Diabetes Model of Care

The aim of the Diabetes Models of Care (MoC) project is to create a practical toolkit of examples of various models of care that may assist health practitioners across Australia review and consider revisions of their own current MoC for managing people with type 2 diabetes. 

The target audience of health professionals includes general practitioners, endocrinologists, diabetes educators, health services managers and other multidisciplinary practitioners across the spectrum of health-care.

There is strong evidence supporting lifestyle and medical management programmes to improve outcome measures and quality of life for people with diabetes. Many people with diabetes often have other co-morbidities, including (but not limited to) obesity, cardiovascular disease, renal, eye and foot disease, that manifest into a complex array of treatments highlighting the need for a multidisciplinary and comprehensive diabetes management approach.

The essential ingredient of effective diabetes management in an interdisciplinary system of care is the empowerment of the person with diabetes to become engaged to actively manage their health. When people with diabetes (and often their carers) are more informed, involved, and empowered, they interact more effectively with healthcare providers and strive to take actions that will promote healthier outcomes.

There are many MoC being used within diabetes services across Australia. Many of these models promote the importance of integrated care across health professional disciplines and have been successfully implemented into practice. However, more needs to be done to improve integrated and collaborative care nationally. One such area that needs improving is the collection of outcome measures that could lead to the identification of which primary care attributes support high quality care for people with diabetes. This toolkit focuses on MoC for the management of type 2 diabetes, concentrating on integrated care from primary to specialist care, and includes models that target diabetes complications, screening and management. The models illustrated in this document are not a complete list and have been included as examples only. It is anticipated that any MoC can be adapted to the local population and workplace. This toolkit is designed to be a ‘living document’ and will be added to, edited and revised over time. As such, the document will only be up to date at the time of access or download. Revised versions of this publication will be announced through NADC, ADS and NDSS online resources and available on their respective websites: NADCADS  and NDSS.