Merton diabetes community services

For all diabetes educationand face to face assessments please complete this form and email to or fax to 0300 008 2122.
For e-mail advice/routine scheduled telephone advice please e-mail:
If you feel the patient is not an emergency but may be at risk of hospital admission, please call MERITUrgent (Rapid Response Team) on 0208 687 4840
Mandatory informationrequired is marked with an asterisk*. Incomplete forms will be returned and may cause delay.
The Merton diabetes model is based on the Health Care for London model consisting of four tiers of care.
  • Tier 1: Essential care(delivered from practices)
  • Tier 2: Enhanced essential care (for insulin or GLP 1 initiation)
  • Tier 3: Community consultant-led specialist care from primary care locations (this is delivered from primary care locations in the community supported by a multi-disciplinary team of consultant, specialist nurses and specialist dietitian).
  • Tier 4: Hospital based care (only for the most complex patients and for medical emergencies).

Patient’s details
Forename(s)* / Surname(s)*
NHS number* / DOB*
Address (incl. postcode)*
Daytime contact number* / Alternative contact number*
Will the patient be accompanied by a carer or NOK?* YES NO
Carer/NOK details*
Do we have consent to share health information with the above?* YES NO
Do you undertake house calls to this patient?* YES NO
Interpreter required?* YES NO
Specify language*
Ethnicity (input below if not auto-populated from EMIS)
White British
White Irish
Any other White
Mixed: White & Black Caribbean
Mixed: White & Black African
Mixed: White & Asian / Any other mixed background
Chinese
Asian or Asian British Indian
Asian/Asian British Bangladeshi
Asian or Asian British Pakistani
Any other Asian background / Black/ Black British Caribbean
Black or Black British African
Any other Black groups
Any other ethnic group
Declined to state ethnic origin
Does the patient have a learning disability? YES NO
Does the patient have dementia/cognitive impairment? YES NO
GP letter:
Date
User name
Practice address
Dear colleague
Thank you for seeing
Yours sincerely
Job title – GP Practice nurse Consultant DSN PA Clinical pharmacist Other
Required information (please attach EMIS summary)*
  • Current medical history
  • Past medical history
  • Medication
  • Allergies
  • Weight
  • Height
  • BMI
  • HbA1c
  • Lipids

Do you require:
Email advice/ routine scheduledtelephone advice: please email
(agreed response / call back day and time within seven working days)
OR
Face-to-face assessment: please or fax to 0300 008 2122
Osmotic symptoms, weight loss and ketonuria or a suspected diabetes related admission – please speak to medical consultant on-call at the relevant acute trust urgently – probably a New Type 1. Will be seen in Tier 4 clinic or ED within 24 hours.Acute visual loss, please send to emergency eye clinic the same day at the relevant acute trust.
DKA/HONK call 999and please speak to medical consultant on-call at the relevant acute trust
Tier 2
Type 2 diabetes - to initiate GLP-1 agonist therapy
Type 2 diabetes - to initiate insulin therapy
Tier 3: not an exhaustive list – if you’re unsure, refer.
Type 1 diabetes
Stable type 1 diabetes over 25y
Exclusion criteria
  • Newly diagnosed
  • Needing continuous blood glucose monitoring
  • Recurrent hypos
  • Poorly controlled
  • Associated mental health issues, eg eating disorders
Specialist dietician assessment
Type 2 diabetes
Off-license treatment or using four agents (as a combination of oral agents and injectable(s))
Recurrent hypos/unawareness
Failing injectable treatment
HbA1C>75 mmol/mol and/or unsure of treatment options
LFTs >3 times normal and fully investigated
Peripheral neuropathy
Specialist dietitian assessment
Drivers/DVLA regulation with hypos/HGV/passenger carrying vehicles
Pre-conception
Pre-conception management in type 2 diabetes
Hospital discharges
Supported discharge from hospital
Education
Type 2 (DESMOND) Group Education (newly diagnosed)
Type 2 (DESMOND) Tamil Group Education (newly diagnosed)
Type 2 (DESMOND) Group Education (refresher)
Type 1 diabetes requiring education
Type 2 diabetesnotsuitable for group education
Podiatry – please use podiatry referral form
Other (please write):

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