Table 1

Australian Primary Care Collaboratives diabetes change principles

Change principleChange 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