- Assessment on next step in treatment
- Patients with multiple co-morbidities e.g. heart failure, kidney failure (CKD stage 4 or more), obstructive sleep apnoea, resistant hypertension
- Patients with multiple diabetes related microvascular complications – peripheral neuropathy, autonomic neuropathy, gastroparesis, nephropathy etc.
- Patients on insulin where practices not familiar / confident with advising on insulin dose adjustment. In cases where this is the only issue, the community diabetes nurse will usually see the patient with the practice nurse/GP to educate and empower patients to self-adjust, but will not necessary continue formal follow up
- Patients struggling to gain desired glycaemic control who would benefit from specialist multidisciplinary support from psychologist, diabetes specialist nurse, specialist diabetes dietician, consultant diabetologist
- Uncertainty about classification of diabetes (e.g. Type 1 or Type 2, Maturity Onset Diabetes of the Young, Late Autoimmune Diabetes of Adults, Diabetes secondary to Chronic Pancreatitis etc.)
- Insulin initiation (in many cases, it is beneficial for patients to have a one-stop review by Diabetes Consultant even if practices are set up to do this)
- GLP-1 initiation (in many cases, it is beneficial for patients to have a one-stop review by Diabetes Consultant even if practices are set up to do this)
- Severely insulin resistant patients, especially those patients requiring more than 100 units of insulin /day
- Patients with CKD stage 4 (eGFR < 30ml/min) and/or creatinine > 150µmol/l)
- Difficult to control BP or lipids
* Patients who have reached a stage of their diabetes requiring additional injectible therapy ( insulin or exenatide/liraglutide) because of inadequate glycaemic control will often have other important diabetes related co-morbidities. Most of these patients would benefit, at that stage, from a one-stop Consultant Diabetologist assessment.*
Patients triaged by the community diabetes interface team will have one or more of the following possible outcome(s):
- Patient seen at the next joint interface clinic with GP/PN in the patient’s surgery.
- Patient seen at weekly urgent clinic.
- Patient referred to hospital diabetes clinic or other specialist clinic.
- Home visit by DSN/Community Nurse or Matron
