Diabetes Cycle of Care Follow-Up
Stay on track with comprehensive annual diabetes health reviews – coordinated with your GP and healthcare team to prevent complications and optimise your wellbeing.
Led by an AHPRA Registered Nurse and Credentialled Diabetes Educator. Learn more about us →
Book Your Free Consultation What's Included
What Is the Diabetes Cycle of Care?
The Diabetes Cycle of Care is a structured, evidence-based approach to managing diabetes. It ensures that all aspects of your health are regularly reviewed – from blood glucose control to kidney function, from eye health to foot care.
The Cycle of Care is recommended for all people living with diabetes. It helps you and your healthcare team:
- Identify potential problems early – before they become serious
- Keep your diabetes management on track
- Prevent or delay diabetes-related complications
- Coordinate care between different healthcare providers
At Diabetes Safe, we provide comprehensive Cycle of Care follow-up services. Led by an AHPRA Registered Nurse and Credentialled Diabetes Educator, we work closely with your GP and other specialists to ensure you receive complete, coordinated care.
Who We Help
This Service Is For You If...
Your Cycle of Care Is Overdue
You haven't had a comprehensive diabetes review in the past 12 months.
You Want to Prevent Complications
You want to stay on top of your health and catch potential issues early.
You Need Help Coordinating Care
You're seeing multiple healthcare providers and need someone to keep everything organised.
You Want to Track Your Progress
You want to see how your diabetes management is improving over time.
You Need a Care Plan Update
Your GP has recommended a care plan review and you need support.
You're Supporting a Loved One
You're a carer who wants to ensure your loved one's diabetes care is comprehensive and up-to-date.
What's Included
What Does a Cycle of Care Review Include?
A comprehensive Cycle of Care review covers all the key areas of your diabetes management. We work with you and your GP to ensure nothing is overlooked.
- Review of your blood glucose levels and patterns
- Assessment of your current diabetes management plan
- Review of medication effectiveness and adherence
- Discussion of challenges and barriers to management
- Recommendations for adjustments and improvements
- Blood pressure check and review
- Cholesterol and lipid profile assessment
- Cardiovascular risk assessment
- Smoking status and cessation support
- Lifestyle recommendations for heart health
- eGFR (kidney function) review
- Urinary albumin test coordination
- Early detection of kidney disease
- Referral to specialists if needed
- Coordination of eye checks and screening
- Referral to optometrist or ophthalmologist
- Understanding diabetic retinopathy and prevention
- Foot examination and skin check
- Circulation and sensation testing
- Foot care education and prevention strategies
- Referral to podiatrist if needed
- Weight and BMI assessment
- Nutrition and dietary review
- Physical activity assessment
- Goal setting for lifestyle improvements
- Assessment of diabetes distress and burnout
- Screening for anxiety and depression
- Emotional support and coping strategies
- Referral to mental health professionals if needed
- Comprehensive medication review
- Coordination with your GP for any changes
- Immunisation status review
- Care plan updates and referrals
How It Works
Your Cycle of Care Journey
We make the process simple and stress-free. Here's how it works:
Step 1: Initial Consultation
We meet with you (in-clinic, in-home, or virtually) to assess your current diabetes management and identify any gaps in your care.
Step 2: Health Assessment
We conduct a comprehensive health review – including blood pressure, weight, foot check, medication review, and lifestyle assessment.
Step 3: Coordinated Care
We coordinate with your GP and other specialists to ensure all necessary tests (bloods, urine, eye check, etc.) are completed.
Step 4: Results Review
We review your results together, explain what they mean, and identify areas for improvement.
Step 5: Care Plan Update
We update your care plan with new goals, strategies, and referrals – and share this with your GP.
Step 6: Ongoing Follow-Up
We schedule regular check-ins to monitor progress, celebrate wins, and adjust your plan as needed.
Why It Matters
Why the Cycle of Care Is Important
Prevent Complications
Early detection and management of risk factors can prevent or delay serious complications like heart disease, kidney disease, and vision loss.
Coordinated Care
We bridge the gap between you, your GP, and your specialists – so everyone is on the same page.
Better Outcomes
Structured, regular reviews lead to better blood glucose control, lower HbA1c, and improved quality of life.
Peace of Mind
Knowing that all aspects of your health are being monitored gives you confidence and reduces anxiety.
Why Choose Diabetes Safe
Your Partner in Coordinated Diabetes Care
Registered Nurse & Credentialled Educator
Your Cycle of Care is led by an AHPRA Registered Nurse with advanced training in diabetes care.
Coordination with Your GP
We work closely with your GP and specialists to ensure complete, coordinated care.
Comprehensive Reviews
We cover all aspects of the Cycle of Care – no shortcuts, no gaps.
Compassionate, Supportive Approach
We create a safe space where you can be honest about your challenges – without guilt or shame.
Learn more about our approach →
What Our Clients Say
Real Stories from Real People
Frequently Asked Questions