Stepping up diabetes


1 June 2018

Funding Amount:




Moonee Valley



Melbourne Macedon Ranges Yarra Moonee Valley Darebin Maribyrnong Hobsons Bay Wyndham Brimbank Moorabool Melton Hume Merri-bek


The ‘stepping up’ diabetes model seeks to reorient clinical roles to use existing resources in a smarter way to improve patient outcomes and reduce the burden of care.

By building the capacity of general practice and practice nurses to deliver intensified diabetes treatment in primary care, the confidence of specialists to discharge patients from clinics may increase and enable clinic access for new patients genuinely requiring specialist intervention. Read the research behind the model.

Registered Nurse Credentialled Diabetes Educators (RN-CDEs) are integral to key aspects of the model, including:

Education sessions

  • Case-based training will be delivered by RN-CDEs to introduce clinician and patient educational resources and simple clinical algorithms and checklists for treatment intensification to GPs and Practice Nurses.

Practice and practice nurse support structures

  • RN-CDEs support practices to identify patients who would benefit from review and intensification, as well as identifying patients for referral to specialist clinics and managing patients discharged from clinics.

Specific role of the practice nurse and RN-CDE

  • An enhanced role for Practice Nurses in type 2 diabetes care and treatment intensification is at the centre of the model.
  • RN-CDEs play an important role providing support for practices and spanning the boundary between general practice and specialist clinics.


Patient outcomes

  • Improved HbA1c in patients identified and managed through the project.
  • Improved patient experience of living with T2D and seeking care for T2D.

Community health services

  • Increased appropriate and timely referrals to allied health services – diabetes education, exercise physiology, podiatry, group programs.
  • Increased engagement with hospital and general practice.

Hospital service

  • Increased engagement with community health centres and general practice, including high referring practices.
  • Increased appropriateness of referrals.
  • Increased use of HealthPathways resources to guide intensification of treatment in general practice rather than referral.

Services involved