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.
- 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