Diabetes management plan
A diabetes management plan should be prepared in partnership with each patient (and other people involved in their care). Ideally, it should be part of the patient’s general health management plan, incorporating all aspects of their health care not only those relating to diabetes.
A multidisciplinary team for diabetes can provide the best environment to support the patient and help them to achieve their goals. The team may include general practitioners, endocrinologists, diabetes educators, social workers, dietitians, pharmacists, podiatrists, Aboriginal health workers, dentists, exercise physiologists and psychologists. Input from these health professionals will vary for each patient according to their needs. One health professional (eg nurse practitioner, diabetes educator, general practitioner, endocrinologist) should be responsible for coordinating the diabetes management plan with the patient to ensure continuity of care.
The diabetes management plan may be comprised of separate components or plans relating to the various aspects of diabetes and overall health management. It should consider the patient’s age, health literacy, level of education reached, occupation, cultural and health beliefs, social situation, financial circumstances, comorbidities and life expectancy. The plan should include:
- individualised and prioritised short- and long-term goals, including treatment targets
- a plan for dietary intake
- a physical activity and exercise plan
- a medication management plan
- a sick-day management plan (see Sick-day management for adults with type 1 diabetes and Sick-day management for adults with type 2 diabetes)
- a schedule for screening for and monitoring of complications of diabetes (see Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 1 diabetes for type 1 diabetes and Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 2 diabetes for type 2 diabetes)
- ways to reduce cardiovascular disease risk, in particular smoking cessation, and blood pressure–lowering and lipid-modifying drug treatment, if appropriate
- a plan for self-management of diabetes, including provision of written information on resources and other available supports
- review dates for care plans.
Use of technology such as mobile health (mHealth, eg apps for smart phones) and electronic health (eHealth, eg telehealth using videoconferencing) can assist in self-management and home monitoring, and reduce the need for face-to-face visits.