Published: June 2025. Next review: 2030.
Diabetes Alliance Program Plus (DAP+) is now using virtual care to enhance the experiences and health outcomes for patients with diabetes in Hunter New England Local Health District.
Using a collaborative care model, DAP+ brings together specialists from John Hunter Hospital with primary care teams for case conferencing. This supports education, performance monitoring and capability building within primary care.
Case conferences allow general practitioners (GPs) to manage complex cases locally, with support from specialists. This improves access to care for these patients, and increases the capacity of specialist teams to treat new patients.
The program initially involved a full day of in-person case conferencing with DAP+ visiting GPs or Aboriginal medical services. The program has now expanded to include virtual case conferences and an advice line.
Reasons for change
- Patient preference: after positive experiences with virtual care during the COVID-19 pandemic, patients now want the choice to be able to receive their care at home, or close to home.
- Community need: there is disparity in access to healthcare services for those in rural and remote areas, especially Aboriginal people.
- Extending scope: to allow smaller regions to participate. Previously they were unable to participate as they could not meet the required patient numbers for an in-person clinic.
- Sustainability: need to build local clinician capability for better ongoing management of diabetes patients.
Consumer story
Not living in fear changed my whole life.
Annie* lives in the rural town of Boggabilla, around 8 hours' drive from Newcastle. After living with diabetes for 27 years, she met with the DAP+ team in May 2023.
Following Annie’s first case conference appointment, the DAP+ team arranged for Annie to use a continuous glucose monitor sensor to monitor her glucose levels. A 6-week virtual case conference follow-up appointment was scheduled using the myVirtualCare platform.
Through virtual case conferencing, Annie and the DAP+ team were able to review accurate blood glucose levels in conjunction with her medication and lifestyle. A tailored diabetes management plan was developed by the DAP+ team, the GP and Annie.
"I have never felt so safe," says Annie. "I thought I would one day fall asleep and never wake up."
The glucose monitor educated Annie about her glucose levels and prompted her to eat better.
She doesn’t have to prick her finger all the time and feels this is more discreet. Her family and friends have also noticed a positive change.
*Name changed for privacy.
Clinician feedback
“Virtual case conferencing between primary care and specialist care teams fosters capacity building within primary care, reduces inconvenience for patients in terms of travel, and provides an efficient model of care for all parties involved.”
“As the GP assumes the primary responsibility of managing patients following the case conference, specialist teams are subsequently able to accommodate more new patients instead of continuing to review existing patients. It is a big win for everyone involved.”
“DAP+ virtual case conferencing is an effective strategy to manage demand that contributes to reducing waiting times for patients referred to see a diabetes specialist by their GP, and enhances the use of modern technologies.”
Workflow
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Criteria
- 18+ years old
- Type I or Type II diabetes diagnosis
- Not under private endocrinologist care
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Referral
- GP and community services to John Hunter Hospital (JHH) Diabetes and Endocrine department
- DAP+ specialist recommendation from GP call to Diabetes and Endocrinology Advice Line
- GPs can submit an expression of interest for a full day in-person joint case conference clinic
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Triage
- JHH Diabetes and Endocrine staff specialist team
- Suitable referrals are allocated to the DAP+ waitlist
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Onboarding
- DAP+ implementation manager onboards the GP practice
- DAP+ administration officer schedules appointment for patients triaged and on the waitlist
- Primary health network (PHN) partner provides additional digital support if GP practice is not equipped to provide virtual care
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Scheduling
- Administration officer schedules the initial and 6-month follow-up joint case conference appointments with the GP and patient
- 8 to 10 virtual case conference clinics (VCCCs) are held each day for 2 to 3 days per week, based on specialist availability
- Multiple GPs from across the Hunter New England region participate in VCCCs
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Connect
- DAP+ administration officer conducts a test call one week prior to appointment
- Appointment conducted with patient at GP clinic, videoconferencing with DAP+
- Patients can join via videoconference from home if unable to attend GP clinic
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Care
- Arrange continuous glucose monitoring, if required
- Diabetes management plan developed with GP and patient
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Transfer
- Patient is discharged back to GP care
Team
The DAP+ team includes:
- General medicine specialists
- Endocrinologists and endocrinology advanced trainees
- Credentialled diabetes educators
- Registered nurses
- Dietitians
- Podiatrists
- Aboriginal health workers
- Implementation managers
- Administration officers
- Research and support staff
Key elements
- Virtual case conferencing: diabetic patients attend their GP practice and join a myVirtualCare (myVC) video conference with the DAP+ team and the GP.
- Urgent advice line: primary and tertiary care clinicians within Hunter New England region can connect with an endocrinologist advanced trainee for clinical advice on diabetic treatment.
DAP+ operates the advice line Monday to Friday, 8:00am to 4:30pm. After hours calls are directed to the on-call John Hunter Hospital staff specialist consultant. - Case conferencing clinics: DAP+ specialist teams (endocrinologist and diabetes educator) visit GP practices or Aboriginal medical services for in-person case conferencing clinics aiming to see 10 patients each day.
- Education sessions and masterclasses: regular sessions are held throughout the Hunter New England region. This gives healthcare professionals an opportunity to extend their knowledge on diabetes screening, diagnosis and advanced diabetes management.
- Traineeships: 12-month endocrinology traineeships are offered to build capability and develop skills of future practicing endocrinologists. The trainees are mentored by DAP+ endocrinologists and participate in the case conferences.
- Virtual support: Hunter New England Central Coast PHN provides hardware support to ensure GPs have access to the equipment needed, such as computers and webcams. Hunter New England LHD telehealth team provides software support, including myVC access and troubleshooting.
- Recruitment and administrative support: the DAP+ team provides support and guidance with administrative and patient recruitment activities for in-person and virtual case conferencing clinics.
Enablers
Partnership
DAP+ is a powerful collaboration between key organisations, each bringing unique expertise and resources to the table:
- Hunter New England LHD: provides clinical diabetes specialist expertise and operational support for the program.
- Hunter New England Central Coast PHN: funds DAP+ operational management positions, facilitates joint case conference clinics within GP clinics, and supports education events.
- University of Newcastle: delivers evidence-based lifestyle modules, including physical activity, nutrition and mental wellbeing, and evaluates the program’s effectiveness.
- Hunter Medical Research Institute: contributes to the program’s robust research and innovation efforts by providing data sciences, philanthropic and corporate services expertise.
This partnership enables the sharing of skills, knowledge and resources to develop person-centred models of care that are efficient, cost-effective and sustainable.
Need
- DAP+ is a clinical innovation that arose from a critical community, general practice and health service need; to ensure that people with diabetes are getting the best available care and support for their condition regardless of where they work and live.
- Rural and remote Australians face significant health disparities, including shorter lifespans and heightened prevalence of diseases such as diabetes. Challenges in accessing healthcare services and achieving continuity of care exacerbate these disparities, especially for Aboriginal people.
Technology
Virtual consults are conducted using the web based myVC platform. Patients and general practices can access the platform on multiple devices, such as smartphone, tablets and computers.
- Glucose monitoring devices: when clinically indicated, DAP+ team will organise a CGM device for patients to wear for 2 weeks. The device data informs clinical decision making and improves patient knowledge. The CGMs are funded under company trial programs.
- Monitoring and evaluation: evaluation of DAP+ shows that case conferencing led to notable improvements in diabetes control, metabolic health and cardiovascular outcomes, including significant reductions in key indicators such as HbA1c, weight, blood pressure and lipids.
Funding
A philanthropic gift allowed expansion to include virtual case conferencing and the advice line. The gift also led to the inclusion of Hunter Medical Research Institute and University of Newcastle in the partnership, strengthening the evidence base, reach and impact.
Impacts and outcomes
For patients
- Increased accessibility for patients to specialist diabetes care and resources
- Reduced wait times for specialist treatment
- Improved patient health outcomes
- Increased capacity to self-manage through involvement in case conferences and CGM data
- Improved care coordination
- Reduced costs, such as travel, parking and accommodation
Clinician benefits
- Reaching patients who otherwise may not attend
- Flexibility of timing
- Provides an option if clinical areas or physical rooms are unavailable or limited
Service benefits
- Reduction in hospitalisations
- Financially efficient
- Integrates primary and tertiary care
Scalability
When developing the partnership model, DAP+ aimed to present a prototype for a model of care that can be applied to other chronic diseases and geographical areas. See DAP+ Annual Impact Report, 2023 for more information.
Western Sydney Diabetes use a similar partnership model of care and experiences good outcomes for the patient, clinician and health system, demonstrating the transferability of the model between districts.
Contact us
Contact the Diabetes Alliance Program Plus on 02 4964 7172 or HNELHD-DiabetesAlliance@health.nsw.gov.au