Hamilton patient Alex is an ex-practice nurse, a full time professional worker in her 50s, fit and happens to have been diagnosed with Type II diabetes about 10 years ago.
Alex, who wishes to remain anonymous, says that people often think of chronic care as related to elderly people, but she is proof that it can happen to an average woman like her.
"I've gone through a process of diet control and oral medication. But it hasn't worked out as well as I had hoped," she said.
"I ended up with an unpleasant infection and hospital admission in the middle of 2014, possibly due to poor diabetes control."
Alex was already in discussion about starting insulin with the clinical team at her Hamilton general practice.
"The process was awesome. After being discharged from hospital, I talked to a nurse who said we need to start thinking about using insulin. Their service was incredibly patient-centred, I found it helpful, useful, streamlined, and easy."
"I had an initial conversation, then a one hour appointment with the diabetes specialist nurse, which my husband came to as well. The nurse went through absolutely everything."
Alex started on six units of insulin and is now injecting 28 units.
"Every time I go up two units, it means I need to contact my practice. Given I work full time, I don't want to visit them on a regular basis. Being able to do this via email is so easy, it's a great alternative to playing telephone tag with my GP or nurse."
Alex's GP uses ManageMyHealth, and between them they've sent about 10-15 emails via the Patient Portal.
"I take my blood sugar readings and put them into ManageMyHealth, so my general practice team can see up-to-date results. This helps us make better decisions," she says.
Alex's blood sugars are lower and she has more control, she is being managed completely in primary care with support from the multidisciplinary teams.
"I have an upcoming appointment with a podiatrist. He told me to bring in all my shoes. Do you have any ideas how many shoes I have?" joked Alex.
"I've had my annual diabetes check and we've set some goals, including getting fitter and losing weight. I was offered support from Sport Waikato and some resources through the Green Prescription, I was also offered nutritional advice."
Pinnacle general practices across the network can access services such as podiatry, social work, community pharmacy and dietetics simply by referring patients to the multidisciplinary team (MDT).
MDTs are an important part of the Long Term Conditions Management Programme. They are coordinated in primary care using shared processes and pathways so patients receive appropriate, timely care.
For more information, visit www.midlandshn.health.nz/programmes/mdt.