Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
This project describes a remote, nurse practitioner (NP)–led paediatric type 1 diabetes model of care following regional diagnosis. The model demonstrates safe, high-quality local management that supports families to remain in their community.
Dates: Not available
Implementation sites: Darling Downs Hospital and Health Service, Toowoomba Hospital
Aim
To demonstrate how a remote, NP-led model of care can deliver effective paediatric type 1 diabetes management close to home following regional diagnosis.
Outcomes
- HbA1c 6.9% at 11 months post-diagnosis
- Successful insulin pump commencement within four months of diagnosis
- Ongoing diabetes management delivered entirely in the remote setting
- No diabetes-related hospital presentations or adverse events
- Reduced parental anxiety and increased confidence
- Resolution of school-based safety concerns
- Family decision to remain in community, with the child participating in normal childhood activities
Background
Children diagnosed with type 1 diabetes (T1D) in remote Cape York communities typically require retrieval to a regional centre for diagnosis and initial management. This commonly involves fixed-wing aeromedical transfer to Cairns and an inpatient admission of approximately one week. While clinically necessary, this pathway places a significant burden on families, including time away from employment, separation from other children, and disruption to family and community supports. Following discharge, care is often delivered through regional -based models that assume proximity to specialist services and regular face-to-face follow-up.
In metropolitan and regional centres, post-diagnosis care usually includes weekly individual or group education, a six-week Endocrine review, and ongoing three-monthly specialist follow-up. For remote families, this model requires repeated travel to regional centres, adding logistical, financial, and emotional strain at a time of significant adjustment. These pressures are amplified for younger children, where diabetes management is highly dependent on caregivers, schools, and predictable routines.
At the time of this child’s diagnosis, there was no established paediatric diabetes service in Weipa. The local diabetes nurse practitioner (NP) role had been vacant for approximately 18 months and intermittently covered by locum Credentialled Diabetes Educators, resulting in limited continuity. While GP support, visiting general paediatrics, and adult diabetes/endocrinology services were available, paediatric diabetes care remained regionally-led. Dietetic input was provided by a generalist dietitian without paediatric diabetes expertise, and schools had not previously received diabetes-specific training for T1D.
Several early risk factors were identified. The child entered the honeymoon phase, resulting in increased insulin sensitivity, glycaemic variability, and heightened hypoglycaemia risk. Parental anxiety, particularly relating to hypoglycaemia, was significant and required repeated education and reassurance. School-based challenges emerged early, including concerns regarding insulin access and safety during school hours. These risks were compounded by contextual factors, including food shortages associated with regional flooding, which disrupted consistent carbohydrate availability.
These challenges were not theoretical. The family explicitly raised relocation due to concerns about safety, school management, perceived lack of local expertise, and distance from tertiary services. This highlighted the need for a place-based model prioritising continuity, trust, and access, while maintaining high clinical standards. The reinstatement and expanded utilisation of the diabetes NP role provided an opportunity to deliver advanced paediatric diabetes care locally, reduce fragmentation, and support families to remain safely in their community.
Methods
This project utilised a nurse practitioner–led, place-based model of care to transition paediatric T1D management from regional services to a remote community following diagnosis. Care was delivered by a Nurse Practitioner (Diabetes and Chronic Disease) practising autonomously, with independent prescribing authority and insulin pump initiation within scope. Paediatric diabetes expertise was formally recognised through local Hospital and Health Service credentialling and supported by seven years of specialist experience.
A structured transition to local care was initiated following inpatient management in Cairns. The first review in Weipa occurred within one week of discharge and was conducted in person. Handover included a written management plan, direct phone communication, and a joint virtual review involving the family while still in Cairns. A shared care model was established early, with primary management delivered locally and regional input accessed as required.
In the first three months post-diagnosis, reviews occurred weekly to fortnightly using a mixed face-to-face and phone model. As stability and confidence improved, review frequency transitioned to eight-weekly to three-monthly. Between scheduled reviews, the family had access to the NP via phone, text, and email during business hours, with CGM data reviewed between visits as needed.
Education was delivered through one-on-one, repeated, bite-sized sessions. Early priorities included hypoglycaemia recognition and treatment, insulin adjustment during the honeymoon phase, sick day management, carbohydrate counting, interpretation of glucose data, and clear delineation of school responsibilities. Parental anxiety was addressed as a clinical priority through repetition, reassurance, practical planning, shared decision-making, and real-time CGM review. Additional psychosocial supports included GP engagement for maternal wellbeing, RFDS psychology referral, and paediatric psychology input for the child via virtual care.
School engagement was a core component of the model. This included meetings with school leadership and staff, development of a written diabetes management plan, delivery of diabetes-in-schools education, mediation between school and parents, and liaison with state school nursing services. Challenges related to insulin access and peer participation were addressed through changes to insulin delivery methods, improving safety and engagement.
CGM was commenced at diagnosis and transitioned to pump-integrated CGM at the time of insulin pump initiation. Insulin pump therapy commenced locally in June 2025 following structured preparation and confidence-building. Post-initiation support included weekly to fortnightly follow-up for one month, remote data review, and local troubleshooting.
Key initiatives developed included a structured regional-to-local transition pathway, an NP-led paediatric diabetes follow-up model, a diabetes-in-schools engagement process, and a locally delivered insulin pump initiation pathway. These initiatives were refined iteratively in response to family feedback, school challenges, and glycaemic data trends, consistent with informal quality improvement principles. Outcomes were monitored using HbA1c, CGM metrics, attendance, and qualitative family feedback at 11 months post-diagnosis.
Discussion
This project demonstrates that high-quality paediatric T1D care can be delivered safely and effectively in a remote setting when advanced practice roles are utilised to full scope and embedded within the community. Continuity of care was central to success, with consistent clinical oversight enabling trust, reducing fragmentation, and allowing care to be tailored to the child’s real-world environment.
Frequent early follow-up during the honeymoon phase supported proactive insulin adjustment and addressed hypoglycaemia risk, while acknowledging parental anxiety as a legitimate clinical concern. Relationship-based care, reinforced by access to real-time glucose data, was critical in building confidence over time.
School engagement emerged as a key determinant of success. Early system challenges had a direct impact on safety and family confidence. Direct engagement, education, mediation, and collaboration with school nursing services enabled practical, sustainable solutions and reduced escalation over time. Local initiation of diabetes technology further reduced reliance on tertiary services and supported continuity.
This model relied on a credentialled NP practising autonomously within governance frameworks, workforce stability, and clear escalation pathways. While outcomes are illustrated through a single child in one community, the principles underpinning this approach—continuity, trust, access, and place-based care—are transferable across remote settings.
The next step is to continue embedding this approach within routine remote diabetes care, with a focus on maintaining continuity and local confidence. Supporting families to manage complex care close to home reduces disruption, builds trust over time, and enables children to participate fully in everyday life within their community.
References
Limbert C, Tinti D, Malik F, Kosteria I, Messer L, Jalaludin YM, Benitez-Aguirre P, Biester S, Corathers S, von Sengbusch S, Marcovecchio L. Chapter 07: The delivery of ambulatory diabetes care to children and adolescents with diabetes. In: ISPAD Clinical Practice Consensus Guidelines. International Society for Pediatric and Adolescent Diabetes; 2022. DOI: 10.1111/pedi.13417
Key contact
Fiona Sellers
Nurse Practitioner, Diabetes Chronic Disease
Weipa Health Service