Staying on Board: The Diabetes Cycle of Care

Diabetes is a long term condition that currently affects more than one million Australians. A diagnosis of diabetes may be quite overwhelming but plenty of support is available. Learn how to manage your condition and take control of your future health. You are the central member of your health care team. Develop a care plan and get on board the ‘Diabetes Cycle of Care’.

Taking control

Learning about and understanding your diabetes will help you monitor and shape your own health care plan. As the central member of your health care team you will play a vital role, and with the help and support of family, friends and health professionals you can learn to be confident in managing your diabetes. Getting good control of your diabetes now can help prevent complications in the future.

So who is on your team?

Along with yourself and your GP, your team may include:

  • practice nurse
  • pharmacist
  • diabetes educator
  • dietitian
  • podiatrist
  • psychologist
  • optometrist or ophthalmologist
  • exercise physiologist
  • endocrinologist
  • dentist
  • community care nurse
  • social worker
  • family & carers
  • other health professionals as recommended by your GP.

Gold and white card holders may be eligible for services provided by health professionals.

Getting into the routine of the Diabetes Cycle of Care

After you are first diagnosed, your doctor will undertake a full health assessment. These initial checks and the advice of your doctor begin the Cycle of Care. It is important that these tests and examinations become part of a regular routine.

Remember these dates are just a guide: follow the advice of your doctor and health team members.


Every 3 months...

Visit your doctor for a review of your diabetes, including:

  • Reviewing your lifestyle including quitting smoking, eating a balanced and nutritious diet, limiting salt and alcohol intake and taking part in regular physical activity. (Remember *SNAP = smoking, nutrition, alcohol, physical activity).
  • Measuring your weight and waist circumference.
  • Having your blood pressure checked.
  • Reviewing your blood test results.
  • Having your feet examined. This may be done by your doctor, practice nurse or podiatrist, to see if diabetes is causing damage to the nerves and blood supply of your feet.
  • Checking your medicines.

Every 6 months...

  • Visit your doctor again to review your diabetes and health. He/she will order a blood test called HbA1c to measure how well your glucose levels are being controlled.

Every 12 months...

  • At 12 months your doctor will repeat a physical assessment and will check if your immunisations are up to date.

He/she will also order:

  • A test to measure your cholesterol level.
    A test to measure protein in the urine to see if diabetes is affecting your kidneys.
    An HbA1c blood test to measure your glucose levels.

At this time, talk to your team about:

  • Reviewing your medicines and using them effectively. Talk to your doctor and pharmacist about having a Diabetes MedsCheck or Home Medicines Review.
  • Managing your health through diet and nutrition. A dietitian can help you to establish a healthy eating plan which, along with regular physical activity, can control your weight and provide good nutrition. A small weight loss can make a big difference and healthy eating can be enjoyed by the whole family.
    Reviewing your exercise program. An exercise physiologist can give you some ideas about physical activity such as walking, swimming, gardening or playing a round of golf.
  • Your doctor may refer you to a podiatrist for an examination of your feet, or to another specialist.

Every 24 months...

  • Your doctor will arrange for a comprehensive eye examination with your optometrist or ophthalmologist. Diabetes can affect your eyes, this test is not just about getting your glasses checked.

Talk to your doctor and your team about the best possible way to manage your diabetes.


Establishing a long-term lifestyle plan

Long-term habits are not easy to change. However, members of your team are there to help you make healthy lifestyle choices that promote good health. Having diabetes may bring some new challenges but it doesn’t stop you continuing to enjoy a full life.

Going for a walk or a swim, joining in local community activities such as volunteering, or just catching up with friends for a chat can keep you active and in touch with your mates. Being active for 20 to 30 minutes each day, doing something you enjoy will make a big difference to improving your health. You may also find it helpful to join a diabetes support group.

Living with a chronic disease like diabetes may increase a person’s risk of depression. But just like other illnesses, it can be treated. Treatment can help lift the depression, which in turn can improve the management of your diabetes. Talk to your doctor about how you are feeling. Remember, you are not alone. Diabetes is manageable and there is a team of people there to support you.

The following link may be valuable to seek more information.

Diabetes Australia:

There are a number of things to remember

A good place to start is to set up regular appointments with your doctor. Plan ahead and make a specific appointment to talk about your diabetes.

Your doctor, practice nurse or diabetes educator will help you plan these appointments, at least every three months.

Make a note in your diary, mobile phone, computer or calendar and tell your family or carer as well.

The ‘Cycle of Care’ diagram in this brochure may help you to remember and plan your appointments.

Remember, as the central member of your health care team, you can take control of and manage your diabetes with confidence by getting on board the Diabetes Cycle of Care.

Engaged and positive patients who are actively involved in their health care achieve better results.

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