Integrated Community Diabetes Services (ICDS) GP Referral Guide Version 3 - October 2014

Transcription

1 Integrated Community Diabetes Services (ICDS) GP Referral Guide Version 3 - October 2014

2 Introduction The Integrated Community Diabetes Service (ICDS) will deliver high quality care to individuals who have diabetes and are registered with a GP in Bury and Heywood, Middleton and Rochdale (HMR). Support will also be provided to their carers. The service s multi-disciplinary team comprises diabetes specialist nurses, dietitians and podiatrists, consultant diabetologists and a GP with a specialist interest in diabetes. The providers will deliver a fully integrated diabetes service that is responsive to the differing needs of individuals with type one, type two and other types of diabetes. Care will be delivered as close to people s homes as possible. The service is clinically-led, community-based and designed to meet the explicit needs of each individual. Full recognition has been given to the significant challenges posed currently and in the future. The remit of the service is to support and compliment primary care and allied services. The service will offer a specialist, goal-orientated and time-limited intervention with the intention of repatriation to patients primary care provider. The service will not undertake non-specialist services such as annual reviews. The ICDS provides three main elements of service: 1. Direct patient care Consultant led multi-disciplinary clinics GP with specialist interest-led clinics Diabetes specialist nurse-led clinics Diabetes specialist dietitian-led clinics Joint diabetes specialist nurse and diabetes specialist dietitian-led clinics e.g. carbohydrate counting or domiciliary visits Triage on to specialist care e.g. renal and vascular services Specialist psychological support 2. Delivery of structured education programmes e.g. X-PERT/DAFNE/ DESMOND/MAP. Bespoke education programmes will be offered to meet individual needs 3. Professional education e.g. MERIT (*) (Meeting Educational Requirements, Improving Treatment) training and bespoke education packages (*) MERIT is also the name for the community-based mental health team for people aged over 65 years in Rochdale and Heywood. There is no link between the two.

3 Referral criteria Patients must: Have diabetes and be registered with a GP in Bury or HMR Be aged 18 years or above Be referred via Choose and Book, with the minimum data set completed (see below for guidance) Be aware of the referral and give their consent (or a carer on their behalf) Inclusion criteria Patients with a new or suspected diagnosis of type one diabetes, or suspected type one diabetes Patients who are treated on insulin and have an elevated HbA1c above 69mmol/mol (8.5%) Patients with a diagnosis of type two diabetes who have an elevated HbA1c above 69mmol/mol (8.5%) that is not controlled on maximum therapy, as per NICE guidelines. Patients who are being considered for insulin or other injectable therapy and require support with initiation of this Diabetes where aetiology is uncertain and needs confirmation e.g. co-existent exocrine pancreatic failure requiring pancreatic enzyme replacement/m.o.d.y./l.a.d.a Patients who require assessment following their discharge from hospital, who were admitted as a result of one or more of the following acute diabetic emergencies: persistent hypoglycaemia, ketoacidosis, hyperosmolar hyperglycaemic state (HHS) (previously known as HONK) Patients with type one diabetes requiring specialist education via DAFNE or a carbohydrate counting clinic Patients with type two diabetes requiring a structured education program and who have consented to attend Patients with persistent problematic hypoglycaemia and/or loss of hypo awareness who require a diabetes assessment Patients with a primary diagnosis of diabetes and a BMI of less than 18 Patients with type one or type two diabetes who are planning a pregnancy and therefore require pre-conception education and advice Patients with diabetes who are approaching the end of life and require symptom control around their diabetes management Patients who are being considered for insulin therapy and require support with insulin initiation Patients with diabetes requiring review for a vocational license Patients with uncontrolled diabetes-specific complications (e.g. peripheral neuropathy, pain symptoms suggestive of autonomic neuropathy, chronic kidney disease grade four) and who require a diabetes assessment Patients already under the care of the high risk foot team who require a diabetes assessment Patients who have psychological issues directly related to diabetes, which are impairing glycaemic control and/or quality of life Patients below a level of 69mmol (8.5%) may be referred into the service where the referring GP deems this to be the most clinically appropriate pathway and provides the rationale behind the referral

4 This list is not exhaustive and referrals will be considered on an individual basis. To aid this decision-making, receiving adequate and accurate information about the patient is of paramount importance. Domiciliary visits can be undertaken if a patient meets the referral criteria for the service and, due to illness, disease or disability, is unable to leave their home without considerable help and support from another person(s) or the ambulance service. Exclusion criteria The following are exclusion criteria, where patients may require hospital admission or referral onto sub-specialist services: Acute diabetic metabolic emergencies Active foot ulceration Pregnancy Patients under the age of 18 years Triage process Following a referral via Choose and Book, a robust triage process will be undertaken within 72 hours. Patients who meet the referral criteria will be directed to the most appropriate element of the ICDS. All patients seen within the ICDS will have a personal management plan while within the service and on repatriation to primary care. Discharge criteria New referral patients who do not attend (DNA) their first appointment Follow-up patients who DNA two consecutive appointments, or who have a history of consecutive DNAs and cancellations of appointments Patients who, despite having had maximum specialist intervention through informed choice, chose not to comply with the management plan (option to rerefer after three months) Patients who have been seen in the service and who have a bespoke management plan which will be implemented in partnership with their GP GP referral letter minimum data set (MDS) Please ensure the following information is included in all referrals: Referring GP information: GP name GMC code Practice address, including postcode Practice code Telephone number Fax number

5 Specialty/department Date of referral Patient information: Surname and forename(s) Date of birth and age Sex Address, including postcode House and mobile telephone numbers NHS number Do they require an interpreter? If so, which language? Has the patient any special needs e.g. communication difficulties, learning disabilities Do they require an ambulance or other transport to attend their appointment? Has the patient has given consent to be referred to the service? Details of the presenting complaint Treatments that have been tried and the outcomes Significant past medical history Relevant investigations Details of their current medication Details of their allergy history The reason for their referral The expected outcome Their BMI (to assess suitability for offering providers with BMI referral criteria) Their smoking status (if clinically relevant) Details of the their up to date bloods (HbA1c, LFT s, renal and lipid profile) taken within last three months Inclusion criteria for out of hours clinical advice line An out of hours clinical advice line has been established that will be operational between 5pm and 8pm Monday to Friday and 8am to 8pm on Saturdays. The number is This number can also be used in-hours (9am to 5pm) for any clinical queries. Any routine queries should be directed to the hub on: or The patient must be registered with a GP in Bury or Heywood, Middleton or Rochdale, aged 18 and over, and have a confirmed diagnosis of diabetes. Inclusion criteria: Symptomatic and confirmed hyperglycaemia >13 mmol/ls > 24 hours relating to presenting complaint Acute unexplained episode of hypoglycaemia < 4mmol/ls Recurrent episodes of hypoglycaemia within last 24 to 48 hours - symptomatic and suspected diagnosis of type 1 diabetes, ie. BG > 13mmol/l + positive ketones Patients with diarrhoea and vomiting with hypo/hyperglycaemia