Diabetes Regional Education, Access and Management (DREAM)

The DREAM initiative is a new outreach diabetes service within St Vincent’s Hospital Network Sydney (SVHNS) which aims to address the inequity of access to specialist diabetes services in regional areas of NSW. The DREAM initiative houses a Diabetes Outreach Team who conduct a full day of face to face initial clinics within General Practice surgeries.

The DREAM initiative team conducts an initial case conference for patients, who are followed up by the team via telehealth post 6 month their initial clinic visit. The Diabetes Outreach Team will collaborate with the practice and Primary Health Network staff to set up clinics and provide guidance.

During the clinic, the patient sits with their General Practitioner (GP) and practice nurse, alongside the Diabetes Outreach Team comprising of an Endocrinologist and a Clinical Nurse Consultant (CNC) - Diabetes Educator.

Selection Criteria
  • GPs to select patients with diabetes who would benefit from specialist input. Examples include patients with:
  • Type 1 diabetes
  • Type 2 diabetes with poor control (HbA1c > 9%)
  • Type 2 diabetes with significant comorbidities including heart disease, chronic kidney disease, liver disease
  • Recurrent hypoglycaemia/hypoglycaemia unawareness
  • Hyperglycaemia due to glucocorticoid therapy
  • Undifferentiated diabetes, for example those with confirmed or suspected maturity-onset diabetes of the young (MODY)
  • Complex anti-hyperglycaemic pharmacotherapy
  • Complex psychosocial issues, diabetes self-management issues or difficulties
  • Foot complications of diabetes 
Exclusion criteria
  • Pregnant women
  • Aged < 18 years (to be referred to Children’s Diabetes Services)
  • Patients with pre-diabetes
  • Patients with diabetes already managed by a public or private diabetes service
How to participate

Contact diabetesmobilehealthservice@svha.org.au or phone 02 8382 2622 to register your interest. You will receive an email with a General Practice pack which includes a ‘SVHNS Expression of Interest (EOI) form’ and ‘GP Agreement Letter form’ for your completion and return via email. On completion of these documents, our CNC will be in contact to organise next steps with you. Please contact us for more information. 

Our team

Professor Jerry Greenfield
Head of Department, Endocrinology and Diabetes SVHNS

Gael Holters- Clinical Nurse Consultant (CNC), Credentialed Diabetes Educator (CDE)
Clinical Nurse Consultant- Diabetes Services

Dr Nele Lenders
Endocrinology and Diabetes SVHNS

Dr Lisa Raven
Endocrinology and Diabetes SVHNS



Gael heading to Tumut, NSW