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 SNSWLHD-CommunityIntake@health.nsw.gov.au. 

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