Diabetes Care Clinic (DCC) and Diabetes Self-Management Education Classes (DSME) Referral Guidelines

1. Purpose - To provide guidance for referring providers to determine what patients are eligible to be seen in the DCC, and who can be referred for DSME classes
2. Intent - The current model will ensure that newly diagnosed diabetics who required initial education and instruction will be seen in the DSME. It will also provide instructions for the DCC which will provide a one-on-one visit with a Diabetic Nurse Practitioner to evaluate and manage complicated Type 1 and 2 diabetes.
3. Procedure –
   1. Diabetes Care Clinic (DCC)
      • PCM will refer patients by placing a consult in CHCS/AHLTA under “Diabetes Clinic”.
      • The referral should be generated by the PCM or managing provider and include the following information: type of diabetes if known, duration, A1C% and clinical question or concern to be addressed.
      • Active Duty prediabetics should be referred to prevent progression to diabetes.
      • Type 1 Diabetes - The target patient population who has the highest priority are all Type 1 diabetics regardless of current control.
      • Complicated Type 2 Diabetics - Those who continue to have complications despite appropriate management will also be seen. Priority will be given to type 2 Diabetics who have had 6mo of care from their PCM with limited progress, and/or have significant co-morbidities or complications related to poor control to include the following:
        • Glycemic variability
        • Severe or recurrent unexplainable hypoglycemia
        • Severe insulin resistance requiring >80 Units of insulin per day , and failing usual titration of insulin to achieve glycemic control
        • Pregnant diabetics, or those in preconception care
      • Patients will be medically managed by the DM NP under the supervision of an Endocrinologist. These patients will be referred back to the PCM for continued care once an adequate treatment plan has been established for the patient.
      • The DM NP will refer refractory patients to the Endocrinology Clinic for further management as indicated.

4.  Diabetes Self-Management Education (DSME) class

• PCM will refer patients to the DSME classes by placing a consult in CHCS/AHLTA under “Diabetes Clinic”.
• The referring provider must state that the patient is referred for ‘diabetes education’.
• Referral guidelines include all Type 2 Diabetes (see criteria below). Patients who have pre-diabetes are also welcome to attend.
• Classes are held the first and second Wednesday of each month from 1100-1500.
• Patient are required to attend both classes.
• Maximum class size is 15. Family members can attend.
• Patients will have routine follow up at 6 weeks and 6 months.
• Management recommendations will be provided to the referring PCM to implement at their discretion.

 5. Criteria for the Diagnosis of Diabetes

• A1C greater or equal to 6.5%
• Fasting plasma glucose greater or equal to 126mg/dl. Fasting is defined as no caloric intake for at least 8 hours.
• 2-h plasma glucose greater or equal to 200mg/dl during an oral glucose tolerance test as described by the World Health Organization.
• Classic symptoms of hyperglycemia or hyperglycemic crisis, with random plasma glucose greater or equal to 200mg/dl.
• In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.