RPM for people with type 2 diabetes

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Clinicians can use this guide to enhance care for patients living with type 2 diabetes who may benefit from remote patient monitoring (RPM).

It is intended to support clinicians with limited experience managing patients in community settings with one or more chronic conditions, or who may have varying access to primary care services and specialist support.

Use the general patient journey information together with these specific steps for people with type 2 diabetes.

What is type 2 diabetes?

Type 2 diabetes occurs when the body becomes resistant to the normal effects of insulin, and the pancreas gradually loses the capacity to produce sufficient insulin.

More on type 2 diabetes from Diabetes Australia

Patient identification and referral

When determining a patient's eligibility for RPM, take into account patient suitability and alignment with the service model.

Based on clinical judgement and the following criteria, patients with type 2 diabetes may be eligible for RPM when they:

Patients with type 2 diabetes at higher risk of hospitalisation who may benefit from RPM include those who:

  • have a new diagnosis of type 2 diabetes
  • have HbA1c > 8% with complications or comorbidities
  • have chronic wound infections (requiring hospitalisations) related to type 2 diabetes
  • are post-hospitalisation with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS)
  • are experiencing hypoglycaemic events or frequent hyperglycaemia (depending on acuity and the type of monitoring available)
  • have commenced on medications likely to impact blood glucose levels ( e.g. insulin, corticosteroids, sodium-glucose co-transporter-2 inhibitors - SGLT2i), or have changed treatment.

For generalist services providing RPM, consider referring the patient to a specialised diabetes service (if not already referred).

In addition to general RPM suitability considerations, use the following key factors to assess RPM's alignment with, and responsiveness to, the clinical needs of a patient with type 2 diabetes.

Key factorsConsideration
Type of monitoring Can the service offer the type of monitoring (intermittent or continuous - see Types of Monitoring) that is needed to manage the patient's condition?
RPM platform capabilities

Can the RPM platform collect and present data to track the types of treatment (e.g. insulin) and lifestyle factors (e.g. food and physical activity) that influence blood glucose (BGL) readings?

Patient’s present condition and available support Consider whether it is clinically appropriate for the patient to be remotely monitored in a non-hospital setting if facilitating early hospital discharge or hospital substitution. The admitting clinician should determine the following:
  • Is the patient haemodynamically stable?
  • Has a medical officer reviewed the patient?
  • Does the patient or their family member or carer have the capacity to follow care and escalation plans?
  • Is the patient safe to be at home with existing supports?
  • What is the expected baseline functioning for this patient?
  • Are there defined and current altered calling criteria (ACC) for the patient, if required? (Current documented ACC for the patient should be part of the transfer of care.)
  • Is there a current diabetes sick day action plan for the patient?
Goals of care

Review the referral to establish the patient's expected care goals and, where necessary, liaise with the patient before onboarding to assess overall suitability for RPM.

Goals of care will be based on the patient's current condition and baseline; the service model capabilities; RPM platform functionality; and the patient's preferences.

Onboarding

Below is an example of a type 2 diabetes care pathway that can be allocated to a patient through an RPM platform. A care pathway task, frequency and schedule should be adjusted based on the patient’s individual requirements and clinical need.

Example of a type 2 diabetes RPM care pathway

Care taskType Frequency (minimum)Schedule
Default
Blood glucose Vital sign Daily 6–11am
Optional
Blood ketones Vital sign Optional (as clinically indicated) 6–11am
Consent form Survey Once (optional per LHD) Onboarding
Wellbeing check-in Survey Optional (as clinically indicated) 6–11am

NSW Health has endorsed patient-reported outcome measure (PROMs) that are suitable for patients with type 2 diabetes. At a minimum, these should be completed at patient onboarding and offboarding from the RPM service.

The following PROMs can be accessed by NSW Health staff through the Health Outcomes and Patient Experience (HOPE) platform:

  • Patient-Reported Outcomes Measurement Information System- 29 (PROMIS-29): used in the adult population to measure the level of concern and their overall wellbeing.
  • Diabetes Distress Scale (DDS) or Problem Areas in Diabetes (PAID): validated tools for detecting diabetes-related distress.
  • Partners in Health (PIH) scale: a patient activation measure to be used as clinically indicated where chronic disease management and self-management information forms part of shared decision making.

More about patient-reported measures

Technology

For general information on types of monitoring and devices, see technology to support RPM.

Types of monitoring

RPM can be continuous or intermittent. For diabetes management, 24-hour continuous glucose monitoring (CGM) technology is available to give clinicians access to real-time data. Some specialised endocrinology clinics may cover expenses for a two-week CGM trial for patients with type 2 diabetes before review by an endocrinologist. However, these specialised services are not accessible everywhere across NSW.

Before enrolling a patient in an RPM service, clinicians should assess whether intermittent monitoring is appropriate for their needs.

RPM device selection

Consider the following guidance when selecting RPM devices for patients with type 2 diabetes.

  • Patients with type 2 diabetes often have their own glucometer, which is unlikely to have Bluetooth capacity needed by the RPM platform in use. If patients are more comfortable with, and prefer to, BYOD, they will need to manually enter their measurements into the supplied tablet or smartphone app.
  • Discuss with the patient and their family member or carer what their preferred option is; both for the period when the care team will be monitoring results, and for ongoing self-management.
  • Educating patients to use their own equipment will support their capacity to self-manage more effectively after discharge from the RPM service.

  • Clinicians should customise device kits to suit their patient's individual care needs and preferences, adding or removing items as required.
  • Consider including consumables in the kit. For type 2 diabetes, the clinician should determine the quantity of blood glucose and ketone test strips based on the patient's monitoring schedule. Additionally, patients may require a lancing device, lancets and a sharps container. Clinicians must provide education on safe sharps disposal.
  • The below example is a kit suitable for use with intermittent monitoring, aligned with the sample care pathway above.
  • A patient’s comorbidities may also benefit from monitoring, and this should be considered when developing the care pathway and creating their device kit.
Warning: Bluetooth devices pose a risk to implantable cardiac devices when placed directly over the chest or within 6 inches/15cm. If applicable, ensure the patient and their family member or carer is aware of device placement when taking their measurements.
Type 2 diabetes sample kit
Tablet
  • Tablet with cover
  • Tablet charging plug and cable
  • SIM card
Biometric devices
  • Glucometer (with ketone-testing feature)
  • Ketone meter (if feature is not available in glucometer)
Accessories and consumables
  • Kit protect case
  • BGL test strips
  • Ketone test strips
  • Lancet device
  • Lancets
  • Sharps container
Consider the total weight of the kit, including devices, consumables and case. Patients may require support when receiving, using and returning the kits.

Monitoring and review

Consider the following factors when choosing and scheduling which vital signs to monitor for patients with type 2 diabetes.

Observation Considerations for patients with type 2 diabetes
Blood glucose monitoring Frequency of monitoring should be individualised, depending on:
  • type of glucose lowering medications (insulin and oral medications including SGLT2-i)
  • other medication affecting BGL (e.g. corticosteroids)
  • level of glycaemic control
  • risks of hypoglycaemia and hyperglycaemia.

Consult with the patient and their general practitioner, diabetes educator, nurse practitioner or endocrinologist to determine the preferred monitoring schedule.

Ketone monitoring
  • Consider for patients on SGLT2-i medications, which are associated with an increased risk of diabetic ketoacidosis (DKA) that does not always occur with significantly elevated blood glucose levels. This makes it difficult to diagnose unless the clinician is aware of this risk.
  • SGLT2-i is a class of oral medicines used with diet and exercise to lower blood sugar in adults with type 2 diabetes. They may be used in people with chronic kidney disease (CKD) and/or heart failure to lower the risk of heart attack, and/or heart failure exacerbations, including in people who do not have diabetes.
  • The risk of DKA induced by SGLT2-i medications appears greatest during periods of acute illness at home or in hospital (with or without decreased oral intake); during preparation or fasting; for procedures and particularly perioperatively.1
  • Consult with GP or relevant specialist regarding the discontinuation and recommencement of medication and the need for ketone monitoring.
  • See Use of SGLT2-inhibitors for type 2 diabetes.
Blood pressure
  • Consider the risk of cardiovascular disease (CVD) and the benefit of blood pressure monitoring. About 30% of people with type 2 diabetes also have CVD.
Pulse rate
  • If patient has been diagnosed with arrhythmias during RPM onboarding, determine benefit of measuring pulse rate. Consider undiagnosed arrhythmias when troubleshooting frequent self-measurement errors.
  • If patient is newly diagnosed with atrial fibrillation (AF) during an episode of RPM, they should be reassessed to determine baseline vital signs. Consider altered calling criteria.
  • For pulse rate monitoring in patients with a diagnosed arrhythmia, be aware of pulse rate error alerts and provide patient with strategies to manage any associated anxiety.
Pulse oximetry (SpO2)
  • Add or remove from the type 2 diabetes care pathway, considering whether the patient has a respiratory condition and whether medical officer/clinician determines pulse oximetry would be of benefit.
  • Consider carefully in people with poor peripheral perfusion, which can impact the accuracy of finger oximeters measuring SpO2. This can trigger unnecessary alerts and escalation pathways.
  • If SpO2 is scheduled and the patient has poor peripheral perfusion, provide additional support on optimal finger probe use. Use of the finger probe on the ear is not recommended for RPM patients at home.

Monitor blood glucose levels to identify signs of hypoglycaemia and hyperglycaemia (Diabetes Australia). Both are indicators of potential clinical deterioration in patients with type 2 diabetes.

Patient blood glucose readings may deviate from their target range sometimes; however, ongoing or significant changes can indicate clinical deterioration. If a patient has noticeable and consistent changes in readings outside the target range, support them to seek advice from their doctor or a credentialed diabetes educator. This consultation can help assess the risk of clinical deterioration and support the patient to adjust their diabetes management plan as needed.

Common causes of blood glucose fluctuations include:

  • illness, such as virus or flu
  • presence of illness or pain
  • dietary factors, including timing, type and amount of carbohydrates consumed (including bread, pasta, cereals and dairy products)
  • levels of physical activity or exercise
  • type and dosage of diabetes medication
  • impact of alcohol consumption
  • effects of emotional stress
  • interactions with other medications
  • accuracy and consistency of blood glucose monitoring techniques.

Health coaching and care coordination

The following considerations will assist RPM clinicians caring for patients with type 2 diabetes.

Registration with National Diabetes Services Scheme (NDSS) If appropriate, check the person is registered for the National Diabetes Services Scheme (NDDS) to receive subsidies that may be used for glucose testing strips and needles if prescribed insulin (NDSS forms will need to be signed by approved providers every six months).
Diabetes sick day plan Check patient has access to a sick day plan and understands when it should be used to support the management of their type 2 diabetes. See Sick day management (Diabetes Australia).
Structured blood glucose self- monitoring schedulesConsult the diabetes specialist team to decide if structured blood glucose self-monitoring would benefit the patient. This involves checking blood glucose levels at certain times of day for a given period (e.g. after meals for two weeks), then working with the diabetes healthcare team to analyse how food, physical activity and medications are impacting blood glucose levels. See Blood glucose monitoring (Diabetes Australia).
Risks of hypoglycaemia and hyperglycaemia Ensure patients understand the difference between hypoglycaemia and hyperglycaemia, including information on prevention, early symptom recognition, and effective treatment measures. See Hypoglycaemia and hyperglycaemia (Diabetes Australia).
GP access/diabetes annual cycle of care Ensure patients have consistent access to a dedicated general practitioner (GP) and actively encourage the development of a personalised GP management plan or Diabetes annual cycle of care (NDDS). This plan should involve regular assessments with members of the specialist care team, including podiatrists, diabetes educators, community nurses, Aboriginal health workers, optometrists, exercise physiologists, psychologists, dietitians, and endocrinologists. Regular assessments play a pivotal role in the early detection and treatment of diabetes complications, such as retinopathy, neuropathy, and nephropathy; thereby, promoting optimal management of the condition.
Medication support Ensure patients who need insulin injections are proficient in safe injecting techniques. This includes the rotation of injection sites to prevent the development of lipohypertrophy (lumps of fat or scar tissue caused by repeated injections in the same area). See Teaching patients with type 2 diabetes to self-administer insulin (Australian Journal of General Practice).
Diabetes and daily life Incorporate opportunities to empower patients to manage diabetes while living fulfilling lives, where possible, during care delivery. Support patients and their family members and carers to make informed decisions and achieve health goals by providing practical guidance and resources on exercise, nutrition, and coping strategies. See Diabetes and daily life (Diabetes Australia). Refer patients to the nearest local in-person or online Beat It program (Diabetes Australia), an 8-week fitness program that involves moderate-intensity aerobic, strength, and balance exercises, and education on healthy living.
Alcohol consumption Share advice on alcohol consumption for people with type 2 diabetes, see Should I drink alcohol? (Diabetes Australia)

Resources

National Diabetes Services Scheme (NDSS)
Education resources for patients living with type 2 diabetes.
Source: National Diabetes Services Scheme (NDSS)

Living with diabetes
Comprehensive education and management resources for people with type 2 diabetes.
Source: Diabetes Australia

Educational videos for patients
Practical guidance and insights into diabetes management from Western Sydney Local Health District.
Source: Western Sydney Diabetes

National Diabetes Services Scheme (NDSS)
Comprehensive support and resources for clinicians.
Source: National Diabetes Services Scheme (NDSS)

Diabetes Australia: For health professionals
A range of resources, e-learning opportunities and tools available to assist you to support people living with diabetes.
Source: Diabetes Australia

Diabetes and Endocrine Network
Resources and information for clinicians supporting people living with diabetes.
Source: NSW Agency for Clinical Innovation

References

  1. NSW Agency for Clinical Innovation. Use of SGLT2-inhibitors for type 2 diabetes. Sydney: ACI; 2023 [cited 3 May 2024].
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