Table 1

Australian Primary Care Collaboratives diabetes change principles

Change principle	Change idea
1. Establish a system for creating, validating and updating a register of people with diabetes	Agree on a clear definition of diabetes and the two subdivisions (type 1 and 2) using existing guidelines Develop a register of people with diabetes Develop systems to maintain valid registers
2. Be systematic and proactive in managing the care of people with diabetes	Establish a multidisciplinary team (micro team) to manage the care delivery of people with diabetes Identify a lead health professional to coordinate the care for people with diabetes Establish practice protocols (or customise existing protocols) for the care of people with diabetes Embed the use of protocols through the use of computerised templates Establish proactive call and recall arrangements for people with diabetes Ensure people with diabetes receive optimal care, including the use of drug therapies Undertake annual cycles of care to claim service incentive payments
3. Involve patients in delivering and developing their care	Maximise self-management by people with diabetes Develop a deliberate strategy for self-management Integrate the patients' perspective in the design of services Ensure written communication is appropriate and understood Pay special attention to the needs of hard-to-reach groups
4. Adopt a multi-skilled, multi-agency approach to ensure effective coordination of the care of people with diabetes	Support joint working between health professionals and managers in practice and local state health services to enable integrated care for patients Analyse the patient journey and redesign if necessary