The Diabetes Cardiometabolic Care Programme supports Dr Martine Joffe's patients entirely


The Diabetes Cardiometabolic Care Programme is of great benefit," explains Dr Joffe. "Patients on the programme are engaged in their care, and know they have to come in for a certain number of visits which are funded in full. People are price-sensitive, particularly through the economic decline we saw in 2020.

The fact that access to the Diabetes Cardiometabolic Care Programme is funded through risk benefits - so does not impact members' medical savings - goes a long way to encouraging their adherence to the programme's timetable. In this way I can keep good tabs on them too.

GP, Dr Martine Joffe, has worked in a very busy general practice in Johannesburg North for the past 14 years. "We deal with everything from chronic disease management to psychiatric, gyneacological issues and acute traumas," she explains. "We also work with a core team of specialists beyond the practice. We take a very holistic approach to our patient-management - particularly in our management of diabetes.

For the past 11 years, she has dedicated much of her time to a satellite unit within the broader practice, dedicated to treating patients who are affected by diabetes.

Dr Joffe has a personal interest in ensuring optimal diabetes management. "My late grandmother lived with type 2 diabetes and was a bilateral amputee, so I understand the effects of unmanaged diabetes very well," she explains.

"We aim to enrol every member who require diabetes management - on the Diabetes Cardiometabolic Care Programme. The programme ensures - and funds - specific, personalised and relevant care for each patient and aligns very much with the holistic approach that is fundamental to achieving optimal management of the condition and nipping complications in the bud.

Giving patients who have diabetes access to the right healthcare providers at the right time

Once members have registered their condition on the Chronic Illness Benefit, their Premier Plus or Diabetes Cardiometabolic Care (DCC) doctorcan register them on the Diabetes Cardiometabolic Care Programme, which is designed to offer additional cover and support for people who have diabetes. This includes cover for:

  • One additional consultation with a dietitian each year (in addition to the consultation covered through the Chronic Illness Benefit)
  • One consultation a year with a biokineticist
  • A diabetes coach (for qualifying members)
  • And a personalised Diabetes Management Scorecard on the Discovery app

"We also apply the Diabetes Cardiometabolic Care Programme holistic care model to all our patients"

"Using the Diabetes Cardiometabolic Care Programme as our scaffold, we have built up processes to make sure that all the healthcare providers within our satellite unit speak the same language around diabetes management, ensuring that our patients hear the same, consistent, clear messages," adds Dr Joffe. "At the end of the day, we apply the Diabetes Cardiometabolic Care Programme type model to all our patients, whether they are members of a medical scheme or not. What we do is about far more than just sitting a patient down and explaining blood sugar readings and how diabetes can affect their life. It's about creating a partnership between the patient and their doctor to catch the condition early, treat it optimally and connect the patient with the right allied healthcare practitioners - a diabetic nurse educator, ophthalmologist, biokineticist, podiatrist and dietitian - at the right intervals through the year, to ensure that the complications associated with the progress of diabetes are prevented on every level."

"We are very hands on. We have an open door policy can call us with any query."

The unit's diabetic nurse educator plays a key role on several fronts. "She proactively books appointments with patients to ensure that they are on track with check-ups needed in line with the Diabetes Cardiometabolic Care Programme or over and above the programme's dictates, depending on the individual patient's needs. She also reminds people of their appointments, sorts out the few private accounts we have - the majority of claims go directly to the medical schemes- and educates our patients on all aspects of day-to-day diabetes management: taking their prescribed medicines correctly, insulin injection techniques, monitoring blood glucose levels and more."

"We are very hands on. We have an open-door policy, and patients can call us with any query. Overall, we hold patients' hands all the way, whether we've managed to catch their diabetes early, or are dealing with the complications of progressed and unmanaged disease. Unfortunately, we have had people come in with diabetes that may have been picked up years ago, but that has been poorly managed and has resulted in advanced eye disease, kidney disease, peripheral vascular disease and other complications associated with unmanaged diabetes. We refer them on for specialist care but keep very close tabs on them.

"We see far fewer diabetes-related complications in those patients we have had attend our diabetes unit for years, than in those who have come in already diagnosed with advanced, unmanaged disease."

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