Diabetes Program In-home/Telephone Screening Guide 

Initial Contact:  Patient/Family/Other ______________________________________________________________________
1.	Introduce yourself (see sample script)
2.	Verbal consent for telephone/video check in call:      Yes      No   
3.	Inform patient/family member that information may be requested from or provided to the primary care provider and/or pharmacy.

Surveillance screening (COVID-19): (If YES to any of the below) -> please call the primary care provider
□	Do they have fever and/or cough or difficulty breathing AND have travelled outside of Canada within the past 14 days before onset of illness?
□	Have they had close contact with a confirmed or probable case of COVID-19?
□	Have they had close contact with a person with acute respiratory illness who has been to the impacted areas within 14 days prior to their illness onset? 	

Diabetes Status			
What medications are you on ?- doses and frequency			
Glucose test results? - frequency and results			
Additional Questions:	Yes	No	
Have you had any symptoms or episodes of hypoglycemia?			
Do you understand hypoglycemia prevention and treatment recommendations?			
Do you have an appropriate source of fast acting sugar for hypoglycemia treatment, if necessary?			
Do you have symptoms of hyperglycemia? polyuria/nocturia			
Do you have symptoms of chest pain/SOB/ankle swelling? (If needed, suggest acetaminophen/Tylenol not NSAIDs for pain or fever)			
Has the patient had recent bloodwork? Review results			
Are you aware of sick-day management and which medications to hold?
(If Type 1 Diabetes include insulin management and ketone testing)			
Do they have all of their current medications that they require?			
Do they have a plan in place in the event they run out of medication?			
If they had assistance with medication administration, do they still have that assistance?			
Does the patient have follow up through other specialist( Heart Function, Kidney Care Center etc)?- if yes- send note			
Does the patient/caregiver understand when to contact the Diabetes Educator, primary care or 911?			
Does the patient/caregiver understand current recommendations from public health re: social distancing and if applicable self monitoring and self isolation?			
Potential for Social Isolation	Yes	No	
Have family/friends checked on them recently?			
Is there somebody that can check on them?			
How often will they be checked on?_________________________________			
Do they currently receive homecare or community support services(paramedicine, meals on wheels etc)			
Do they have enough groceries or a way of obtaining them?			
Other: Do you  have any other concerns about the clients wellbeing currently?(Describe)
____________________________________________________________________________________________________
If there were any social concerns -Would we have your consent to pass their information on in the event that a community resource might become available e.g., to help with food, medications etc. (Yes/No)			
Current care plan for diabetes management/supports involved:
Family/Others ____________________     Primary Care Provider ____________________     HCC ____________________
Issue/Plan:			
Response -  Priority:   Urgent     Not urgent
Identified Need:  ___________________________________________________________________________________
Linkage with resources:  yes/no (describe)__________________________________________________
Diabetes Educator follow-up:      yes/no                    Location (circle): clinic/ home/ video/ telephone  Date:
Physician (e.g) In person/telephone/virtual visit required:  yes/no (name/ date)___________________________________			

 Follow-up Date:  ________________________  Team Member Name:  _________________________________________