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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
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):
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.
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
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
Initial GP Work Up
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
Initial GP Work Up
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
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
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
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.
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)
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
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
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 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
Initial GP Work Up
Diabetes: At a glance
Diabetes is a condition in which there is too much glucose (sugar) in the blood.
Diabetes: Different types
Diabetes: How do I know; What do I do?
It is important that diabetes is diagnosed and treated early.
Symptoms include:
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
Please call: (03) 8768 5147
Monash: (Monashlink CHS)
Kingston: (Central Bayside CHS & Bentleigh Bayside CHS)
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F: (03) 9554 1544