|
DIABETES
Diabetes 12-month
Cycle of Care Service Incentive Payments (PIP/SIP)
Establish a register of all known patients attending the practice with a
diagnosis of diabetes. The minimum amount of information should include the
patient’s name, identifier (e.g. practice file number) and contact details. The
register can be either electronic or paper based.
Activate a
patient recall system to ensure that patients return in a timely manner to
complete their annual cycle of care.
Must
Do:
Complete an annual cycle of care for diabetic patients before claiming for a SIP
payment. This means that over 12 months, the patient must receive the minimum
requirements of care. Additional levels of care will be needed by
insulin-dependent patients and those with abnormal review findings,
complications and/or co-morbidities. The minimal requirements of care include:
|
ACTIVITY |
FREQUENCY |
|
Assess
diabetes control by measuring HbA1c |
At least
once per year |
|
Ensure that
a comprehensive eye examination is carried out |
At least
once every two years |
|
Measure
weight and height and calculate BMI |
At least
once every six months |
|
Measure
blood pressure |
At least
once every six months |
|
Examine
Feet |
At least
once every six months |
|
Measure
total cholesterol, triglycerides and HDL cholesterol |
At least
once every year |
|
Test for
microalbuminuria |
At least
once per year |
|
Provide
self-care education |
Patient
education regarding diabetes management |
|
Review Diet |
Reinforce
information about appropriate dietary choices |
|
Review
Levels of physical activity |
Reinforce
information about appropriate levels of physical activity |
|
Review Smoking |
Encourage smoking cessation
(if relevant) |
|
Review of
Medication |
Medication
review |
Can
Do:
The cycle of care for patients with diabetes can be carried out, in consultation
with the GP, by the practice nurse with the support of allied health care
workers.
Incentives
A one-off sign
on includes development of a diabetic patient register and is approximately
$1000 per GP. On completion of the cycle of care claim the SIP - $40 per
patient per
year.
When 20% of
the diabetics attending the surgery have had HbA1c pathology completed an outcome
payment (PIP) of $5.00 per quarter calculated on SWPES is made to the practice.
Resources
Monitoring Diary
Patient Booklet
(8 pages)
Guidelines
for Stabilisation
Diabetes Insulin Stabilisation Request Form
Referral
to Diabetes Service
Basic
Foot Assessment Checklist
MBS Item -
Diabetes Flowchart
PIP
Diabetes Incentive Booklet -
(8 pages)
Important Contacts
Enhancing General
Practice in Western NSW
| 