HOUSEBOUND / RESIDENTIAL HOMES ANNUAL REVIEW
Read Code: 13CA
Definition of housebound
“Only able to leave home by ambulance, or if there is a nursing
reason that makes a home visit more appropriate”
Caveat:
With respect to the Diabetes Annual Review, patients will be
assessed by the District/Community Nurse who will make
the decision, based on clinical evidence, as to whether or
not the patient is considered to be housebound.
The National Service Framework for Diabetes requires that all people with diabetes
receive an annual review. It is, therefore, necessary for all Practices to identify their
housebound patients and those living in a residential or nursing home in order for them
to initiate the annual review for these patients. All GPs will need to ensure that they add
the above Read Code to their templates to assist them in identifying all housebound or
residential home patients.
District Nurses have agreed to take up training in order to equip them to carry out some
aspects of the annual review when visiting patients who are housebound or living in a
residential home.
Aspects of Annual Review District Nurses will be trained to do:
 BMI
 Initiate blood tests
 Foot assessment
 Patient education, assessment, diet, exercise, medication, appropriate
investigations, etc.
 Referral on to appropriate health care professionals
It will be the responsibility of the GP to initiate the Diabetic Annual Review via
referral to the District Nurse who will carry out components of the Annual Review.
The District and Community Nurses must be flexible when making decisions whether or
not patients are housebound, giving particular consideration to patient circumstance.
GUIDANCE TO DISTRICT NURSES
HOUSEBOUND AND RESIDENTIAL DIABETES ANNUAL
REVIEW
Tools required that enable District Nurses to carry out the annual review

Annual review form

Blood pressure machine

Protein urine sticks

10g monofilaments

Literature
o what is diabetes
o foot care leaflet
o basic diet advice
o smoking cessation
o exercise
o alcohol
o sharps bin disposal
Information packs will be made available to District Nurses when visiting housebound
patients with diabetes
All completed Annual Review forms should be copied to the GP and the patient
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ANNUAL REVIEW FORM - DIABETIC HOUSEBOUND AND
RESIDENTIAL AND NURSING CARE
Name
MPI
Date of Diagnosis
DoB
Ethnic Group:
Code…………………………………………….
Patient Category:
Type 1
Type 2
MEASUREMENTS
Weight……………………………..
BMI ……………………………………. BMI >25
BP……………………………………
BP >140/80
Urine test:
Glucose:
Pos
Neg
Protein:
Pos
Neg
Ketones:
Pos
Neg
Blood:
Pos
Neg
Blood taken for Annual Review (including HbA1c):
DIET
Yes
Have you been seen by a Dietician? Yes
No
Food prepared by:
Home Care
Self
Family
No
ACR//Urine
Diet discussed: Yes
No
Other
TREATMENT – DIABETES MEDICATION
Insulin:
Dosage:
Tablets: …………………………………………..
………………………………………………………..
…………………………………………………
……
………………………………………………………..
Lipid lowering
Yes
No
Anti-Hypertensive
Yes
No
Aspirin
Yes
No
…………………………………………………
……
Last Hypo
………………Frequency…………..
Sites Assessment
………………………………
Administered by:
Self
HOME MONITORING
(either / or)
Blood: Yes
No
Urine:
Yes
No
Carer
District Nurse
Frequency
<wkly
<wkly
Results
Recorded
Other
Most results
>wkly
<8mmls
Yes
No
Yes
No
>wkly
Neg
3
>8mmls
Pos
LAST DIABETES EYE SCREENING (Fundoscopy) TEST
…………………………..
In the last 1 year
Date (if known)
Longer than 1 year
FOOT ASSESSMENT (in line with Diabetes Guidelines)
Inspect feet::
Done
Not done
Evaluate footwear:
Done
Not done
Condition of nails and skin:
Not at risk
Pulses:
Dorsalis pedis/Posterior tibia
Sensation:
10g Monofilament:
Enhanced foot care education:
At risk
Present
Present
Done
Absent
Absent
Not done
Patient Education:
Relevant written information Yes
Medication
Diet
No
Exercise
Alcohol
Smoking
Feet
Other support
NB
Shaded areas highlight risk factors and require further investigation and may require
referral
Signature of Nurse
……………………………………………………..Date…………………………………….
Actions required:
Referral to:
Professional advice given :
……………………………………………………………
GP
…………………………………………………………..
DSN
…………………………………………………………..
Dietician
……………………………………………………………
Chiropody
……………………………………………………………
Education
…………………………………………………………..
Optician
…………………………………………………………..
Exercise
…………………………………………………………..
Other
Date
Signature
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