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Specialist Diabetes Clinics

The Nurse Practitioner Diabetes service is a new mobile diabetes service incorporating advanced assessment and treatment planning. Based at the Queanbeyan Health Service, it provides face-to-face visits at Community Health centres located within the Southern NSW Local Health District on a rotating schedule every three months.

Services include:

  • comprehensive assessment, identification and prioritising of clinical issues
  • planning, implementation and evaluating treatment strategies
  • medication management
  • assistance with continuum of care and integration of services across sites and disciplines
  • case management and consultation of patients with other diabetes team members
  • identification of patients requiring referral to diabetes medical specialist clinics.

Criteria for referral include:

  • patients >15 years who have an identified diabetes-related health care concern that is not able to be managed by standard community service
  • patients who are at risk of presenting to the emergency department or being admitted/re-admitted, and who would benefit from a management plan as part of hospital avoidance.

Full criteria listed below.

How to refer:

Community referrals can be made by GPs through Southern NSW LHD Community Health Central Intake on 1800 999 880 or by emailing

Referral form and details can be accessed at ACT & SNSW HealthPathways – search for Routine Diabetes Team Referrals and click on SNSW.

Full list of criteria for referral 

Referral inclusion criteria:

  • patients with type 1 diabetes, LADA, type 2 diabetes
  • HbA1c >8.5% (>69mmol/mol) with or without hospital presentation/admission in the past 12 months)
  • blood glucose levels consistently elevated
  • eGFR >45mL/min/1.73m2
  • type 2 diabetes requiring insulin or GLP-1 initiation or titration
  • newly diagnosed type 2 diabetes not stabilised within three months
  • prescribed corticosteroids (prednisolone and dexamethasone) regardless of HbA1c
  • prescribing of all glucose lowering medicines and glucagon (except where CTO listed)
  • prescribing of all blood pressure lowering agents (except where CTO listed)
  • prescribing of all lipid modifying agents (except where CTO listed)
  • dose alteration or cessation of above medicines

Referral exclusion criteria:

  • patients aged 15 years and under
  • women with pre-gestational diabetes and pregnancy
  • women with gestational diabetes mellitus (GDM) requiring insulin prior to 20 weeks gestation
  • patients suspected/diagnosis with pancreatic cancer
  • patients with stage 3b, 4 or 5 chronic kidney disease (Kidney Health Australia)
  • patients with class III or IV heart failure (NYHA grading system)
  • unstable or life threatening medical conditions (non-diabetes)
  • patients in whom diabetes management is not the current focus of treatment



Last updated: 29 June 2018