  Declining referrals from inpatient to outpatient Inpatient education service discontinued Hospital staff not familiar with Joslin services

   Patients with Diabetes account for 30% of hospital admissions 85% of outpatient follow-ups referred by our Joslin endocrinologists Endocrinology consults make up only 20% of all consults (inpatient)

     Educate PCPs, Hospitalists and Nursing Diabetes Care Collaborative Team participation Diabetes Nurse Champion on each inpatient unit Simplify referral process Develop education DVD (potential routing mechanism to Joslin outpatient)

 Pre  Average referral about 2/month Post Average referral ranging between 10 and 16/month

                            The Western Pennsylvania Hospital Forbes Regional Campus DIABETES EDUCATION PRESCRIPTION NAME______________________________SSN________________________DOB____________ PHONE (H)______________________(W)_____________________(C)____________________ TYPE OF CONSULTATION: Comprehensive Diabetes Education : FBS________ HbA1C______ Group______ or Individual________ Insulin Instruction Type________ Dose_________________ Medical Nutrition Therapy/Non Diabetes Reimbursement Requirements: To meet Medicare and other insures’ regulations, please complete all sections Diagnosis: DIABETES: TYPE 1 ____ TYPE 2 ___ GESTATIONAL ___ Obesity/Weight Management ______ Hypertension ________ Lipid Disorder______ Pre Diabetes_______ Other __________ Referral to Endocrinologist (only if specifically ordered): Dr.Rajupet____ Dr. Sharma ____ Dr. Tal _____ Current Complications: Retinopathy___ Neuropathy___ Nephropathy___ Cardiac___ Medicare provides coverage for DSMT services when a provider providers a referral certifying that DSMT services are needed I certify that DSMT services are needed under a comprehensive plan for this patient’s diabetes care.

Physician Signature_________________________________________________Date______________________ Print Physician Name__________________________________________________________________________ The Joslin Diabetes Education program has met the American Diabetes Association National Standards for Diabetes Education Programs