The Community Diabetes Service offers clinical support for adults with type 2 diabetes through a multi-disciplinary team, providing insulin and non-insulin therapy management, personalised dietary guidance, and structured education programmes, such as DESMOND, to enhance self-management skills and promote effective diabetes control in the community.

Eligibility Criteria

Inclusions

• patient with Type 2 Diabetes with acute or persistent hyperglycaemia (on 3 or more glycaemic agents at maximum tolerated dose)
• steroid-induced diabetes
• initiation of insulin or GLP-1
• review of insulin regime OR change of regime
• supporting discharge from the hospital
• acute or persistent hypoglycaemic episodes
• patient education programme DESMOND (newly diagnosed OR never had education before - not for pre-diabetes)
• dietetic individual assessment: for poorly controlled Type 2 diabetes/education re: carb
• awareness; and those unsuitable for group patient education programme i.e. language barriers, learning disabilities
• patient education group session for insulin titration support (suitable for multiple daily injection regimens, such as twice daily mixed insulin or basal bolus regimen)
• patient education group session for patients receiving GLP-1 or GLP-1/GIP medication (not for initiation, suitable for patients already taking Victoza, Trulicty, Rybelsus, Ozempic, Mounjaro)

Exclusions

• Type 1 Diabetes, LADA and MODY
• pregnancy
• insulin pumps
• CKD 4 and 5

How to Refer