Care Partnership – Diabetes in Western NSW

The Western NSW Diabetes Hub is a multidisciplinary virtual clinical service that provides care for people living with type 2 diabetes in the Western NSW LHD region that have had difficulty accessing services or making improvements in their health. We work with people so they can receive quality diabetes care close to home with support from their local care providers.

The Hub offers timely, short to medium-term interventions including intensive diabetes education, allied health support, and Aboriginal wellbeing coordination. Patients accessing the Hub are supported to receive quality transfer of care with their local primary health provider.

The Western NSW Diabetes Hub supports:  

• Patients with type 2 diabetes who will benefit from improved self-management and strengthened local support. These include patients: 
  • Living with a recent diagnosis or a diagnosis in hospital;  
  • Managing a transition point such as starting on insulin or a significant complication; and/or  
  • Who have not been able to access a service in a timely manner that may or may not be available in their community.   
• Clinicians who want to improve type 2 diabetes care that is supported by expert advice, upskilling, supervision and/or consultation. 
• Clinicians, community members, Aboriginal leaders and Elders who wish to lead a deliberate response to diabetes needs with their community.  

Health practitioners can access Diabetes Hub services by emailing the Western NSW Diabetes Hub.

Virtual endocrinologist advice for patients, their GPs and multidisciplinary teams in Western NSW LHD are available. These sessions are designed to increase access to specialist advice for patients living with type 2 diabetes and to enhance skills for local health practitioners to manage their ongoing care.

GP practices and ACCHSs in Western NSW are eligible to book GP-Endocrinology sessions. CP-D has engaged two endocrinology providers, MetaDiab and Western Sydney Diabetes eCare, that offer bulk-billed telehealth case conferences with GPs, patients and other health practitioners.

Email the Western NSW Diabetes Hub for information on booking GP-endocrinology sessions and/or to express interest in contributing to the local design of this service.

CP-D has limited seed funding to support the establishment of GP practice or ACCHS-led models of care or quality improvement projects that are centred on improving care for patients with type 2 diabetes.

The program has capacity to support approximately 15 practices and ACCHOs to design and implement initiatives that meet practice or ACCHS population needs. Supported models include: 

• Shared appointments – involving groups patients attending eight weekly medical or allied health sessions; 
• Diabetes education mentoring for practice nurses and Aboriginal Health practitioners and workers – involving quarterly clinical sessions with a diabetes educator;
• Patient re-engagement projects – involving analysis of patient data to identify and provide quality care for patients that the system is not supporting appropriately; and 
• Other service enhancement – innovative, customised service enhancement that increase access. This could include (but not limited to) high risk or general foot care, eye care or other areas of need.

The process for identifying GP practices and ACCHSs that will design and deliver these models is being developed. The program will likely prioritise services that have substantial type 2 diabetes needs in their practice population or local community and are interested and have capacity to implement a model before June 2026.  

Please direct queries about this program component to westernT2DM@nswrdn.com.au. 

CP-D supports local health professionals to pursue further professional development by facilitating access to grants that contribute to the cost of further study or professional development.

The program has supported more than 50 scholarships, bursaries or study leave grants for health practitioners in Western and Far West NSW including many who have completed or are pursuing Credentialled Diabetes Education qualifications. The participating health practitioners are on track to significantly increase these regions’ Credentialled Diabetes Educator workforce.

Eligible health practitioners can apply to the Health Workforce Scholarship Program for grants to support further study or professional development in managing type 2 diabetes. Grants are available for medical, nursing, midwifery, allied health, dental and Aboriginal and Torres Strait Islander health professionals who work in rural primary health settings. 

Health practitioners who don’t work in primary care settings can write to westernT2DM@nswrdn.com.au to explore professional development opportunities or grants available to support their care for people living with type 2 diabetes.

The CP-D program works with partners to deliver upskilling events for health professionals who have a broad or specialised role providing care for people with type 2 diabetes in Far West and Western NSW. 

Professional development events provided so far include a series of upskilling workshops for non-clinical health professionals; diabetes education sessions for clinicians pursuing CDE qualifications and Aboriginal health practitioners; and the Type 2 Diabetes ECHO series. 

Information about relevant professional development events can be viewed on the WNSW PHN’s Upcoming Events page, or on the Rural Health Training Calendar and searching for ‘diabetes’. You can also choose 'diabetes' as a professional interest in your Rural Health Pro profile to make sure you see diabetes related events.

Project ECHO® (Extension for Community Healthcare Outcomes) sessions support peer virtual learning for health practitioners through case discussions. Two series of Type 2 Diabetes ECHO sessions have already been delivered and more are planned for GPs and primary health practitioners. These sessions support clinicians’ access to evidence-based, multidisciplinary information for their patients by discussing patient cases with a panel of experts and peers. An introductory video explaining the Project ECHO® model is available here.  

Project ECHO® sessions can offer: 

• Increased knowledge and confidence in diabetes management 
• Opportunity to earn CPD points 
• Multidisciplinary advice for your patients 
• Support from an engaged community of practice 
• MBS case conferencing items for GPs presenting cases may be claimable 

Information about upcoming ECHO sessions can be found on WNSW PHN’s Upcoming Events page and the Rural Health Training Calendar.  

Please write to echonetwork@wnswphn.org.au If you would like to participate in an upcoming ECHO session, request a topic or patent case study, or contribute on the panel.

The CP-D program team is actively looking to support health professionals in Western and Far West NSW to provide quality diabetes care for communities in the region. This includes identifying and responding to:  

• The needs of the region’s existing workforce; 
• Workforce gaps and shortages; and  
• Future workforce needs. 

The program is exploring supports for these regions’ diabetes educator workforce, mentors of those in-training, and linking newly qualified diabetes educators to roles where they can utilise their skills.  

If you would like to raise a workforce need or solution, contribute to governance or evaluation, or other opportunity, please write to westernT2DM@nswrdn.com.au.

HealthPathways is a web-based portal for health practitioners that:  

• has online clinical guidance and resources; 
• is written by local GPs designed to be used in a consultation; and 
• includes referral information for local services and specialists. 

The diabetes pages on HealthPathways have been localised for the Far West and Western NSW regions and will continue to be updated.  

Health practitioners can login or register to access localised HealthPathways or email HealthPathways for more information. 

Inca is a secure web portal and mobile platform that allows you to create patient-centred Medicare-compliant GP Management Plans and Team Care Arrangements to:  

• collaborate easily with internal and external care team members in real-time,  
• reduce administrative burden on clinical staff with convenient, one-click electronic approvals of EPCs and care plans, 
• allows patients to be active participants in their care - provide patients with online access to personalised care plans and chronic disease educational material, 
• monitor patient measurements remotely. 

Learn more.

To inquire about using Inca, please email our Digital Health Team.

Practices can receive customised practice reports every six months which shows how your patient population is utilising the broader health system including GP and hospital presentations. The Lumos program provides insights into patient pathways through the NSW health system by linking de-identified data from general practice with other health service data. Learn more about Lumos here.  

In addition to practice population insights for practices, Lumos data will be utilised to support CP-D quality improvement and evaluation. 

To inquire about using Lumos, please email our Digital Health Team.

Participating GP practices and ACCHSs have free access to the healthdirect Video Call platform to help support access to care for rural and remote communities. Powered by the COVIU system and administered by the WNSW PHN digital health team, the healthdirect Video Call platform is a secure, private platform and all calls are fully encrypted making it compliant for many clinical consultations.

• healthdirect Video Call offers a range of practical advantages to patients, doctors and clinics. It mimics the in-person appointment process via a virtual waiting room and virtual consulting room. 
• Remote (indirect) examination by observation and with patient assistance.
• Reviews and multi-disciplinary consultations are more practical to conduct when clinicians and patients can attend remotely. Supports NSW Health Type 2 Diabetes Case Conferencing sessions.
• Can allow for multiple guests to join calls via email link invites.

To register a healthdirect Video Call account, please email our Digital Health Team.