After several years of collaboration, the Care Partnership – Diabetes (CP-D) Program concluded on 30 June, leaving behind a stronger, better-connected diabetes workforce, enhanced clinical pathways and a sustainable diabetes care capability that will continue to support communities across Western and Far West NSW.
Funded by NSW Ministry of Health and delivered through a partnership between Western NSW Local Health District (WNSWLHD), Far West Local Health District (FWLHD), Western NSW Primary Health Network (WNSW PHN) and Rural Doctors Network (RDN), the program was established to improve outcomes for people living with Type 2 Diabetes by strengthening workforce capability, improving access to care and creating a more integrated health system.
Over the life of the program, partners worked together to address the unique challenges of delivering diabetes care across one of the most geographically dispersed regions in NSW. Through education, clinical support, service improvement initiatives and stronger integration across primary and hospital care, the program has helped build a sustainable foundation for better diabetes management into the future.
Improving patient access
Improving access to timely, high-quality diabetes care was a central focus of the CP-D program. Across Western and Far West NSW, partners implemented different but complementary models of care to ensure people living with or at risk of Type 2 Diabetes could access support closer to home.
In Western NSW, the program funded the establishment of the Western Diabetes Hub, creating a multidisciplinary virtual model of care designed to reduce barriers to diabetes support for people living in rural and remote communities. Importantly, the investment in designing, testing and embedding the service has resulted in a sustainable capability that will continue to support communities beyond the life of the CP-D Program. The Hub is now an established component of diabetes care delivery in Western NSW, providing ongoing access to expert clinical support, education and care coordination.
The Hub provides access to expert diabetes support, including for people newly diagnosed with Type 2 Diabetes or prediabetes, helping connect patients with education, clinical advice and ongoing management closer to where they live. Through early intervention and individualised, goal-directed support, people have achieved improved health outcomes, including reductions in HbA1c and other clinical markers. Patient experience with the program has been extremely positive, with 92% of patients reporting that the Hub has helped them to better manage their diabetes, and 100% reporting that the Hub makes it easier to access diabetes care.
The Western Diabetes Hub team includes diabetes educators, a dietitian, an exercise physiologist and Aboriginal Health Practitioners (AHPs). The AHPs are integral to the model of care, supporting all patients referred to the service, including 46% of Hub patients who identified as Aboriginal.
Community education, engagement and screening activities further strengthen early identification and intervention efforts in Western NSW. Through community-based HbA1c point-of-care testing and diabetes education activities, the Hub helps to identify people at risk and connect them with appropriate services and supports earlier in their care journey.
Access to specialist care has also been expanded through the introduction of Type 2 Diabetes case conferencing and bulk-billed telehealth endocrinology services delivered through eCARE and MetaDiab. This service improves access to specialist advice and supports more timely intervention for people requiring complex diabetes management.
In Far West NSW, the program adopted an integrated, community-led model of care delivered in partnership with primary care providers, Aboriginal Community Controlled Health Organisations and community partners. By delivering services within community settings and embedding coordinated care pathways, the program improved prevention, early detection and management of Type 2 Diabetes while reducing barriers to accessing care.
A key achievement was the delivery of more than 1,000 point-of-care HbA1c screening tests, which established community screening as a routine entry point into the diabetes care pathway. The program also introduced a hybrid diabetes education service, combining face-to-face and virtual support delivered by Diabetes Educators and Aboriginal Health Practitioners, providing people with greater flexibility in how they accessed care and education.
The Far West model strengthened links between community screening, primary care and specialist services through integrated referral pathways, ensuring people identified as at risk or living with diabetes could be connected to appropriate support more quickly. Strong partnerships with Aboriginal Community Controlled Health Organisations, primary care providers and community organisations also helped deliver more coordinated, person-centred care across the region.
Building a stronger workforce
One of the program’s most significant achievements has been the development of a stronger local diabetes workforce.
Connecting health professionals
In Far West NSW, the program established the Far West Diabetes Network, bringing together clinicians, services and partner organisations to strengthen collaboration, improve service coordination and support ongoing workforce development across the region. The network has helped build stronger professional connections and create a more coordinated approach to diabetes care.
Similarly in Western NSW, the program established the Western Diabetes Education Network, which now connects 45 health professionals from across the region. The network has reduced professional isolation, encouraged peer learning and strengthened collaboration across the region.
Rural Health Pro – a community designed by RDN to support health professionals working in rural and remote settings – was used to strengthen the diabetes workforce in Western NSW through a dedicated microsite that brought together in one place details of the workforce enablers delivered by the CP-D program partners. The microsite featured details about CP-D services, technology enablers, training, news and an online community of practice. This enabled a community of practice where professionals could share knowledge, seek advice and collaborate.
Professional development grants and upskilling events
Through scholarships, bursaries and study support, the program enabled 14 health professionals to complete a Graduate Certificate in Diabetes Education and Management, with a further four participants progressing towards completion. The program also supported five Aboriginal Health Practitioners to undertake diabetes education studies, helping strengthen culturally responsive care across the region. If all supported participants achieve credentialling, the program is projected to increase the Credentialled Diabetes Educator workforce across Western and Far West NSW by 80 per cent from the 2023 baseline.
More than 50 health professionals were supported through professional development funding, travel grants and accommodation subsidies, improving access to education opportunities that are often difficult to access in rural and remote communities.
The program also recognised the important role of non-clinical staff in supporting people living with diabetes. More than 100 non-clinical health professionals participated in workshops covering diabetes awareness, culturally safe communication, health literacy and patient engagement.
Workforce mentoring
In the Far West, workforce capability was further strengthened through multidisciplinary education and mentoring opportunities that supported health professionals to build skills and confidence in diabetes care.
ECHO learning
A cornerstone of the workforce development effort was the Type 2 Diabetes ECHO series.
Since launching in mid-2022, the program has delivered 32 virtual sessions and two face-to-face ECHO events, engaging 950 health professionals from across Western and Far West NSW.
Using the internationally recognised Project ECHO model, the sessions connected local clinicians with specialist expertise and peer support through case-based learning. Topics included treatment updates, therapeutic carbohydrate reduction, continuous glucose monitoring, chronic kidney disease, diabetes complications, nutrition, oral health and high-risk foot management.
The sessions were supported by an expert multidisciplinary panel including endocrinologists, GPs, nurse practitioners and chronic disease specialists.
Participant feedback highlighted the practical impact of the program, with clinicians reporting improved diabetes management strategies, greater collaboration with Aboriginal health teams and increased confidence supporting patients living with Type 2 Diabetes.
Type 2 Diabetes Masterclasses
The annual Diabetes Masterclasses, delivered in partnership with Western Sydney Diabetes, provided additional opportunities for health professionals to learn from leading experts and share their experiences.
The 2025 Masterclass attracted 92 participants and explored topics including emerging diabetes treatments, nutrition, lived experience perspectives, diabetes prevention and management.
In 2026, attendance grew to 101 participants, with sessions covering incretins, atypical diabetes, high-risk foot care, eye disease, culturally safe conversations and emerging digital technologies. Participants consistently praised the quality of presenters, practical content and opportunities to connect with peers and specialists.
Supporting general practice and Aboriginal Community Controlled Health Services
Alongside workforce development activities, CP-D invested in service enhancement initiatives delivered through 14 general practices and Aboriginal Community Controlled Health Services (ACCHSs) across Western and Far West NSW. These projects were designed to strengthen local diabetes services, improve access to care and support innovative approaches to diabetes management within primary healthcare settings.
Through tailored service enhancement models, participating practices and ACCHSs were supported to improve diabetes care pathways, increase patient engagement, enhance care coordination and strengthen multidisciplinary approaches to diabetes management. The projects enabled services to identify local priorities and implement solutions that responded to the unique needs of their communities, helping to improve access to diabetes support closer to home.
The service enhancement stream enhanced collaboration between primary care providers, Aboriginal health services and local health partners, contributing to more integrated and patient-centred diabetes care. Importantly, these initiatives helped build organisational capability and supported sustainable improvements that will continue to benefit people living with diabetes beyond the life of the program.
Strengthening the health system
The program has contributed to a more connected and coordinated health system through collaboration, shared resources and improved clinical guidance.
A key achievement was the partnership between CP-D and HealthPathways, which helped integrate primary care, community health and hospital services through a shared platform of local clinical guidance. The collaboration resulted in the development of 19 diabetes-related pathways and referral pages, supporting clinicians to assess, manage and refer patients appropriately while improving access to consistent, evidence-based care across the region.
The pathways cover the full diabetes journey, including screening and diagnosis, Type 1 and Type 2 Diabetes, diabetes in pregnancy, medications, complications, hypoglycaemia, driving, elective procedures, sick day management and referral pathways for specialist assessment, education and support.
As diabetes services evolved through the program, HealthPathways was continuously updated to ensure healthcare professionals had access to the latest local information and referral options.
A lasting impact
One of the program’s greatest achievements has been the partnerships it created between healthcare providers, educators, community organisations and health services across Western and Far West NSW. These collaborations enabled locally responsive initiatives that addressed workforce challenges while improving access to diabetes care in rural and remote communities.
In Far West NSW, the program has created a sustainable foundation for integrated diabetes care, with collaborative partnerships, referral pathways and workforce networks continuing beyond the life of the project.
In Western NSW, one of the most significant legacies is the Western Diabetes Hub. What began as a CP-D funded initiative has evolved into an established and sustainable service capability, ensuring ongoing access to multidisciplinary diabetes care and support for communities across the region. The Hub demonstrates how strategic investment can create lasting system change, embedding new models of care that continue to deliver benefits long after the original program has concluded.
While the CP-D Program has come to an end, its impact will continue through the services it helped establish, the health professionals it supported, the relationships it fostered, the resources it developed and the stronger systems it put in place. Together, these achievements have created an enduring legacy that will continue to improve diabetes care and health outcomes for communities across Western and Far West NSW for years to come.
