veterans:

Referral required: Yes


This information can also be accessed on the DVA websites indicated above. The full list of DVA funded health services is available on the DVA website at


  1. Diabetes Australia and The Royal Australian College of General Practitioners. General practice management of type 2 diabetes - 2014/15. Melbourne. 2014. Available at: [Accessed 16 June 2015].
  2. American Diabetes Association. Standards of medical care in diabetes - 2015. Diabetes care: The Journal of Clinical and Applied Research and Education. 2015; 38(suppl 1): S1-S93.
  3. Gæde P et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. The New England Journal of Medicine. 2003; 348(5): 383-393.
  4. Chen L et al. Effect of lifestyle intervention in patients with type 2 diabetes: a meta-analysis. Metabolism Clinical and Experimental. 2015; 64: 338-347.
  5. Roehr B. Potential benefits of "well engaged patients" are akin to those from a blockbuster drug, say experts. BMJ. 2013; 346: 1886.
  6. DVA Health Claims Database, University of South Australia. QUMPRC. [Accessed June 2015].
  7. Stratton I et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000; 321:405-412.
  8. Inzucchi S et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach. Diabetes Care. 2015; 38: 140-149.
  9. Cheung N et al. Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus. MJA. 2009; 191(6): 339-344.
  10. d'Emden M et al. Guidance concerning the use of glycated haemoglobin (HbA1c) for the diagnosis of diabetes mellitus. MJA. 2015; 203(2): 89-91.
  11. d'Emden M et al. The role of HbA1c in the diagnosis of diabetes mellitus in Australia. MJA. 2012; 197(4): 1-3.
  12. Malanda U et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin (review). The Cochrane Collaboration. 2012, Issue 1. Available at: [Accessed 16 June 2015].
  13. Farmer A et al. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ. 2012; 344:e486 doi: 10.1136/bmj.e486
  14. Zhou M et al. Diabetes mellitus as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. PLOS ONE 2014; 9(8): e102972.
  15. Speight J et al. on behalf of the Diabetes MILES - Australian Reference Group. 2011. Diabetes MILES - Australia - 2011 Survey Report. Diabetes Australia - Victoria, Melbourne.
  16. Speight J. Managing diabetes and preventing complications: What makes the difference? MJA. 2013; 198(1): 16-17.
  17. The Royal Australian College of General Practitioners. Smoking, Nutrition, Alcohol, Physical Activity (SNAP): A population health guide to behavioural risk factors in general practice, 2nd edn. 2015. Melbourne.

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