Why diabetes is still a key priority in primary care and what we can do about it.

I often start our Chronic Disease Management Workshop with a simple question: What are the most common chronic conditions you see in your clinic? Almost always, the first answer is diabetes.

Right now, around 1.3 million Australians are living with diabetes, and nearly 90% of them have type 2 diabetes (ABS, 2023). The numbers keep climbing, making diabetes one of the most significant contributors to Australia’s disease burden. In 2022, diabetes was the 7th leading cause of death in Australia (ABS, 2023).

For healthcare providers, these aren’t just statistics—they’re a daily reality. Primary care teams play a critical role in diabetes prevention, early detection, and long-term management. Whether through lifestyle interventions, routine health assessments, or culturally appropriate care, we have the power to reduce complications and improve outcomes.

With National Diabetes Week approaching, now is the perfect time to reflect on how we can better support patients and communities in tackling this growing health challenge.

Prevention & Early Intervention: A Primary Care Priority

Prevention is key in managing type 2 diabetes, and primary care teams are well-positioned to address modifiable risk factors early. In addition to health assessments and lifestyle discussions, tools such as the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) can help identify patients at high risk. For patients aged 40-49, the Type 2 diabetes risk evaluation (40-49 years) health assessment offers an essential opportunity to identify risks and early signs and intervene before the disease progresses. By proactively offering this assessment, healthcare teams can provide timely care that reduces the risk of developing type 2 diabetes.

Case Example: Identifying Diabetes Risk During an Unrelated Visit

Sarah, a 43-year-old woman, presents to the clinic for wound care. While waiting for the GP, the nurse uses the AUSDRISK tool to assess Sarah’s risk for type 2 diabetes, revealing a high score of 14. The nurse informs Sarah she’s eligible for a time-tiered health assessment – type 2 diabetes risk evaluation. The GP invites Sarah back for the health assessment, where they discuss her elevated risk and work on a plan to address modifiable factors like diet and exercise. The GP uses the time-tiered health assessment billing (MBS Items 701/703/705/707) for the attendance, ensuring Sarah receives the support she needs to reduce her diabetes risk (MBS Online, 2025).

Adapting to MBS Changes in Diabetes Care

With the removal of the Diabetes Annual Cycle of Care item from the MBS in November 2022, some feared a decline in structured diabetes care. However, primary care teams have adapted by using GP Management Plans, Team Care Arrangements, and follow-up items such as MBS item 10997 to maintain continuity of care. It’s also important to remember that patients with type 2 diabetes and a GPMP can access up to eight group allied health sessions with a diabetes educator, dietitian, or exercise physiologist—an often underutilised but valuable support option.

How to Strengthen Diabetes Management in Your Practice

If you’re looking for ways to optimise diabetes care, consider these key strategies:

Review your GPMP templates—do they include clear, patient-specific diabetes goals? Maximise follow-up care—are you making full use of MBS item 10997 for ongoing monitoring?

Encourage group allied health referrals—many patients are missing out on these valuable sessions.

Prioritise routine health assessments—catch prediabetes early and support prevention.

Check your recall and reminder system—are at-risk patients coming in for regular reviews?

Quick-Action Checklist for National Diabetes Week

Here’s a quick checklist to ensure your practice is ready for National Diabetes Week and beyond. Are you making the most of available CDM tools? Are your patients getting the support they need?

✔️ Audit your GPMPs to ensure they include tailored diabetes management goals.

✔️ Identify patients eligible for group allied health referrals and proactively offer them.

✔️ Review recall systems to ensure at-risk patients are booked for follow-ups.

✔️ Engage patients in education—share resources on diabetes prevention and management.

✔️ Leverage National Diabetes Week as an opportunity to promote proactive diabetes care.

To help primary care teams strengthen their approach, our Type 2 Diabetes Health Promotion Box provides practical resources to enhance patient education and engagement. This toolkit includes ready-to-use patient education materials, recall and reminder templates, and tools to guide lifestyle discussions. If you’re looking for simple ways to enhance diabetes care, explore how this resource can help streamline patient engagement and improve long-term management.

Australian Bureau of Statistics (2023, December 15). Diabetes. Retrieved March 13, 2025, from https://www.abs.gov.au/statistics/health/health-conditions-and-risks/diabetes/latest-release

Australian Government (2022, November 11). The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK). Department of Health and Aged Care. Retrieved March 13, 2025, from https://www.health.gov.au/resources/apps-and-tools/the-australian-type-2-diabetes-risk-assessment-tool-ausdrisk

Australian Government (2023, August 9). Referral form for group allied health services under Medicare for patients with type 2 diabetes. Department of Health and Aged Care. Retrieved March 13, 2025, from https://www.health.gov.au/resources/publications/referral-form-for-group-allied-health-services-under-medicare-for-patients-with-type-2-diabetes?language=en

CDM Plus (2025). Type 2 Diabetes – Health Promotion Box. Retrieved March 13, 2025, from https://cdmplus.com.au/product/type-2-diabetes-health-promotion-box/

Diabetes Australia (2025). Type 2 Diabetes Risk Factors. Retrieved March 13, 2025, from https://www.diabetesaustralia.com.au/diabetes-risk/

Diabetes Australia (2025). National Diabetes Week 2025. Retrieved March 13, 2025, from https://www.diabetesaustralia.com.au/national-diabetes-week/