Diabetes management in general practice


Practice nurse-led diabetes consultations allow patients with poorly-controlled diabetes to receive enhanced care for their condition at their local medical practice. By attending these consultations, in addition to regular GP visits, patients gain significant additional support to achieve identified diabetes management goals. They also have opportunities for education and discussion about their condition.

This approach aligns with the principles of the Patient Centred Medical Home (PCMH), which aims to provide a comprehensive and integrated service for patients in a primary care setting.


Diabetes is a common cause of illness and premature death in the South Eastern NSW region, and a recognised national health priority. Despite its serious nature, some patients who have been diagnosed with diabetes only present to their GP on an ad-hoc basis, limiting the time and focus available to adequately manage their condition.

Practice nurse-led diabetes consultations offer benefits across all levels including:

  • patients receive enhanced diabetes care, and feel supported and empowered to better manage their condition
  • GPs have access to additional diabetes-related information about their patients, without needing to allocate additional time
  • practices are able to offer more comprehensive care to their patients, increasing client satisfaction.

Lakeside Medical Practice’s nurse-led diabetes program was one of 13 initiatives supported by COORDINARE. It was part of a project designed to build the capacity and capability of our region’s general practices to move towards a PCMH model of care.

With funding from COORDINARE, the practice was able to develop and deliver practice nurse-led diabetes consultations.

During the first half of 2018, the practice nurse completed relevant training, worked with a GP at the practice to develop a structured template for diabetes review, then ran a series of consultations with a target group of patients with high-risk diabetes mellitus type 2. Since completing the funded program, Lakeside Medical Practice has continued to offer nurse-led diabetes consultations as part of its standard diabetes care for high risk patients.


The practice nurse's perspective - Melinda Pavser

“I have thoroughly enjoyed the experience of setting up nurse-led diabetes review appointments with our lead GP. I had always
wondered how a clinic like this would operate – now I am running these diabetes reviews I can see just how well they work.

Patients are loving the additional time taken with them. They’re taking on board with the education I’m giving them and it’s also made them feel accountable. With a lot of participating patients, we’re seeing their HbA1c levels slowly coming down… so we’re going in the right direction. And it’s improving our practice on diabetes care as a whole.”

A GP’s perspective - Dr Katherine Michelmore

“We found that many of our patients weren’t presenting on a regular basis for diabetes care. There was a disconnect between how we as GPs view good diabetes control, and how well our patients were managing their condition.

We decided to develop a nurse-led model of care, where patients could come in for a lengthy consult and talk through every aspect of their diabetes. Patients often feel more comfortable discussing issues with a nurse in a relaxed setting, and this can lead to more reliable information about how they’re doing with their diabetes.

We’ve got some good feedback from patients saying that they felt very positive that an interest was being taken in their chronic illness, and more empowered to make some lifestyle changes. A lot of the problems with diabetes management can be sorted out here in general practice, if we do it right.”

Want to get involved?

At different times COORDINARE offers funding to support initiatives such as this. Practices which do not apply or are not selected for funding can still work with us and explore other opportunities. If we are outside of a funding round, we have resources to support practices on their change journey.

For further details on the steps involved to implement this model of care click here. For more information or support contact your Health Coordination Consultant, or phone 1300 069 002.

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