Social worker removes barriers to diabetes care

Shane had been working with his diabetes dietitian for some time when he revealed he couldn’t actually make the meals she had been recommending to him.

A vascular condition meant the single dad from Rocky Cape suffered from a mix of intense pain and loss of feeling in his hands that made pushing a shopping trolley and driving a car difficult – at times impossible.

“The hardest thing is trying to eat healthy – it’s only a half-hour drive to Wynyard, but fresh stuff doesn’t last that long and it’s so bloody expensive as well,” Shane says.

“My oldest son does probably ninety per cent of the cooking, because my hands just can’t take too much of it.”

Cue Neeta Oakley – social worker with Diabetes Australia in Tasmania. That’s right – social worker.

Not a common member of a diabetes clinical team but, for the organisation, an increasingly critical member.

Diabetes Australia introduced this new role as part of its Primary Health Tasmania-funded clinical services in early 2021, in response to feedback from clinical staff about an increase in psychosocial issues that were preventing clients from achieving diabetes self-management.

The complexity of some clients’ situations was felt to be beyond the clinicians’ own scope of practice, and immensely time consuming.

Neeta says as with any chronic (long-term) health condition, the core focus of diabetes health care is enabling self-management.

“The aim is to support people to be able to live well with their diabetes and there are certain skills, knowledge and behaviours they need to be able to do that,” she says.

“But there can be a lot of barriers to people in our community achieving self-management.

“A diabetes educator can ask someone to start doing finger pricks, but if you’ve got a major life event happening like a separation or caring for a sick relative or you have your own mental health challenges going on, that’s going to be fairly low on your list of priorities.

“If your personal life is in chaos, your diabetes management generally will be too. It’s important to provide coordinated support at those times and prevent a crisis.

“Social workers can support people with those challenges so they can get through that time then say OK, now I can think about food, or I can think about getting a blood test or seeing a doctor.

“Everyone wants to be healthy and look after themselves, but it is seriously hard for some people.”

Interviews with Diabetes Australia clinicians and clients identified poor mental health, limited access to services, and financial distress as key psychosocial barriers to diabetes self-management.

“There will be a newly diagnosed woman who can’t face having to look after her diet or even actually turn up to health appointments because her husband recently died,” Neeta says.

“Or someone in chronic pain who can’t afford to get from their rural home to their doctors, who have now stopped bulk billing.

“Or someone who is temporarily homeless and has nowhere to store their insulin, which needs to be refrigerated.”

Neeta, who had previously worked with cancer and palliative care teams, took the qualitative data from the interviews and developed a social work service providing brief counselling and short-term care coordination via telehealth.

“Our team is skilled at working collaboratively with all people with diabetes and working out if their barriers to health are low health literacy, a complex social or personal situation, or a very complex set of medical demands,” she says.

Her support might be in the form of arranging a referral into one of Primary Health Tasmania’s funded mental health services; ensuring safety for older people at home by connecting them to a falls prevention program and home services; finding a pharmacy willing to store insulin on behalf of a community member; or counselling a carer in distress who is trying to look after their own diabetes.

“Many people are very confused and lost in the healthcare system. I help them coordinate their health and social care when they have obviously fallen through the gaps,” Neeta says.

A large focus of her role is linking people into the range of high-quality but often siloed services that exist across the state.

“I help people build a bridge into their local services and communities and make sure they’re totally connected in and using those services before I say goodbye.”

As well as her direct contact with clients, Neeta facilitates psychosocial educational workshops and offers formal peer consults with her 15 clinical team colleagues across the organisation’s offices in Hobart, Launceston and Devonport.

“They can just ring me to go through a case and they don’t necessarily have to hand it over – we will brainstorm the best pathway together. Or we might decide that actually, that is quite serious and needs someone like me with mental health training to respond immediately,” she says.

Both clinicians and clients have reported significant benefits from the inclusion of a social work service in diabetes care.

Neeta presented on the service at the Australasian Diabetes Congress in 2022, where she told delegates that 80% of staff had reported the addition of a social worker had enhanced the team approach to diabetes care.

The ability to respond to complex cases and improve referral pathways was seen as allowing the whole team to focus more on their core practice.

“I work pretty much with everyone, including the admin team, because they’re front-of-house and they sometimes take calls from people who are very distressed,” Neeta says.

“Our educators and dietitians establish such strong relationships with their clients, they’re talking with them sometimes for an hour every month; they discuss things that their GP often wouldn’t have time to know, which we can act on with them.”

Which brings us back to Shane, whose diabetes dietitian connected him with Neeta when he disclosed his lack of progress on the meal prep front.

After talking to Shane about the challenges he was facing, Neeta helped organise home care services including some cooking support, cleaning and yard work.

Young carers support was arranged for his son, and Neeta helped fill out forms and arrange medical reviews to support an application for the disability support pension.

“They’ve been absolutely marvellous – I’ve been extremely grateful,” Shane says.

“Unless someone tells you what help’s out there, you don’t know.

“Without their support, I would have gone crazy by now. I can’t thank them enough – that’s for sure.”

This story features in Issue 17 of our Primary Health Matters magazine. Click here to read the rest of the issue.