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My passport to health

NamePlease do not share, distribute or copy any part of this book for any purpose other than for use by the person named above

My passport to healthfor Queensland Diabetes and Endocrine Centre (QDEC) patients

Parts of the material in My Passport to Health have been reproduced and adapted with permission from New South Wales Health from its publication My Health Record (revised and reprinted in June 2005 and reprinted in 2006).

Mater Health Services also recognises and acknowledges Queensland Health’s Managing Well…Staying Well booklet, a key resource that informed the development of the My Passport to Health wallet.

Copyright protects this material, except as permitted by the Copyright Act, reproduction by any means (photocopying, electronic, mechanical, recording or otherwise) making available online, electronic transmission or other publication of this material is prohibited without permission of Mater Misericordiae Health Services.

© 2012 Mater Misericordiae Health Services Brisbane Limited

ACN 096 708 922

For information about the resource, please contact

Queensland Diabetes and Endocrine Centre Phone: 07 3163 2500 Fax: 07 3163 1543

Enquiries should be addressed by email to:

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Key

When you see this symbol YOU fill in this section

When you see this symbol your HEALTH PROFESSIONAL fills in this section

About you

Personal details........................................................ 3Emergency contacts ................................................ 6

About your diabetes care

The Queensland Diabetes and Endocrine Centre ..... 9Diabetes care information ..................................... 10The diabetes specialist team .................................. 11Contact with your GP ............................................ 12Ongoing management of your diabetes................ 12Commencement of care agreement – Diabetes .... 13

Your appointments

Agenda setting ..................................................... 17Problems and concerns ......................................... 20Health issues/diagnosis ......................................... 24

Recording your health status

Diabetes appointment data sheet ......................... 27General appointment data sheet ........................... 29

Your annual care plan

Your Annual Cycle of Care .................................... 31Annual Diabetes Health Screening ........................ 32

Medications

Allergies /side effects /medical alerts ...................... 37Medications........................................................... 39Immunisation and vaccination ............................... 43

Diet and exercise goals

Diet and exercise goals .......................................... 45

Appointments

Appointments ....................................................... 49

Valuable information

Guardianship ......................................................... 55Interpreter services ................................................ 56Websites ............................................................... 57Government initiatives .......................................... 58

Transitioning care

Transfer of care to GP – Diabetes .......................... 59

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Patient GPs and other health professionals l Fill in your sections of My Passport to Health

and if you are able, any other sections.

l Keep test results, care plans and other information in the plastic sleeves.

l Keep My Passport to Health in your bag and take to all visits to health professionals.

l Tell your GP and other health professionals that you are using My Passport to Health to help organise your care.

l Keep writing in My Passport to Health as your treatment progresses and show your health professional any relevant information contained in it.

l Ask your GP and other health professionals for copies of test results, latest medication lists, care plans, and disease specific action plans to place in the My Passport to Health wallet.

l Look for the health professional icon in My Passport to Health and assist the patient to fill in if required.

l Encourage the patient to use the goal and action plan brochure located in the front of My Passport to Health.

l Provide the patient with print-outs of relevant reports, copies of test results, latest medication lists, care plans/disease specific action plans, and hospital discharge plans.

l Encourage patients to store all their information in the My Passport to Health. Keep it up-to-date, and bring their wallet to appointments.

l Check the wallet regularly for information contributed by other health professionals.

l Provide the patient with replacement pages from the Mater Health Services webpage: www.mater.org.au/Home/Services/Queensland-Diabetes-and-Endocrine-Centre/About-the-Queensland-Diabetes-and-Endocrine-Centre

How to use this wallet

Run out of pages? l If you are able, download extra pages by accessing the My Passport to Health webpage on the Mater Health Services QDEC

website: www.mater.org.au/Home/Services/Queensland-Diabetes-and-Endocrine-Centre/About-the-Queensland-Diabetes-and-Endocrine-Centre

If you are unable to download extra pages, contact your healthcare provider:_____________________________________________

About you• Personal details

• Emergency contacts

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Family name:

First name (s): Preferred name (s):

Sex: ¡ Male ¡ Female Date of birth:

Home address:

Postcode:

Mailing address (if different from home address):

Postcode:

Phone: Home Work Mobile

Email: Medicare number:

Personal detailsYour healthcare providers can help you complete the details, if necessary.Complete your details when you are first given this wallet.Remember, if your details change, ask your healthcare provider for a new ‘personal details’ page or download another page from the Mater Health Services QDEC website and print on A5 paper.

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Ethnicity: ¡ Aboriginal ¡ Torres Strait Islander ¡ Both Aboriginal and Torres Strait Islander

Other:

Language spoken at home: Do you need an official interpreter? ¡ Yes ¡ No

If no, nominate a contact person who speaks English:


This wallet is looked after by ¡ me ¡ some other person (e.g. principal carer)

If ‘some other person’ looks after your health record, provide details below:

Other person’s name: Relationship:

Contact address (if different from yours):

Postcode:


Personal details (continued)

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Are there any other people you usually care for (e.g. parents or children)?

¡ Yes ¡ No If Yes, provide details below.

Do they live with you? ¡ Yes ¡ No ¡ Sometimes

Name 1: Relationship:




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Emergency contacts

* See guardianship and advance health directive information at the back of the booklet.

Does anyone else have formal authority to make decisions about your health? (e.g. guardianship)*

¡ Yes ¡ No If Yes, provide details below:

Name: Relationship:

Address:


Email:

Enter details of your emergency contacts when you are first given this book.Your doctor or other healthcare providers can help you complete the details if necessary.Remember to ask for a new ‘emergency contacts’ page if your details change (e.g. you commence an advance health directive) or download this page from the Mater Health Services QDEC website and print on A5 paper.





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Have you made an Advance Health Directive?* ¡ Yes ¡ No

If Yes, provide details of where your Advance Health Directive is located (e.g. location at home, name of GP or person holding the Directive on your behalf):

Have you appointed an Enduring Power of Attorney (EPA) for personal/health matters? ¡ Yes ¡ No

If Yes, provide details of the person who is your Enduring Power of Attorney:

Name: Relationship:

Address:


Email:

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Emergency contacts (continued)

Please list each hospital you attend and your hospital record number, if known:

Hospital name: Medical record number (or UR number):

Hospital name: Medical record number (or UR number):

Hospital name: Medical record number (or UR number)

Are you on a pension? ¡ Yes ¡ No

Do you have a Department or Veterans’ Affairs number? ¡ Yes ¡ No

If yes, please supply the number:

Are you privately insured? ¡ Yes ¡ No

If yes, name of Insurer: Policy number:

About your diabetes care• The Queensland Diabetes

and Endocrine Centre

• Diabetes care information

• The diabetes specialist team

• Contact with your GP

• Ongoing management of your diabetes

• Commencement of care agreement

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Where are we located?We are located on the Mater Health Services campus at South Brisbane.

What is the best way to contact us to get directions?Our central phone number is: 07 3163 2500

The Queensland Diabetes and Endocrine CentreThe Queensland Diabetes and Endocrine Centre (QDEC) offers comprehensive care tailored to individual needs and is committed to providing diabetes and endocrine care in alignment with the Mater’s core values of Mercy, Dignity, Care, Commitment and Quality.

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Diabetes care information

Goals after the first few weeks include:

l Having your blood glucose level within the target range of: 4–8 mmol/L. This will be adjusted according to age, circumstances and experience.

l Maintenance of a balanced healthy diet as recommended by the dietitian.

A summary of my hospital stay includes:

If diagnosed with type 1 diabetes and admitted to hospital your discharge summary (a summary of your treatment while in hospital) will be faxed to your GP and may include the following latest results:

Admission date Discharge date

Presentation with type 1 diabetes Past medical history

Dehydration estimate (with % after the no.)

Blood glucose level (with mmol/L after the no.)

Insulin (with mIU/L after the no.) C-peptide (with mmol/L after the no.)

HbA1c (with % after the no.) Venous pH (acid/alkaline level taken from venous blood)

Serum bicarbonate (with mmol/L after the no.)

Blood ketone level (with mmol/L after the no.)

TSH (with mU/L after the no.) Creatinine

fT4 (with mmol/L after the no.) IgA (g/L)

IgA anti tTG antibody IA2 (<3)

GAD (<6) Triglyceride (with mmol/L after the no.)

Cholesterol (with mmol/L after the no.)

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The diabetes specialist teamTo support your care in the best possible manner, you will be assisted with your diabetes management by:

Endocrinologists – The endocrinologist is the specialist doctor who will look at your diabetes management regularly and will consult with your GP for stabilisation and adjustment if necessary. In conjunction with your GP, they will discuss and manage any health concerns that you might have.

Diabetes nurse educators – The registered nurse diabetes educator will cover issues related to:

l The beginning of your diagnosis: what is diabetes, insulin therapy, injection technique, blood glucose monitoring, hypoglycaemia and sick day management.

l Creating an ongoing tailored plan that is designed to meet your need for stable and effective diabetes management in the long-term.

Dietitians – The dietitian will cover:

l Initial education sessions: food, the body and diabetes, usual eating patterns, healthy eating guidelines for adults, recognising carbohydrates, and understanding your digestion and function.

l Ongoing education: relationship between food and diabetes, meal planning including factors affecting selection and preparation, management for life activities, and self-management.

Psychologist – The psychologist is available to discuss issues related to: grief and guilt, marital stress, adjusting to having diabetes and its treatment, and behavioural management.

My diabetes/endocrine specialist

My diabetes educator

My dietitian

My psychologist (if applicable)

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If you are diagnosed in hospital, QDEC will send a letter to your GP after you go home to update your GP and make plans for long-term follow-up. You will be asked to sign a form to consent for this to happen.

Maintain regular contact with your GP and specialist.

Your GP is still your primary care provider for your diabetes. When planning your appointments with the GP book the time in advance and confirm the appointment at least 24-hours beforehand. Use your Appointment TAB to keep track.

When planning your appointment with the specialist, always confirm appointments early and write the confirmed date into your Appointment TAB.

Your appointment schedule is maintained to meet your clinical needs by providing:

l Specialist appointments to look after complications and ongoing specialist care.

l A team care, or shared care arrangement with your GP and specialist team.

Contact with your GP about your care

Ongoing management of your diabetes

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Outline of careAt the Queensland Diabetes and Endocrine Centre (QDEC), a multi-disciplinary team of health professionals will work to provide you with short term/intermediate/complex care to help you manage your diabetes.

This means we expect you will need to visit our specialist clinics over a period of __________ months for __________ visits. Over this time, we will work with your GP for ongoing management of your diabetes. If, and when appropriate, we will discharge you back to your GP for ongoing care.

Treatment goalsAs your diabetes and endocrinology specialist team, we will work with you and your GP to assist you in achieving healthy goals in your diabetes management.

Goals Targets

1. HbA1c

2. Blood pressure

3. Cholesterol

Commencement of care agreement – Diabetes

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The role of your GPYour GP will continue as your primary care provider. It is important you:

l Visit your GP for any other health concerns, including referrals to other specialists and scripts for medications.

l Visit your GP every three months for general monitoring of your diabetes.

Your GP can develop and maintain your GP management plan or team care arrangement, so please ask for a copy of this if you don’t already have one.

Responsibilities and expectationsPlease read the outline of our mutual responsibilities and expectations on the other side of this sheet. This is important information on what we will do and what we need you to do in order to make the most of your specialist care at QDEC. If you have any questions or concerns, please ask a member of the QDEC specialist team.

We look forward to partnering with you to improve your health.

Queensland Diabetes and Endocrine Centre Specialist Team

Patient name: Specialist name:

Signature: Signature:

Date: Date:

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What we will do… What you need to do…Before appointments

l Send you a letter with your appointment details at least one week prior to your appointment.

l Reschedule your appointment if you phone us with at least 24 hours notice – this enables us to offer the appointment time to another patient who is waiting.

l If an urgent matter arises on the day of your appointment, we will discuss as a team how we can reschedule your appointment.

l Call us as early as possible if you cannot make an appointment.

l Write down any questions or concerns you may have to bring to your appointment.

l Bring your My Passport to Health wallet with your blood glucose readings and meter readings to every appointment.

l Provide us with notice if you are unable to attend an appointment or you would like to reschedule your appointment. The phone number for QDEC is 07 3163 2500. Please note: If you do not attend an appointment and you do not phone us in advance to tell us why, we will need to discharge you back to your GP.

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What we will do… What you need to do…At appointments

l Treat you with respect and listen to your needs.

l Answer your questions and provide answers that are clear and relevant to you.

l Share your test results with you and explain what they mean.

l Monitor your HbA1c – this is a blood test to assess your blood glucose (sugar) control.

l Once a year we will:

– take a blood test to check your lipids (blood fats),

– take a urine test to check for early signs of kidney problems,

– check your feet for signs of poor circulation, ulcers, infections and abnormalities,

– make sure that you have had an eye check for any changes to your retina (the back of your eye).

l Please check in at the reception desk when you arrive for your appointment.

l Please advise the clinic coordinator on arrival if you require a certificate for your driver’s licence at this appointment.

l Tell the specialist if you need a medical certificate (to explain work or school absence) for the appointment.

l Have a list of your current medications with you.

l Treat all of our staff and other patients with respect.

l Ask us to explain anything that you don’t understand.

Between appointments l Inform your GP of any changes in your diabetes

management, including medications.

l Ask you to provide another referral from your GP if you fail to attend the clinic and do not provide a valid reason.

l Take your medications as recommended.

l Follow diet and exercise guidelines.

l Visit your GP if you have any health concerns.

l Write down your blood glucose levels in the booklet provided and look at patterns twice a week.

l Complete your My Passport to Health wallet. Please take the time to enter in the names and contact details of any health professionals who support you in your diabetes management.

Your appointments• Agenda setting

• Problems and concerns

• Health issues /diagnosis

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Agenda settingFor every appointment refer to the list below and tick the diabetes education topics you would like to discuss with your health professional during your specialist appointment: (Please tick)

TopicDate Date Date

TopicDate Date Date

What is diabetes? Exercise

Diabetes and food/counting carbs Alcohol

Diabetes and kidney disease Weight management

Insulin treatment Smoking

Insulin devices/techniques/sites Driving and insurance

Insulin storage/needle disposal Foot care

Oral diabetes medication Annual review

Self-adjustment of medication Complications/illness

Blood/urine testing Employment

Hypoglycaemia/sick day mgt. Pregnancy

Glucagon Sexual health

HbA1c and diabetes controlTravel (6–8 weeks prior to trip if on a pump)

Any other diabetes related topic important to you:Ask about the Dose Adjustment for Normal Eating (DAFNE) Program?

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TopicDate Date Date

TopicDate Date Date














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TopicDate Date Date

TopicDate Date Date














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Problems and concerns Date Time Team/health professional actions and results

Problems and concerns

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No. Health issues/diagnosis Date diagnosed

Date ended Comments

Health issues/diagnosis

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No. Health issues/diagnosis Date diagnosed

Date ended Comments

Health issues/diagnosis

Recording your health status• Diabetes appointment data sheet

• General appointment data sheet

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Diabetes appointment data sheet

GP & Specialist appointment health data sheet (fill in during each appointment)

Date BP Weight HbA1c Treatment regimen Comments

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Date BP Weight HbA1c Treatment regimen Comments

Diabetes appointment data sheet

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General appointment data sheet


Date BP Weight Key blood result Medication/treatment regimen Comments

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Date BP Weight Key blood result Medication/treatment regimen Comments

General appointment data sheet

Your annual care plan• Your Annual Cycle of Care

• Annual Diabetes Health Screening

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In addition to regular health checks, a yearly check-up is an essential part of your ongoing diabetes management. Annual check-ups can identify potential complications and reduce the risk of both short-term and long-term diabetes problems.

An annual health check-up is a broad health assessment to show possible changes in the eyes, kidneys, feet, blood pressure and blood fats so that any complications from diabetes can be detected and managed early.

Who will do it?This can be done by a range of health professionals. For some patients, it will be completed at QDEC. For others it will be performed by the GP and for particular patients, a number of health professionals will collaborate (e.g. podiatrist, optometrist, specialist, GP etc.)

What does it involve?A general physical examination: height, weight and blood pressure.

Nerve tests: A painless examination that shows the response to vibrations in the feet and sometimes temperature.

Eye tests: Testing vision and photographing the retina (back of the eye). Drops are placed in your eyes to enlarge your pupils. Please bring sunglasses to protect your eyes until the effect of the drops have worn off (up to two to four hours) and consider organising someone to pick you up as you will not be able to drive or operate heavy machinery until after the effects have resolved.

Kidney function: Measuring the amount of albumin in the urine and a blood test to check kidney function.

Blood test: Blood sample is taken for cholesterol, thyroid function, B12 and coeliac disease.

How will we find out the results?If completed at QDEC, a full report will be sent to your GP within approximately six weeks of your appointment.

Appointment timeYou should allow at least two hours for your appointment at QDEC.

Your Annual Cycle of Care

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Annual Diabetes Health Screening (can be completed by a range of health professionals)

Date of annual diabetes health check-up ................................. /............................. / ...........................

Eyes

Retinal examination (R) (L) Visual acuity (R) (L)

Feet

Sensation (R) (L) Pulses (R) (L)

Reflexes (R) (L) Skin/foot care (R) (L)

Blood pressure lying down / Blood pressure standing /

Kidneys albumin excretion tests

First morning urine sample collected for albumin/creatinine ratio on three consecutive mornings.

Date 1. 2. 3.

Time 1. 2. 3.

Blood tests

HbA1c T4 TSH B12 Cholesterol HDL

Cholesterol LDL

Triglycerides Creatinine/ eGFR

IgA anti tTG antibodies

Other:

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Eyes


Feet






Date 1. 2. 3.

Time 1. 2. 3.

Blood tests


Cholesterol LDL



Other:

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Eyes


Feet






Date 1. 2. 3.

Time 1. 2. 3.

Blood tests


Cholesterol LDL



Other:

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Eyes


Feet






Date 1. 2. 3.

Time 1. 2. 3.

Blood tests


Cholesterol LDL



Other:

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Eyes


Feet





(first morning urine sample collected for albumin/creatinine ratio on three consecutive mornings).

Date 1. 2. 3.

Time 1. 2. 3.

Blood tests


Cholesterol LDL



Other:

Medications• Allergies /side effects /medical alerts

• Medications

• Immunisation and vaccination

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Allergies/side effects/medical alerts

Date Type Reaction Severity (mild, moderate, severe)

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Allergies/side effects/medical alerts

Date Type Reaction Severity (mild, moderate, severe)

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Medications (include any over-the-counter medicines you take)

Date Name of medication

Strength on label

What is it for?

How much do I use and when Date to stop or reviewMorning Lunch Dinner Bedtime

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Strength on label

What is it for?


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Strength on label

What is it for?



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Strength on label

What is it for?



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Immunisation and vaccination

Immunisation/Vaccination

Batch number

Sign and date

given

Date next due

Batch number

Sign and date

given

Date next due

Comments

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Immunisation and vaccination

Immunisation/Vaccination

Batch number

Sign and date

given

Date next due

Batch number

Sign and date

given

Date next due

Comments


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Date Current and planned diet and exercise regimen

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Appointments

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Appointment information

What you need to do…Before you come to an appointment

l Call QDEC as early as possible if you cannot make an appointment.

l Write down any questions, problems, issues or concerns you may have in your My Passport to Health wallet and bring to your appointment.

l Bring your My Passport to Health wallet with your blood glucose readings, meter readings, and care documents to every appointment.

l Give us notice ahead of time if you cannot attend an appointment or you would like to reschedule your appointment. The phone number for QDEC is 07 3163 2500. Please note: If you do not come to an appointment and you do not phone us in advance to tell us why, we will need to discharge you back to your GP.

During your appointment l Please check in at the reception desk when you arrive

for your appointment.

l Please advise us on arrival if you require a certificate for your driver’s licence at this appointment.

l Tell the doctor if you need a medical certificate (to explain work or school absence) for the appointment.

l Have a list of your current medications with you.

l Treat all of our staff and other patients with respect.

l Ask us to explain anything that you don’t understand.

After you come to an appointment l Take your medications as recommended.

l Follow diet and exercise guidelines.

l Visit your GP if you have any health concerns.

l Write down your blood glucose levels (BGLs) in the booklet provided and look at patterns twice a week.

l Complete your My Passport to Health wallet. Please take the time to enter in the names and contact details of any health professionals who support you in your diabetes management.

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Date Time Appointment with (e.g. specialist, GP, nurse practitioner, dietitian, psychologist, podiatrist, diabetes nurse educator)

Reason for appointment and treatment to be provided

Appointment information

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Next appointment

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Next appointment

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Next appointment

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Next appointment

Valuable information• Guardianship

• Interpreter services

• Websites

• Government initiatives

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Valuable information – Guardianship

Contact details for all guardianship issues

Phone: +61 7 3234 0870 or 1300 653 187 (local call outside Brisbane)

Fax: +61 7 3239 6367

Email: [email protected]

Webpage: www.justice.qld.gov.au/justice-services/ guardianship

The Adult Guardian

The Adult Guardian protects the rights and interests of adults with impaired capacity and investigates claims of exploitation, abuse or neglect.

Healthcare decisions Community Visitor Program

Go to the guardianship webpage (see above) to find out how to make your treatment wishes known when you are unable to communicate. The information will also assist you if you have to make decisions about someone else’s healthcare.

The Community Visitor Program protects the rights and interests of adults with impaired decision-making capacity who reside in supported accommodation facilities and mental health acute care units across Queensland.

Advance Health Directive Power of Attorney l This is a formal way of giving instructions for your

future healthcare, including when to stop medical treatment in the event of a terminal illness, or conditions for resuscitation after an accident. It comes into effect only if you are unable to make your own decisions.

l You can make an Advance Health Directive whenever you like.

l You can change or revoke an Advance Health Directive whenever you like.

l A General Power of Attorney is a legal document which enables you (if you are an adult and are capable of making your own decisions) to give someone else the power to make personal or financial decisions on your behalf for a defined period.

l An Enduring Power of Attorney allows you to appoint someone to make personal and/or financial decisions on your behalf when you are unable to make your own decisions.

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Interpreter servicesIf you want an accredited interpreter to translate into another language, one can be booked for you prior to your appointment.

An accredited interpreter may be needed:

l When you get to the clinic to discuss issues with reception.

l When talking to the doctor about your illness history, your needs and any concerns you may have about your treatment.

l To get consent from you to a treatment.

l To talk about your medication.

l To tell you about rights and responsibilities.

l When you are being assessed by a health professional.

l If you or your family or guardian request it.

l During your appointment when the doctor is explaining your treatments or care plans.

If the interpreter is only available via the telephone, a two or three way conversation can be set up between you, your health professional and the interpreter.

Family members, friends, bilingual staff and people without accreditation may be able to help with simple communication of messages, however to avoid any misunderstanding it is best you use an accredited interpreter when discussing your health in detail.

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Websites

For your diabetesGeneral diabetes websites Pump supplier brochures and websites

l National Diabetes Services Scheme – www.ndss.com.au (for information and resources in different languages)

l Australian Diabetes Educators Association lists Pump Centres of Excellence – www.adea.com.au

l Diabetes Australia – www.diabetesaustralia.com.au

l Diabetes Australia Queensland member website – www.daq.org.au

l Diabetes Health – www.DiabetesHealth.com

l DiabetesNet – www.diabetesnet.com

l Animas – Australasian Medical & Scientific www.animascorp.com

l Dana11S – Diabetes Australia NSW www.diabetesnsw.org.au

l Medtronic – www.medtronic-diabetes.com.au

l Roche Accuchek Spirit – www.accu-chek.com.au

l Insulin Pump Information Booklet 2007 – DA Vic [email protected]

Diabetes in pregnancy

l Australasian Diabetes in Pregnancy Society – www.adips.org

l Gestational Pregnancy resources – www.ndss.com.au

l You2 Program – www.you2.org.au

For a healthier lifestyle and dietKeeping active Diet

l www.diabetesaustralia.com.au/Living-with-Diabetes/Keeping-Active/

l www.diabetesvic.org.au/type-2-diabetes/physical-activity

l www.diabetesvic.org.au/type-1-diabetes/oz-dafne

l www.healthdirect.gov.au/#!/partners/australian-diabetes-council

For your emotional healthGeneral resources for young people Specifically related to diabetes General resources for adults

l www.headspace.org.au l au.reachout.com

l behavioraldiabetesinstitute.org l realitycheck.org.au

l www.beyondblue.org.au

Information current as at August 2014

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Government initiativesGeneral diabetes

l National Diabetes Services Scheme (NDSS). The NDSS assists people with diabetes to self-manage their condition and ensures access for individuals no matter where they reside in Australia. www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs-healthpro-supply-ndss.htm-copy2

l Type 1 Diabetes Insulin Pump Program provides a means-tested subsidy to assist young people under the age of 18 years (who have type 1 diabetes) with the cost of purchasing an insulin pump. www.health.gov.au/internet/hta/publishing.nsf/Content/other-1 – Type 1 Diabetes

l The Australian Type 2 Diabetes Risk Assessment Tool is a tool which consists of a short list of questions that, when completed, provides a guide to your current level of risk of developing type 2 diabetes over the next five years. www.health.gov.au/internet/main/publishing.nsf/Content/diabetesRiskAssessmentTool

General Health l Shape Up Australia is an initiative to help Australians

reduce their waist measurements and improve their overall health and wellbeing. There are many everyday changes you can make to help you Shape Up and get on your way to a healthier lifestyle. shapeup.gov.au

Multidisciplinary care planning l Management of a chronic condition with complex care

needs that requires a structured approach to care by a multidisciplinary team including your GP and at least two other healthcare providers may mean you are eligible to have a GP Management Plan (GPMP) or Team Care Arrangements (TCA) to assist in the effective coordination of your care.

l A GPMP involves your GP assessing you, developing with you a number of management goals and identifying actions that you will need to take to meet these goals including treatment and ongoing services. The GP will document these with you and include a review date.

l Review of a GPMP – you will be asked to come back on the review date to check how you are going, plan any further goals and action and set another review date if necessary.

l A TCA involves the GP and other providers involved in your care communicating and discussing progress of treatments and services in place for you and documenting any changes to your TCA.

l If you have a multidisciplinary care plan prepared by a health professional other than your GP, you can have your GP contribute to this.

l You may also receive monitoring and support services from your GPs practice nurse under the care planning process to support your ongoing management.

Transitioning care• Transfer of care to GP – Diabetes

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Outline of careYou are ready to return to your GP for ongoing management of your diabetes care. We will provide your GP with information on the care you have received at our clinic, recommendations for ongoing medical management, and also a re-referral process should you need to return to our service.

Visiting your GPPlease make an appointment to visit your GP in three months for a routine diabetes review.

Transfer of care to GP – Diabetes

Managing your diabetes

Medications

Monitor your glucose levels

Physical activity

Diet

Frequency of GP visits

Frequency of allied health visits (per year)

Podiatrist Dietitian

Other Other

Eye review

Target HbA1c

Target blood pressure

6060

Will I need to return to Queensland Diabetes and Endocrine Centre?At this point, your care can be managed by your GP and you will not need to visit our specialist clinics for follow-up appointments. However, if you have any concerns please visit your GP. Your GP can refer you back to our service if needed.

Thank-you for partnering with us in your diabetes care and management. Queensland Diabetes and Endocrine Centre Specialist Team

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