Diabetes

About Us

Monash Diabetes provides leadership in outstanding research and evidence-based, patient centred clinical care. We provide care for the ever increasing burden of diabetes and traverse the spectrum from public health prevention activities to supporting community and primary care to caring directly for the most complex cases across the lifespan and across a range of adaptive models of integrated care run throughout South East Melbourne.

Monash Diabetes is a large multidisciplinary unit covering 6 key Monash Health sites (Clayton, Dandenong, Casey, Kingston, Moorabbin and Cranbourne), integrating with Community Health and primary care. We aim to provide integrated care across the continuum. We are the largest service nationally with 45,000 episodes of care annually with 28 services across lifespan from maternity care, paediatrics, adult and aged care, including community based and regional services. We drive health care improvement across the healthcare continuum from directly managing the most complex cases including those with renal failure, diabetes in pregnancy and diabetes in mental health with combined multidisciplinary HARP and outreach services integrated with other disciplines. We link to community and primary care services providing support and outreach services. Monash Diabetes service is also a recognised exemplar of contemporary diabetes care supporting primary care and patient self-management.

Monash Diabetes has a major internationally recognised research arm, fully integrated with the clinical program. We hold national and international leadership positions in diabetes (President Endocrine Society, President Elect Diabetes Society, Chair National Diabetes Centres -45 peak centres nationally, Chair and members of National NHMRC Diabetes Evidence Translation Committee) and members of program organising committees and state and national advisory government bodies.  We have the largest academic training program in endocrinology nationally with 14 current endocrinology PhD students (of 34 trainees / year nationally).

Monash Diabetes partners with consumer advocacy agencies, consumers, community, local, state and federal governments to drive health care improvement. We co-develop our strategic plan and co-design services with consumers and stakeholders whilst continuously evaluating and improving these services. We have board representation on Diabetes Australia and work closely with this consumer organisation. We have also established an innovative partnership centre – Monash Centre for Health Research and Implementation (MCHRI), designed to progress clinical, healthcare improvement and public health through

i) a research and translation program

ii) a capacity building and training

iii) a health care improvement and research/ evaluation support program.

This is a collaborative partnership between Australia’s largest university (Monash University) and Monash Health. MCHRI integrates clinical service, research and leadership to drive evidence based practice and policy and improve outcomes.  Our diabetes research program sits within MCHRI

Please click here to learn about Monash Diabetes Research Activities

Diabetes Outpatient clinics and referral criteria

We aim to provide prompt efficient patient centred care to achieve the Monash Health aims of exceptional care and outstanding outcomes. We work in partnership with our patients, their GP’s and other service to support those with diabetes to optimise care and clinical outcomes. Many of our services provide interim support to GPs and patients, others are chronic disease management services only for the most complex of patients.  We appreciate feedback and are happy to hear how we can improve our services. (Referral Form click here)

List of Monash Diabetes Outpatient Services, with more extensive information listed below):

Diabetes Support Service (DSS)

• Dandenong Hospital
• Monash Medical Centre, Clayton
• Berwick Healthcare
• Kooweerup

Chronic Disease Management Clinic (CDM)

• Dandenong Hospital
• Monash Medical Centre, Clayton

Diabetes Kidney Service

• Dandenong Hospital

Diabetes in Pregnancy Service (DIPS)

• Dandenong Hospital
• Monash Medical Centre, Clayton
• Cranbourne Integrated Care Centre
• MonashLink Community Centre, Clayton

Young Adolescent Diabetes Service (YADS)

• Dandenong Hospital
• Monash Medical Centre, Clayton

Diabetes Fast Track Clinic

• Dandenong Hospital
• Monash Medical Centre, Clayton

High Risk Foot Clinic

Diabetes, Vascular Medicine and Hypertension Clinic

Diabetes Hospital Admission Risk Prevention Clinic

• Dandenong Hospital
• Monash Medical Centre, Clayton

Acute Diabetes Oncology Service

• Monash Health, Moorabbin

Services not provided at Monash Diabetes:

• Routine Uncomplicated Diabetes Care
• Diabetes Education and Dietitian review if Specialist management opinion is not required.

PLEASE NOTE:  All referrals received by Monash Diabetes are triaged by Senior Endocrinologists to determine the eligibility and urgency of referral. Low quality referrals with missing information may be returned with requests for missing information.

• Patients assessed as having an urgent need are offered an appointment within 6 weeks as assessed by the clinician.
• Patients assessed as having a non-urgent need for appointments in clinics will be offered the next available appointment.

Where the waiting time does not meet patient needs, alternative service providers can be found by searching the Human Services Directory at http://humanservicesdirectory.vic.gov.au/Search.aspx

Diabetes Support Service (DSS)

The DSS is run on Wednesday mornings at the Clayton and Dandenong sites and at Casey hospital on Wednesday afternoons. These multidisciplinary clinics are overseen by a lead clinician who supervises a number of medical staff, ranging from trainees to staff endocrinologists. The clinic is also staffed by a Nurse Practitioner, dietician and experienced diabetes educators.

The DSS clinics are a short term service (generally 2 to 3 appointments) where, once stabilised, patients will generally be returned back to the care of their GP as their primary care provider. They can be referred again as needed for future episodes of care.

For the most complex patients, medical staff or the Nurse Practitioner working in the DSS clinics may refer patients directly into Chronic Disease Management for ongoing hospital based follow up.

WHEN TO REFER TO DIABETES SUPPORT SERVICE

• Patients sent home from ED with hypo or hyperglycemia who require rapid assessment
• Patients recently discharged from hospital with:
• Unstable diabetes
• Significant changes to therapy initiated during admission
• Severe recurrent hypo/hyperglycaemia (<2.5mmol/L or >14mmol/L) despite adjustments in therapy.
• Poorly controlled diabetes
• Suboptimal diabetes management where patient has underlying mental illness;
• Suboptimal diabetes control where patient has numerous diabetic complications (micro or macrovascular).

Initial GP Work Up

• HbA1C
• Fasting Glucose
• U & C
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR

Chronic Disease Management Clinic (CDM)

The CDM clinics are run at Monash Clayton and Dandenong on Thursday mornings. They are multidisciplinary clinics staffed by consultant endocrinologists, diabetes nurse educators, a dietician and podiatrist. Point of care HbA1c testing is performed in all patients unless this has been performed within the last 3 months.

Please note that patients from the community cannot be referred directly into this service. These patients must always be initially assessed in the Diabetes Support Service (DSS).

When to refer to chron

When to refer to chronic disease management clinic

• Patients with multiple complications of diabetes eg chronic kidney disease or multiple vascular complications eg IHD, stroke, leg ulceration, Charcot’s;
• Patients with sub-optimally controlled diabetes who are non-English speaking;
• Patients with suboptimal diabetes control who have co-existent mental illness.

Initial GP Work Up

• HbA1C
• Fasting Glucose
• U & C
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR

Diabetes in Pregnancy Service (DIPS)

The DIPS service currently runs across a number of sites including Monash Clayton (Tuesday am), DDH (Friday am), Cranbourne Integrated Care Centre (Friday pm) and MonashLink, Clayton Community Centre (Friday morning). These multidisciplinary clinics are staffed by endocrinologists, diabetes educators and dieticians. The DIPS at Dandenong, Cranbourne and MonashLink manage women with GDM ONLY, while women with T1DM and T2DM are all managed in the Clayton DIPS service.

WHEN TO REFER TO DIABETES IN PREGNANCY SERVICE

• Women with pre-existing T1DM or Type 2 diabetes (T2DM) for pre-conception counselling
• Women with pre-existing T1DM and T2DM who are pregnant
  • (EARLY referral is recommended);
• Women with newly diagnosed gestational diabetes (GDM)
  • (EARLY referral is recommended);
• Women found to have an elevated random glucose in early pregnancy.

Initial GP Work Up

• OGTT (for GDM women only)
• HbA1C (for T1DM and T2DM)
• Fasting Glucose
• U & C (for T1DM and T2DM)
• MicroAlb, ACR (for T1DM and T2DM)

Diabetes Kidney Service

The Diabetes Kidney Service provides patient-centered, coordinated multi-disciplinary assessment and management of patients with co-morbid diabetes and chronic kidney disease (CKD) in partnership with primary care, with the GP remaining the primary coordinator of care. It is unique as it was co-designed by key stake-holders including representatives from primary and specialist health-care, Diabetes Australia and Kidney Health Australia, informed by the results of a health-care improvement project examining the needs, and barriers and enablers to optimal health-care of patients, their care-givers and health-care providers. The service has a Liaison Service/ GP and patient phone advice hotline – to discuss referrals and patient queries real time during office hours (9 am to 5 pm) and education on managing Diabetes and CKD.

WHEN TO REFER TO DIABETES KIDNEY SERVICE

• Patients eligible for the service are those with BOTH diabetes AND chronic kidney disease (eGFR<60mL/min/1.732m²)
• To discuss patient referrals and for patient enquiries, please contact the Diabetes Kidney Liaison Service. Mobile: 0466 566 939 (during office hours)

Initial GP Work Up

• eGFR
• HbA1C (for T1DM and T2DM)
• Fasting Glucose
• U & C (for T1DM and T2DM)
• MicroAlb, ACR (for T1DM and T2DM)

Diabetes in Pregnancy Service (DIPS)

The DIPS service currently runs across a number of sites including Monash Clayton (Tuesday am), DDH (Friday am), Cranbourne Integrated Care Centre (Friday pm) and MonashLink, Clayton Community Centre (Friday morning). These multidisciplinary clinics are staffed by endocrinologists, diabetes educators and dieticians. The DIPS at Dandenong, Cranbourne and MonashLink manage women with GDM ONLY, while women with T1DM and T2DM are all managed in the Clayton DIPS service.

WHEN TO REFER TO DIABETES IN PREGNANCY SERVICE
Initial GP Work Up

• Women with pre-existing T1DM or Type 2 diabetes (T2DM) for pre-conception counselling
• Women with pre-existing T1DM and T2DM who are pregnant
• (EARLY referral is recommended);
• Women with newly diagnosed gestational diabetes (GDM)
• (EARLY referral is recommended);
• Women found to have an elevated random glucose in early pregnancy.
• OGTT (for GDM women only)
• HbA1C (for T1DM and T2DM)
• Fasting Glucose
• U & C (for T1DM and T2DM)
• MicroAlb, ACR (for T1DM and T2DM)

Diabetes Kidney Service

The Diabetes Kidney Service provides patient-centered, coordinated multi-disciplinary assessment and management of patients with co-morbid diabetes and chronic kidney disease (CKD) in partnership with primary care, with the GP remaining the primary coordinator of care. It is unique as it was co-designed by key stake-holders including representatives from primary and specialist health-care, Diabetes Australia and Kidney Health Australia, informed by the results of a health-care improvement project examining the needs, and barriers and enablers to optimal health-care of patients, their care-givers and health-care providers. The service has a Liaison Service/ GP and patient phone advice hotline – to discuss referrals and patient queries real time during office hours (9 am to 5 pm) and education on managing Diabetes and CKD.

WHEN TO REFER TO DIABETES KIDNEY SERVICE
Initial GP Work Up

• Patients eligible for the service are those with BOTH diabetes AND chronic kidney disease (eGFR<60mL/min/1.732m²)
• To discuss patient referrals and for patient enquiries, please contact the Diabetes Kidney Liaison Service. Mobile: 0466 566 939 (during office hours)
• eGFR
• HbA1C (for T1DM and T2DM)
• Fasting Glucose
• U & C (for T1DM and T2DM)
• MicroAlb, ACR (for T1DM and T2DM)

Young Adult Diabetes Service (YADS)

YADS clinics’ are multidisciplinary clinics staffed by paediatric and adult consultant endocrinologists, diabetes nurse educators, dietician, social worker (Monash site only) and optometrist (DDH site only) and provide point of Care HbA1c measurement.

Please note this clinic does NOT provide services for T2DM.

Dandenong:

Young adults aged
between 18-30 years living in the Dandenong and Casey Hospital catchment areas.
When: Thursday evenings 4:00 pm – 7:30 pm, 2 evenings a month (usually 2nd and 4th Thursday evening)

Monash Clayton:

Fifteen year olds with diabetes are transferred from the MMC Paediatric Diabetes clinic to YADS, and are initially managed by the same paediatric consultant. At the age of 18 – 19 years, over a period of 6 – 12 months the teenagers are prepared for transition to one of the YADS adult consultants, with continuity of consultant care maintained.

When: Monday evenings 5:00 pm – 8:30 pm, 2 evenings a month (usually 1st and 3rd Monday evening)

NB: GP’s are requested to refer onto this service using the Victorian Statewide Referral Form housed in most clinical software. More information on VSRF – www.gpv.org.au then click on Resources or contact your local Divisions of General Practice.

WHEN TO REFER TO YOUNG ADOLESCENT DIABETES SERVICE
Initial GP Work Up

• Young Adults aged between 18-30 years with uncontrolled Type 1 Diabetes
• HbA1C
• Fasting Glucose
• U & C
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR
• TFT’s
• Coeliac Serology

High Risk Foot Clinic

The High Risk Foot service offers patients a multidisciplinary model for integrated, comprehensive (including community, ambulatory and inpatient) care for the prevention and treatment of diabetes related foot complications.

The clinic aims to prevent deterioration and maintain the healed high risk foot by providing high risk care coordinators for complex care between community and acute, whilst also looking well beyond the foot to focus on the physical, psychological and social challenges of the patient.

WHEN TO REFER TO HIGH RISK FOOT CLINIC
Initial GP Work Up

• People with Diabetes and a history of ulceration / amputation or active early stage ulceration against a background of peripheral neuropathy or PVD
• Patients with complex ulceration, infection and amputation as a result of their underlying medical condition
• HbA1C
• Fasting Glucose
• U & C, LFT’s, FBE
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR

Diabetes Fast Track Clinic

Patients triaged for the Diabetes Fast Track Clinic have recently been discharged from hospital and require follow up within 2-3 weeks. They are seen in clinic up to 3 times prior to discharge back to GP (if medically stable) or to a long term clinic based on their assessed need. Fast Track Clinic at DDH occurs every Tues morning whilst Fast Track Clinic at MMC occurs every Wed
morning alongside the Diabetes Support Service Clinic. This clinic is staffed by a Nurse Practitioner.

WHEN TO REFER TO DIABETES FAST TRACK CLINIC
Initial GP Work Up

• Patients sent home from ED with hypo or hyperglycemia who require rapid assessment;
• Patients recently discharged from hospital with:-
• Unstable diabetes
• Significant changes to therapy initiated during admission
• HbA1C
• Fasting Glucose
• U & C
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR

Diabetes, Vascular Medicine and Hypertension Clinic

Patients with diabetes and vascular complications/hypertension can be referred to this clinic. The clinic operates at Dandenong Hospital once per fortnight on Wednesdays 1:30 pm – 5:00 pm and is staffed by a vascular physician.

When to refer to Vasc Med and Hypertension Clinic

Initial GP Work Up

• Diabetes with vascular complications/hypertension
• Medical review of pre-operative Vascular Surgery patients
• Post-operative diabetes /vascular follow up of surgical patients
• Follow up of pregnancy associated blood pressure
• Difficult CV risk management
• Primary and secondary hypertension
• Complex vascular arterial or venous disease
• Thrombotic disturbances
• Vasculitic disease

Initial GP Work Up

• HbA1C
• Fasting Glucose
• U & C
• Fasting Cholesterol – HDL, LDL, TG
• Urine ACR

Diabetes: At a glance

Diabetes is a condition in which there is too much glucose (sugar) in the blood.

• Almost one in four Australians aged 25 years and over has either diabetes or pre-diabetes
• Diabetes increases the risk of serious complications like heart disease.
• Increasing diabetes prevalence is linked to increasing obesity and less active lifestyles.

Diabetes: Different types

• Type 1 diabetes is usually diagnosed before the age of 30 but can occur at any age.
• Type 2 diabetes often occurs in those who have a family history of diabetes and can be triggered by being inactive and carrying extra weight around the abdomen.
• Pre-diabetes is when there is a very high risk of developing type 2 diabetes (and a subsequent high risk of heart disease).
• Gestational diabetes occurs during pregnancy and increases the chance of developing type 2 diabetes in the years after the birth.

Diabetes: How do I know; What do I do?

It is important that diabetes is diagnosed and treated early.
Symptoms include:

• Thirst
• Tiredness
• Frequent / excessive urination
• Persistent infections, such as genital thrush
• Skin rashes / itching

Some people will not have any of these symptoms and may be diagnosed during a routine blood test.
A yearly blood test is recommended if you fit into any of the following risk categories:

• Age – the older you get the more likely you are to get diabetes
• Family history
• History of gestational diabetes
• History of cardiovascular disease

Also, the following preventable factors increase diabetes risk:

• Excessive weight – especially around your waist
• Physical inactivity
• Poor/ unbalanced diet

Diabetes: Services

• Consult with your general practitioner (GP) to access the most suitable diabetes service.
• Self management courses & community services if you live in the following areas or have a G.P in the following areas:
• Greater Dandenong
• City of Casey
• Shire of Cardinia

Please call: (03) 8768 5147

• For community diabetes services in the surrounding areas (click on links):

Monash: (Monashlink CHS)

Kingston: (Central Bayside CHS & Bentleigh Bayside CHS)

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