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Diabetes Care and Management in the Community

An initiative to promote the integration of services

Moana Pacifica

A 12-month project has been put into place that uses a different model for DCIP with 11 general practices. The initiative targets people with poor diabetes control with the expectation that the expertise flows into improved diabetes care for all patients enrolled with the practice. The 11 general practices have 33% of the people known to have poor control of their diabetes in the district.

The initiative uses a collaborative approach with the practices. They are funded to improve the management of their poorly controlled patients using clinical support from CM Health (virtual consults and MDTs ), shared learning between the practices, tools and training plus improvement facilitators working with each practice on their own improvements. Improvements are not practice confined and include coordination with allied health services and other resources within localities e.g. self management.


The aim of the practices in the initiative is a 10% reduction in HbA1c in people with poor control of their diabetes by June 2017.


(PPTX, 121 KB)  (Click Image to download)

Learning Session Downloads:

Learning Session Zero: 

Supporting General Practice with Change  (PPT, 2.2 MB)

Learning Session One:  

Learning Session Two:

Learning Session Three:
Invitation to Learning Session Three (DOCX, 146 KB)

Resources and Templates:

Training Opportunities

Useful Links


  Practice Details (DOCX, 22 KB)

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