The main objective is to ensure patient interactions bring the most value to patients by personalising them so that discussions/action plans/educational materials can be tailored to the individual and their circumstances in order to best support them manage their diabetes. This requires:
1. Creation of a standard care planning template for all diabetes clinical interactions (initially practice nurse appointments) that includes a medical and lifestyle action plan.
a. Lifestyle
Points of patient contact that result in patients leaving with an action plan they have ownership over, are committed to, and is realistic for them in their individual circumstances. It should also be specific, measurable and time-bound. Patients should: Know what to do, know how to do it, be able to do it, be motivated to do it, be doing it. They should know how to and be able to access the non-medical support available
b. Medical
Patients receive 9 primary care processes, medicine algorithm and single diabetes management plan followed (in conjunction with project 1)