Diabetes Care Project - how does a specific primary care intervention focused on multidisciplinary teams affect clinical and overall health outcomes when compared to usual care?

Intervention Group 1: - A new IT tool will be used by the patient and primary level care team (patient, general practitioner (GP), practice nurse (PN), allied health professionals (AHPs), specialists) to support care planning, share information with the patient and the team, and support a streamlined referrals process. - An education and training program will ensure that people (both practitioners and people with diabetes) can navigate the resources available to them and improve people’s understanding of diabetes management and include four components: 1. Training specifically on how to implement the DCP for practitioners and will be conducted at the start of the DCP. Practitioners will the option to complete the training in-person or online, however, in-person training will be encouraged. 2. Forums for all enrolled practitioners which will be held once each quarter, in-person, to discuss how the project is progressing and hear from a guest speaker on diabetes. 3. Weekly to monthly (frequency depending on demand) phone access to a diabetes specialist for all practitioners to discuss specific concerns/questions 4. DCP website which includes information on what the DCP is about and links to multiple diabetes related resources for both practitioners and patients which can be accessed at any time during the trial. Intervention Group 2: - A new IT tool will be used by the patient and primary level care team (patient, GP, PN, AHPs, specialists) to support care planning, share information with the patient and the team, and support a streamlined referrals process. - An education and training program will ensure that people (both practitioners and people with diabetes) can navigate the resources available to them and improve people’s understanding of diabetes management and include four components: 1. Training specifically on how to implement the DCP for practitioners and will be conducted at the start of the DCP. Practitioners will the option to complete the training in-person or online, however, in-person training will be encouraged. 2. Forums for all enrolled practitioners which will be held once each quarter, in-person, to discuss how the project is progressing and hear from a guest speaker on diabetes. 3. Weekly to monthly (frequency depending on demand) phone access to a diabetes specialist for all practitioners to discuss specific concerns/questions 4. DCP website which includes information on what the DCP is about and links to multiple diabetes related resources for both practitioners and patients which can be accessed at any time during the trial. - A new funding model will make more funding available for the care of those with the greatest need ('need' is based on a pre-defined set of clinical metrics), and will reward practices for improving patient health outcomes, improving patient experience, and delivering best-practice standards of care (through quality improvement support payments). This funding model will replace care planning MBS items, those items associated with diabetes-related PIPs/SIPs and AHP funding tied to a patients care plan—typical GP consults continue to be claimed through Medicare. - A new Care Facilitator role will be created. Care Facilitators, in collaboration with the general practice team and other members of the care team, will support the patient in finding the best available care options and proactively managing their care. Both Intervention Group 1 and Intervention Group 2 will have a total duration of two years