Diabetes – Improving Healthy Habits

About the practice

Bay Island Medical Service Russell and Macleay Islands are uniquely located in the Southern Moreton Bay Islands area and have a large cohort of patients with complex chronic disease. The practice has 9 GPs, 3 nurses and over 5500 active patients.

There are limited services located on the islands and accessing services often involves patients having to travel to the mainland. For patients, accessing regular support and interventions can be difficult due to the time and travel required to attend appointments off the island.

The clinic recognised this and explored ways to help overcome barriers, enhance access to care and better support our patients.

What inspired the practice to complete this QI activity?

It was the growing number of patients diagnosed with diabetes that highlighted the need for additional support and education within the practice. To address this, the lead nurse decided to undertake advanced diabetes training, resulting in the development of in-house Certified Diabetes Educator expertise.

It was these newly acquired skills and teamwork that strengthened the ability to support patients to make positive lifestyle changes and improve diabetes outcomes, particularly for those with elevated HbA1c levels.

The challenge

The practice reviewed patient data and noted that there was a large cohort of patients (51) with an HbA1c over 9.5%. The challenge and goal were to track and provide a holistic approach to supporting 25 of these patients to improve their lifestyles and ultimately reduce (on average) their HbA1c by 0.5% over a 12-month period. 

Over the 12 months there were many ups and downs.

• at the start the practice established a diabetes exercise physio group on the island which was going well but unexpectedly ceased at the end of 2025 leaving patients to travel to the mainland.

• some of the patients moved from the island, so the cohort dropped.

• the practice struggled to get the final data as some patients avoided their HbA1c check after Christmas as they were afraid of the impact of “blow outs”, this stretched the final outcomes for a further 6 months.

What we did

The practice:

• worked with the whole practice team and established a “Diabetes Clinic” which ran for one afternoon per fortnight on Macleay Island and was run by the RN and CDE.

• reviewed and acquired patient support materials and made-up folders for patients to take home and use. These came from a multitude of places and helped patients not only retain information but also track their day to day.

• created a spreadsheet with the list of patient’s names, dates of blood results and calculated HbA1c changes to help track progress.

• booked patients into the clinic using a referral from their care plans.

• provided holistic advice, care, support and education to help them understand opportunities to improve their diabetes. All First Nations patients were encouraged to join the “My Health For Life” program.

• set the scene so that patients would expect to hear from and see the nurse team and doctors on a regular basis.

• set reminders in patient files for their 3-month review, and some were booked in advance.

• the doctors followed up with regular blood results so that we could track changes and improvements and we documented these in our spreadsheet.

• regular 10997s & 93203s were claimed as an opportunity to review progress and provide additional support and reinforcement.

• would make additional calls to patients who had not had their bloods done.

• care plans were kept up to date ensuring close monitoring of outcomes.

• regularly worked with the QI team coach to track progress and to look at ideas that might support or improve the activity and outcomes.

Results and impact

The impact exceeded expectations, with 70% of the patients achieving a reduction in their HbA1c result. There was a total reduction of 24.43% which was an overall average reduction of 1.22% per patient in their HbA1c. This was more than double the expected outcome with 1 patient achieving a reduction from 14.1% HbA1c down to 8.5% (-5.6%).

The patients HbA1c results continue to be stable, and some have kept improving. The impacts of the activity weren’t just seen in numbers but also real-life changes. Most patients are now exercising and have incorporated better food options and have a greater understanding of what impacts their blood sugars and feel more confident in their everyday choices.

Word has spread about the success of the program so much so that patients are asking to see if they can achieve the same improvements. Doctors have also increased their referrals to the Diabetes Clinic.

What will the practice do to ensure this becomes business as usual 

The Diabetes Clinic is now a regular thing on Macleay Island and will continue to be. Reminders are set for regular follow ups including nursing team 10997s to keep a close monitor on patients. There is a “standard” information pack used in the clinic for patients with diabetes and these resources are checked and ordered regularly. The practice regularly runs the Primary Sense reports to check for any patients that have an elevated HbA1c so they can be identified early and interventions can be implemented.

What can other practices do to participate?

Identify your patients that have elevated HbA1c through the Primary Sense Diabetes report. Use this to help target those in need of additional support. Get your team together and come up with ideas for intervention. Tell your patients that “Everything is an effort until it becomes a habit” and keep them accountable with follow up appointments and blood tests. Look for free supports and exercise programs that are offered in your area for diabetics. Come up with your own diabetes support tool kit for your patients and allow enough time to give them the support and encouragement they need to improve.