Programme Activation *

Please select the programme that you wish to activate

The EMBRACE Type 2 Diabetes Optimisation Service

Patient Selection: *

Eclipse will identify a list of eligible patients for review, based on criteria agreed with BLMK ICB. Please state whether you would like to review this list prior to us contacting them:

No – we would like patient engagement to go out to all eligible patients.

Yes – we would like to review and refine the list of patients prior to patient engagement.

1. Are you happy for patients within the activated cohort to be contacted by the Eclipse automated patient engagement interface? (NB: this will involve SMS messaging): *

Yes

No

2. Are you happy for patients within the activated cohort to be contacted by the Eclipse patient engagement team? (NB: this will involve telephone calls): *

Yes

No

3. Are you happy for patients to receive a feedback questionnaire for evaluation of the programme and to allow them to express any personal preferences: (optional)

Yes

No

Deferral of clinical assessment if recent results not available: *

Please indicate whether you would like a deferral of the clinical review for those patients whose HbA1c, BP and/or weight are more than 6 months old:

We prefer to defer clinical assessment for these patients and will seek to obtain updated measures within 2 months of being notified.

We prefer not to delay reviews as we cannot commit to obtaining updated measured within a 2-month period. We acknowledge that this may mean some reviews proceed with results more than 6 months old.

Reviewing Patients: *

Please indicate below that you consent to the (CQC accredited)Putting Patients First clinical team providing a diabetes medication review, in line with NICE NG28 and BLMK formulary (please note: any prescribing decisions suggested in the report will always remain with the patient’s GP):

Yes

No

Admin Lead:

First Name

Last Name

Practice Clinical lead:

First Name

Last Name