The individual and practitioner have discussed, agreed on and documented target levels of glycaemic and modifiable cardiovascular risk factors.
Regular monitoring of targets is in place to assess progress.
Individuals not meeting agreed targets are easily identified.
Lifestyle issues are addressed and recommendations and support provided.
Treatment is reviewed and altered if required to enhance control.
Those not meeting targets despite optimal guideline based treatment are referred for expert help.
Data is collected to monitor progress and for reporting purposes.
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