Pre-Diabetes and type 2 diabetes referrals

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Pre-diabetes and type 2 diabetes referral and self-management pathway gives the practitioner/clinician an opportunity to provide a holistic conversation with those at risk of developing type 2 diabetes or diagnosed with type 2 diabetes by offering a choice of options depending on individual preference and needs at that particular time.  

We know it is important to offer the right health information at various stages throughout care and in a variety of formats therefore the pathway incudes.  

  • online information/useful websites to signpost 
  • access to printable information to give out to patients 
  • information about services available in Highland for people with or at risk of type 2 diabetes 
  • peer opportunities for those with or at risk of type 2 diabetes 

The pathway was informed by: 

  • a healthier future: framework for the prevention, early detection and early intervention of type 2 diabetes (Scottish Government, 2018) 
  • Highland health needs assessment carried out in 2018 
  • feedback from primary care colleagues 
  • feedback from people currently living with type 2 diabetes 

Type 2 Diabetes Education

Service/Provision  Live it Highland 1-1 
Service information 

Live it Highland is a patient information pack for people diagnosed with pre-diabetes or type 2 diabetes, ensuring everyone receives quality, baseline information across NHS Highland.  It supports health professional have holistic conversations with people around the following topics.  

  • What is diabetes 
  • Food, mood and diabetes
  • Activity and diabetes
  • Stress and soothing
  • Good sleep matters
  • Ongoing self-management and signposting
Patient group/referral criteria  People with pre-diabetes and newly diagnosed with type 2 diabetes 
Availability 

This is available to all GP's, practice nurses, health practitioners working in diabetes care.  

Please ensure you have read the facilitators handbook prior to using the participants pack.  

To access the participants pack download from patient material section below or alternatively via HIRS health improvement resource service.  

Referral form   
Patient material 
  • Written/printable this can be give out to patient
  • digital this can be emailed to patients

Diabetes participants pack 

Live it Highland Facilitators

Additional details  Live it Highland 6 week group is facilitated by High Life Highland see Live it Highland Group information.  

 

Live it Highland Group 

Service/provision 
  • Live it Highland group
Service information 

Live it Highland is a 6-week programme facilitated by High Life Highland.  It aims to support people with pre diabetes or diabetes with minimum standard education to manage their condition to fit in with their lives.  

An introduction to Type 2 diabetes, session topics include;

  • what is diabetes 
  • food, mood and diabetes
  • activity and diabetes 
  • stress and smoothing 
  • good sleep matters
  • self-care and self-management
Patient group/referral criteria 

 

Availability 

North Highland NHS area 

Referral form 

self-referrals or professional referrals can be made by email to;

active.health@highlifehighland.com or phone 01349 781700

Patient material   
Additional details  available from August 2023 

 

Social Signposting

Service/provision

Lets get on with it together (LGOWIT)

Service information 

LGOWIT is a self-management project for people with long term health conditions whether it is physical or mental, they focus on commonality of symptoms.  

They offer: 

  • face to face living better group, which are peer support groups these will recommence over summer 2022 throughout Highland. 
  • Online activities such as Tai Chi, mindfulness, sound therapy, coffee & Chats, and fun Friday's.
  • Closed facebook just for group members.  Community networkers keep regular contact with group members.  
  • Self-management in challenging times booklet runs alongside the e-learning platform.  The booklet includes eleven modules.  Link can be found on our website www.lgowit.org
Patient group/referral 
  • Anyone with a long term physical or mental health condition can be referred.
  • Self-refer, or a health professional referral- seek permission first
Availability 

Highlands 

Referral form 

no formal referral required.  Email lgowitadmin@hihglandtsi.org.uk

 

Service/provision  Diabetes Scotland peer support 
Service information  Diabetes Scotland are currently offering online peer support for people living with diabetes. These groups are run by our trained facilitators and are giving people living with diabetes a chance to share knowledge and experiences, and gain confidence in managing their diabetes.
Patient group/referral criteria If you know of people who would benefit from talking to others online, or would like more information, please contact Mhairi Macdonald, mhairi.macdonald@diabetes.org.uk
Availability  Anyone with diabetes 
Referral form   
Patient material  
Additional details 
  • Diabetes Scotland Helpline Call or email our specially trained counsellors to get advice and support from Monday to Friday 9am 6pm.
  • T: 0141 212 8710 E: helpline.scotland@diabetes.org.uk
  • Diabetes UK Support Forum Log on 24/7 to find help, tips and a friendly welcome from other people living with diabetes. www.diabetes.org.uk/forum

 

Service/provision  Velocity active health project 
Service information 
  • This project, from social enterprise Velocity started in 2019 to support people to become more ACTIVE as a way of improving their health and wellbeing.
  • The link workers take a motivational, person-centred, trauma-informed and health-inequalities informed approach.
  • Participants meet the link Worker via Near Me video or by telephone for an initial one-hour consultation to help form an activity plan, and usually two subsequent follow-up meetings over a three-month period (although the number and frequency of follow up appointments can be flexible depending on the individual).
  • They can refer on to other organisations, agencies or green health destinations, on a model similar to Community Link Workers.
    • More info can be found here http://velocitylove.co.uk/active-health
Patient group/referral criteria 
  • Over 16 years of age in NHS Highland
  • Those who are physically inactive willing to consider a referral. 
  • Participants often have a wide range of health conditions such asthma, diabetes, obesity, anxiety and much, much more.
  • Patient can be referred or self-refer.  
Availability 
  • Covers all NHS Highland 
  • Available Monday - Friday, including 1 evening.
  • Most appointments are done by video call (Near me) but phone is also possible.  
Referral form 

Email following details to: activehealth@velocitylove.co.uk

  • Name
  • DOB 
  • Postcode
  • Telephone number 
  • Email address 
  • Please do not include any clinical detail 

Highlight to patients that you are sharing the information outside the NHS (to social enterprise Velocity) and document this verbal consent in the patients notes.

Patient material 
Additional details  As this is a social enterprise project funding will be reviewed on a yearly basis

 

Service/provision  iPad Loans 
Service information 
  • iPad on loan through library service
  • SIM card to provide mobile data, if no internet available.
  • Training & support on how to use the iPad
  • pre-populated iPads with health information, access to online peer support, online education and appointments.  

To provide information and support for people with pre-diabetes and newly diagnosed with type 2 diabetes.

Patient group/referral criteria 
  • Anyone with pre-diabetes or newly-diagnosed type 2 diabetes who is digitally excluded.
  • lacks confidence and would benefit from some training and support.
  • does not have access to a digital device (tablet/laptop/mobile) or internet connectivity.
Availability  iPads are available to book through any High Life Highland library including mobile library service.
Referral form 
  • No referrals required just ask at your local library.
  • Information on iPad training is available when booking the device at the library.
Patient material 

Libraries - High Life Highland

Additional details   

 

Service/provision  Think health think nature (THTN)
Service information  A free online resource to help you explore your local greens and find activities to suit your interest and abilities that improve your physical and mental wellbeing through contact with nature
Patient group/referral criteria  Various. Can be referred or self-refer.
Availability  Activities available in every locality. Choice of travel or on your doorstep and even in the home activities.
Referral form No specific form. Lists various agencies from which you can be referred.
Patient material 

Written/printable 

Additional details 

Project funded to 2023.  Its a pilot  Resources being built upon all the time.  

 

Service/provision  Diabetes UK 
Service information 
  • DUK website www.diabetes.org.uk where patients can access trusted information on all types of diabetes. Regular online information/Q&A events throughout the year are available for people to join. Look out for details on the website and social media.
  • The website incudes a section specifically for Healthcare Professionals.
  • DUK Learning Zone diabetes.org.uk/learningzone - videos, quizzes, interactive tools to enable people to get to grips with their diabetes when it suits them
  • DUK online Support Forum – people can log on 24/7 to find help, tips and a friendly welcome from other people living with diabetes diabetes.org.uk/forum
  • Diabetes Scotland Helpline - call or email our specially trained counsellors to get advice and support from Monday to Friday 9am to 6pm.
0141 212 8710 helpline.scotland@diabetes.org.uk
Patient group/referral criteria 
  • The website is accessible to anyone wanting to know more about diabetes.
  • Users of the Learning Zone will have to create a login.
Availability 

 

Referral form 

 

Patient material 

 

Additional details 

 

 

Service/provision  Paths for all 
Service Information 

Health Walks are free, short, safe, social, fun and accessible low-level group walks led by trained volunteers.

Health Walk projects in Highland here

Patient group/referral criteria  Health Walks are aimed at inactive people who would benefit most from doing more physical activity. This can include people who haven’t been active for a while and would like to start again, and people who are recovering from ill health or managing a long-term condition
Availability  There are around 50 Health Walk groups across Highland. Most meet weekly and are open to all. See link in Service provision walks.
Referral form 

No referral forms required.  

Most Health Walk groups are open to all and booking is not required, but please contact the group first before attending. Contact details can be found in ‘more info’ tab on map

Patient material   
Additional details   

 

Service/provision  High life highland 
Service information 

High Life Highland is a charity which develops and promotes opportunities in culture, learning, sport, leisure, health and wellbeing across nine services throughout the whole of the Highlands, for both residents and visitors.

For information on everything from the hugely popular High Life leisure card (which offers affordable access to dozens of leisure facilities), to how to get the best out of our Highland Libraries, what happens at the Highland Archive & Registration Centre or a host of other aspects of cultural, sporting, leisure and learning life in Highland, just follow the links here: https://www.highlifehighland.com/

Patient group/referral criteria 

Open to all – there is something for everyone and if you’re not sure please email: info@highlifehighland.com or phone 01349 781700

Everyone with pre-diabetes and diagnosed Type 2 Diabetes and anyone wishing to improve physical, mental and social wellbeing.

Availability 

Open to all – there is something for everyone and if you’re not sure please email: info@highlifehighland.com or phone 01349 781700

Referral form 

N/A

Patient material  
Additional details 

 

 

Service/provision  New to type 2 digital app 
Service information 

This Highland digital app gives people information about type 2 diabetes. It has written information, video clips, local signposting opportunities and frequent asked questions.

It covered 4 key areas of
• Diabetes Health
• Active Health
• Food Health
• Emotional Health

Patient group/referral group 

Anyone who may find digital apps useful and

• is at risk of developing type 2 diabetes(pre-diabetes)
• is newly diagnosed with type 2 diabetes

Availability 

Available Autumn 2023 

Patient material 

 

Additional details 

 

 

Service/provision  Health improvement resource services (HIRS
Service information 
  • The Health information resource services (HIRS) provide health information and an extensive health improvement resources library which covers the Highland Health and Social Care Partnership.
  • The library offers a wide range of health related materials from loan, free of charge to everyone working or living within the Highlands. 
  • More about who HIRS
  • please visit website HPAC to order resources 

 

Patient material 

HIRS link 
Additional details   

Services available from Community care

Service/provision  Smoking cessation 
 Service information 
  • NHS Highland Smoke Free Service provides an evidence based approach in supporting individuals to quit smoking through advice around medication and support through behaviour change techniques provided by a smoking cessation adviser.
  • Smoking cessation advisers, encourage, motivate and support individuals at every step of their journey. They provide a tailored and unique programme for each individual and if they don’t succeed at first, there will be no judge or criticism.
  • It’s known that willpower alone isn't always enough to stop for good. There is now evidence to show that quitting with help is four times more successful and likely to stay smoke free.  
 Patient group/referral criteria
  • Anyone willing to make a serious quit attempt
  • Patients can be referred or self-refer
  • No age minimum limited
 Availability 
  • All NHS Highland
  • Mon-Fri: 9-5 (evening appointments available in some areas)
  • Near me, telephone, text messaging or e-mail support appointments available if preferred
Patient material   

Visit https://www.smokefreehighland.scot.nhs.uk/contact/

Fill out the contact form and a local adviser will get in touch. Or go to the list of local advisors telephone numbers to contact the local adviser to talk to someone directly.

Alternatively,

Call or chat online at Quit Your Way Scotland on 0800 84 84 84 (Monday – Friday 8am to 10pm, Saturday and Sunday 9am to 5pm) to get started.

Patient material 

https://www.smokefreehighland.scot.nhs.uk/

https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/quit-your-way-scotland

Additional details 

 

 

Service/provision  Community dietetics 
Service information  Dieticians support people with diabetes to manage their condition in the context of their medical and social conditions through completing an assessment and then agreeing interventions and food and health outcomes.  
Patient group/referral criteria 

This is a tier 2 service for adults with T2Dm and another comorbidity requiring a dietary intervention.  Some areas will only see patients who are on maximum doses of oral hypoglycaemic agents and/or insulin. Please check with your local service for local criteria.  

Referrals are accepted from professionals, self-referral may also be accepted.  

Availability 

Community dietetic services are available throughout the area in various locations.  Consultations are by Near Me telephone or face to face. 

Clinics are held on a regular basis, frequently will differ in different localities.  Check with your local service for further information.  

Referral form 
  1.  the preferred pathway is through SCI store to your local dietetic team 
  2.  in Easter Ross, Invernses, Nairn, Badenoch & Strathspey: nhsh.communitydieteticssm@nhs.scot
Patient material 

 NHS highland

Additional details  Florence SMS can be available dependant on individual requirements and staff availability

 

Service/provision 

Type 2 diabetes food and health service 
Service information  Delivering a holistic 1;1 intervention around food, health & wellbeing for people diagnosed with type 2 diabetes.  Food and weight will be discussed and explored as well as focusing on life circumstances and lifestyles. 
Patient group/referral criteria 

we accept referrals for patients:

  • newly diagnosed prediabetes 
  • newly diagnosed T2Dm
  • Diagnosed T2Dm <6years 

The following exclusions apply:

  • advanced dementia 
  • palliative care 
  • specific therapeutic diet e.g. renal disease 
  • pregnancy - however it at annual check up hey have developed IGT/T2Dm further down the line post pregnancy then you can refer as normal.  
  • diagnosed eating disorder 
  • additional learning needs 

On receipt of the referral, we will invite the patient for an assessment followed by 3x fortnightly sessions and 3 reviews at 6 months, 9 months and 12 months if they wish to take part.

Practice nurses/GPs will get an update when the patient has agreed to take part in the program, after the 3rd appointment and at the final.

Availability 

Consultations will take place via telephone and/or near me for Primary care cluster 1,5,&9 listed

Referral form 

We accept email referrals: please include patent's name, CHI, telephone number, HbA1c, weight, height, BMI (if available( and any medical information

In addition to the standard referral details, we would welcome any relevant information on the patients:

  • weight history 
  • previous weight loss interventions e.g. types if diets, urgery, etc 
  • impact of weight on health and social activities 

Cluster 1 & 5: referrals to be sent via email and from August 2021, via SCI gateway: T2Dm food & health service 

Cluster 1: Linda Hilton linda.hilton1@nhs.scot

Cluster 5: Michelle Slater michelle.slater@nhs.scot 

Cluster 9: Arlene Tait arlene.tait1@nhs.scot 

Refer through Caithness dietetics SCI gateway or email for cluster 9

We are currently waiting for our service to be added to SCI gateway: T2Dm food and health service

Patient material   
Additional details 

Type 2 diabetes food & health service currently funded until 31st March 2025 

Specialist support services

 

Service/provision  Community specialist nurses 
Service information To provide support to people with complex diabetes needs and source of specialist advice for primary healthcare professionals.
Patient group/referral criteria 
  • People with Type 2 diabetes requiring to commence on injectable therapies to manage their diabetes (insulin and/or GLP-1).
  • People with Type 2 diabetes already on insulin requiring additional support to improve their glycaemic control.
  • New diagnosis of Type 1 diabetes/LADA
  • Guidance for people with established Type 1 diabetes on how to improve their glycaemic control.
  • Diabetes management advice/commencement of therapy for steroid induced diabetes, MODY, pancreatic pathology or other forms of diabetes in people over 21 years.
  • Healthcare professionals can refer to the service.
  • Self-referral from people with diabetes accepted.
Availability Monday – Friday 9am-5pm
Referral form 

Referral form available on TAM

Completed referral form or queries can be emailed to: nhsh.communitydiabetesnurses@nhs.scot

Urgent referrals must be phoned through. Contact details are listed on referral form dependent on relevant area.

Patient material   
Additional details 

Patients must be blood glucose testing prior to referral 

 

Service/provision  Diabetes specialist dieticians 
 Service information   

To provide specialist dietary and lifestyle education and support to people with complex Diabetes needs in Highland.

To provide support, education and information to other Health Professionals involved in their care.

 Patient group/referral criteria 
  • Type 1 diabetes, MODY, LADA, pancreatic pathology
  • Any diabetes patient considering pregnancy
  • Diabetes in pregnancy
  • Type 2 diabetes on triple therapy or injectable therapy
  • Type 2 diabetes on insulin
  • Recurrent or unpredictable hypoglycaemia
  • Active foot disease
  • Gastroparesis
  • Nutrition support, food allergy, coeliac disease, IBD, IBS or renal patients, where glycaemic control is detrimental to outcomes.
  • Insulin pump therapy
  • Type 1 diabetes structured education on carbohydrate counting
  • Type 2 diabetes structured education for patients on insulin
  • Healthcare professionals can refer to the service.
  • Self referral from people with diabetes accepted.
 Availability Mon to Fri 9am to 5pm Diabetes Dietitians are based at the Highland Diabetes Institute, Raigmore Hospital. Clinics can be organised to suit patients needs e.g. face to face or remotely via telephone or video call.
Referral form   Referrals can be made via SCI STORE or by e-mail:

nhsh.diabetesdietitians@nhs.scot

Patient material 

 

 

Service/provision  Engage programme
Service information 

ENGAGE is an informative and interactive course to provide you with skills, knowledge and support to take control of managing your own Type 2 diabetes.

The course runs over the course of a 4 week period allowing patients time to build on the skills and knowledge developed from week to week with the aim of feeling confident by the completion.

Sessions run for half a day per week over the 4 week period.

Patient group/referral criteria People with type 2 diabetes on insulin therapy.
Availability To date it has only run in Inverness. However, depending on interest consideration could be given to alternative sites
referral form  Contact on nhsh.communitydiabetesnurses@nhs.scot or 01463 704625

 

Service/provision  Psychology service    
 Service information   

Managed by the Diabetes Psychology Service, to help T2D/preT2D patients learn about T2diabetes, health and well-being. It is structured programme offering information and activities within 5 modules designed for small groups (but can be delivered individually), each which focuses on different aspects of managing health and wellbeing

Learning about diabetes and healthy metabolism

managing stress and improving sleep
importance of emotional needs and maintaining helpful relationships
considering behavioural changes related to eating and exercise
Individuals may partake in one or more of these modules

Letter to Diabetes specialists

   
 Patient group/referral criteria  Patients may be referred to this service with

· Newly diagnosed prediabetes

· Newly diagnosed T2Dm

· Diagnosed T2Dm < 3 years

Brief referral form related to screening criteria; if needed, participants will also be screened with a brief series of psychometrics (if needed, individual interview) to assess suitability and personal concerns.

Exclusions will include: individuals with advanced disease states, significant learning disabilities, current eating disorder, moderate-severe psychological disorder or currently high state of distress

   
 Availability  Located at NHSH Highland Diabetes Institute (Raigmore Campus) in Inverness, and Badenoch and Strathspey Community Hospital in Aviemore.

Individual or pair consultations may also take place via Near Me or telephone.

   
 Referral form       
Patient material 

 

   
Additional details 

Referrers will get updates related to patient involvement in this programme as desired. This service is available from 01 September 2021 – 01 July 2022 in the first instance; further offerings will be announced later. 

Last reviewed: 24 June 2022

Next review: 30 June 2025

Author(s): Health Improvement Team

Version: 1

Approved By: Awaiting approval of TAM Subgroup of the ADTC

Reviewer Name(s): Fiona Macleod, Health Improvement Specialist

Document Id: TAM508

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