Southern Melbourne Primary Care Partnership (SMPCP) is committed to supporting agencies to develop and implement best practice service delivery and integrated chronic disease care for their local clients with type 2 diabetes. To help us achieve this aim, a Diabetes Pilot Project was conducted across 2016 - 2017.

Project aims:diabetes word collage

  • To improve the outcomes of people with type 2 diabetes in the SMPCP catchment through sustainable, evidence based clinical pathways enabling clients to receive the most appropriate care in the most appropriate place at the most appropriate time.
  • Engage with GPs to enable them to work with Credentialed Diabetes Nurse Educators (CDNEs) based in community health settings to initiate insulin for clients with type 2 diabetes who require this treatment.

The CDNEs approach diabetes care with a person-centred approach and have ease of access to key allied health professionals across community health services that support the clients’ ongoing care at any stage of disease management.

Prior to initiating insulin, the CDNEs assess the clients’ needs to ensure they are ready and able to commence insulin in a safe and informative setting.

Why Community Health?

  • Community Health provides a centre of excellence for integrated chronic disease care that is consumer driven.
  • Timely access to a range of services at the same appointment provides greater convenience for consumers and improves care coordination at affordable costs.
  • The Community Health Model of Care fits well with the current changes being trialled by the government through the new Health Care Homes trial.


Which Community Health Centres? 

How to refer

  1. Complete the Victoria State-wide Referral Form (VSRF) template in the GP's software
  2. Provide patient summary
  3. Complete the Diabetes Injectable Medication Referral form*.
  4. Fax forms to appropriate community health service (Please note that the fax number for each community health is listed on the form)

*If your practice uses Best Practice, please This email address is being protected from spambots. You need JavaScript enabled to view it. for a rtf version of the Diabetes Injectible Medication Referral form and upload to your system according to these instructions.


What else should referrers know?

  • Remember to check that the patient's phone number is correct (an appointment can't be offered if contact can't be made)
  • The patient should be contacted within 2-3 weeks
  • Feedback will be sent to GPs/specialists after the patient has been seen by the CDNE


What happens next?

The pilot project was completed in late 2017 and the final report made a number of recommendations for the future.

pdfDownload final report...1.11 MB



GP Referral to Community Health for Insulin Initiation...

RACGP Diabetes Guidelines...


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