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DIAGRAM 1: Diabetes Care Pathway
Case Finding for
those at
increased risk
Apply
appropriate
diagnostic test
Appendix 2
Screen yearly when
indicated
Confirmed
Diabetes
No
Yes
Targeted
screening
(Unmet need)
Type 2 :
Newly
diagnosed
Type 2: Controlled
>6 months review if:
*BP <= 140/80 (DM 31)
*HbA1C< = 7.5% (DM
26)
*Cholesterol <=5mmol/l
(DM 17)
Common set of
tests &
management
Type 2:
Controlled,
complex
* Renal,
Limb, Eye
Controlled
and
Type 1:
Not
complex
Type 2: Off-target,
not complex
:
Type 2: on oral
medications
transferring to
insulin
*BP>140/80 (DM 31)
*HbA1C>7.5% (DM 26)
*Cholesterol >5mmol/l
(DM 17)
* Mental
Health
Renal, Limb
& issue
Eye
* Other
Mentallong-term
Health issues
condition
* a secondary long
term condition
TIER 1 GENERAL PRACTICE DIABETES CLINICS
Established Diabetes
Type 2: Off-target,
complex
* Renal, Limb & Eye
* Mental Health issues
* Other long term
condition
Type 1:
Newly
diagnosed,
complex
TIER 2 COMMUNITY DIABETES HUB
Type 1:
Disengaged
from Tier 1/2
services
Gestational
Diabetes
Type 1 & 2 with
complications
requiring
* inpatient care
* const care
TIER 3 SPECIALIST CARE
Available at Hub: Podiatry, Dieticians, mental health, patient education and medical specialties
Nurse led clinics provide:
-
Basic Education at diagnosis
Initial Management and Continuing Care
Family planning and pregnancy advice
Health Promotion – Diet/Exercise/Smoking
cessation
Annual Care Planning including on-going
medication review – oral meds / insulin
Screening – QOF requirements
Patient sign-posting and information
Advice for patients and carers
Diabetic Specialist Nurses available for advice as
required.
Practice based joint clinical consultations with
diabetic specialist nurses as required
TIER 2a PRIMARY CARE led :
Liaison with LHC’s / general practice
TIER 2b DSN led:
Liaison with Tier 3 hospital care
As previous box plus;
-
As previous box plus:
-
Support and develop Tier 1 care
Insulin Initiation, assessment, education and lifestyle advice
Patient education (including targeted education for patients with ketoacidosis or hypoglycaemia )
Integrated pro-active management of people with early complications
Consultant level input (diabetes and other)
Pregnancy planning for complex unstable diabetes
Multi-disciplinary clinics including renal and cardiac support
15
-
Pregnancy
Insulin initiation emergencies
and failed community initiations
Diagnostic uncertainty
Serious complications
Insulin pump & new modes of
delivery
Children & adolescents
Inpatient management
Advice for carers patients and
Tier 2 and 1