Camden Diabetes Integrated Practice Unit (IPU)

Dr Miranda Rosenthal, Strategic Clinical Lead of Camden Diabetes IPU,

Diabetes Consultant, Royal Free

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What’s new for diabetes in Camden ?

• What we had…• Where we are going…• Who we are…• Value based commissioning…• Integrated care…..

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Lead provider role…..

Royal Free (RFL) are:• Lead Providers • Accountable for delivery of high quality integrated

diabetes services across WHOLE pathway (Community-based where possible.)

• Accountable for VALUE across pathway• Responsible for project success.

RFL have subcontracted the achievement of this to Haverstock Healthcare Limited (HHL) who manage the implementation.

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Structure within RFL

Creation of the IPU

Lesley Roberts, Programme Lead, Haverstock HL

“Providers must lead the way in making value the overarching goal”

- Michael E. Porter and Thomas H. Lee, Harvard Business School

• Integrated Practice Unit: One diabetes Team, many providers- (CNWL, UCHL, Whit, RF, primary care, SW, MH, Vol sec working with patient and family)

• Grow excellent services • Integrate care delivery – seamless care

• Measure outcomes • Bundled prices for care cycles• Enabling IT platform – data viewable by all / reduce duplication and aid

communication.

13/14 Q3Oct 13 – Dec 13

13/14 Q4Jan 14 – Mar 14

14/15 Q1Apr 14 – Jun 14

14/15 Q2 Jul 14 – Sept 14

14/15 Q3Oct 14 – Dec 14

14/15 Q4Jan 15 – Mar 15

15/16 Q1Apr 15 – Jun 15

15/16 Q2 Jul 15 – Sept 15

15/16 Q3Oct 15 – Dec 15

15/16 Q4Jan 16 – Mar 16

16/17Q1Apr 16 – Jun 16

16/17Q2Jul-16 – Sept 16

Phase 1– model development and

initial implementation

Phase 2 – Pilot Lead Provider Model with a shadow value-based contract

Phase 3 – Pilot Lead Provider model with Value-based contract

Clinical Model Development

Recruitment and service developments

Patient education resources embedded

GP Practice Visits

Full costing of service Notice

to current contract

s

Sign off service model

Development of value based contract

Contract sign off by all parties

GP Education Events

Subcontracting arrangements in

place

Clinical Model monitoring and development as necessary

Outcomes Measured and Reviewed

Contractual monitoring

Phase 4 – Diabetes service with value-

based contract

Procurement Starts

Notice to pilot

contracts

Long term value-based

contract signed

Significant MilestonesApril 2014 Royal Free London Lead Provider – shadow year

Notice to all providers

Nov 2014 All providers to sign off value-based contract (pilot)

April 2015 Value-based contract to start

June 2015 Notice to Pilot Contract

Procurement for Integrated Diabetes Service to commence

Jan 2016 Value-based contract signed

April 2016 Value-based model to commence

Why integrated care?

Integrated care should be seen as a complex strategy to INNOVATE and

implement LONG-LASTING CHANGE in the way services in the health and social-care sectors are delivered.

European Observatory on Health Systems and Policies

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Why diabetes in Camden?• Low prevalence • Poor glucose control• Inequality in care delivery and outcomes • Lack of integration• Duplication of tests and poor communication• Lack of data on the quality of specialist diabetes care • Difference in the QOF scores for diabetes across Camden • Inadequate incentives • Insufficient and / or inadequate pathways e.g. MH, transient populations,

BME etc.• Inconsistent practice amongst specialist services and inadequate

incentives for making their practice cost-effective.• Inadequate availability and use of information on what is happening in the

system to assess local need to tailor diabetes services appropriately.

Camden Diabetes Integrated Practice Unit Implementation

Aims?

Too many people with diabetes have poorly controlled and managed diabetes, leading to excess early complications and death

Inequality in care delivery and outcomes

Disjointed service have been commissioned : integrated clinical and social care services planned that addresses poor control of diabetes, to prevent complications

What is the need?

Provide High Quality Integrated diabetes care, sharing data to reduce duplication and improve communication across service.

Improve the Health and wellbeing of people living with diabetes in Camden.

Support the Prevention of type 2 diabetes, through raising awareness and education.

Equitable and patient-centred services that enable people to achieve good control, thereby reducing complications.

Well informed, engaged patients and healthcare professionals committed to working in partnership to achieve best outcomes possible.

What will the programme do?

What will the programme deliver?

Patient-Focused: • Structured Patient Education / Patient Involvement and Experience AIM: Integrate around the patient / outcomes that matter to patients / Easier for patients and carers to understand and navigate all services / Promote self-care / More structured patient education and involvement.

• A year on year improvement in number of undiagnosed patients with diabetes in Camden• Improved management of patients with uncontrolled diabetes.• Improved patient experience and quality of life• Reduced mortality and morbidity from diabetes-related causes• Reduction in the numbers of unscheduled attendances and admissions to hospitals

Diabetes services that are not always cost-effective.

Gaps between actual and predicted prevalence of diabetes: Half of people are undiagnosed.

Strong Clinical Services:• Review and amend : Skill mix and Staffing / Pathways / Tiers of Diabetes /

Clinical IT Templates / Referral Forms / Care planning / Diabetes Foot Health / Kidney disease/ Heart Disease / Eye disease.

AIM: Equitable and of consistent high quality, accessible, provided as close to home as possible

Commissioned across a population•Working together across organisational boundaries sharing best practice, delivering value, breaking down barriers and improving outcomes by considering a whole population – prevent and treatAIM: Value Based Commissioning will be implemented.

Highly competent staff at all Tiers of diabetes care• Providing timely access to appropriately skilled healthcare professionals

responsive to the individual, including those with special needs, e.g. housebound.

• Build capacity and capability in primary care

AIM: Increased competencies at all levels

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Group StructureCamden CCG Diabetes GOVERNANCE GROUP

Camden Diabetes IPUOPERATIONAL BOARD

Camden Diabetes IPUTier 1 &2 Development Group

(LES / QOF /Practice Visits/ Prevalence / Annual reviews / referral process)

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2.5 year project plan… Programme Plan Overview - Camden Diabetes IPU Implementation Project (August 2013 - March 2016)

Start Date 10th September 2013

MILESTONE LATEST UPDATE ( MAY 2O14) RAG

PROJECT MANAGEMENT

Develop Service Specification for Diabetes Integrated Care Service CCG completed this for 13-15

Hold Diabetes Workshop to inform programme plan Completed August 2013

Establish Camden Integrated Diabetes Programme Board (prev. Partnership Board) Now Camden Diabetes IPU Strategic Board - meets bi-monthly

Establish Programme Governance Governance paper to be completed

Recruitment of Programme Lead and agreement of funding for Lead and Administrator Start date 10th September

Review Diabetes Workshop objectives and other docs to inform programme plan Within Implemementation plan

Camden Strategic IPU Diabetes Group TOR developed and agreed Agreed October 2013

Receive assurances that the culture of each organisation is "bought into" integrated working. Agreed but still requires constant vigilance

Create implementation plan Implementation plan completed - now PID and Service Handbook required.

PID to be developed Draft complete

Service Handbook to be completed Draft complete

Programme plan to be agreed and communicated to all stakeholdersFull programme Plan is sent to Governance group, Executive Group, Strategic Board Members, Operational Board memebers and members of all subgroups.

Monthly milestone plans to be developed Gantt chart on this plan

Communication Plan developed (incl. process to update Clinical Commissioning Leads regularly) DRAFT developed

Camden IPU Vision

A service that:• Delivers outcomes that matter to patients• Works across organisational boundaries• Considers a whole population – prevent and treat• Patients leading their own care• Provides the best value for Camden taxpayers

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Camden IPU aims…..

Improved:• “undiagnosed” • uncontrolled diabetes• patient experience • unscheduled attendances and admissions• mortality and morbidity

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Patients will innovate….

Delivers outcomes that matter to patients…GP patient survey 2012/13

Camden worse than the England average in giving support to those with long term conditions.

Source: GP patient survey 2012/13

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215

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32

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Diabetes admissions 2012/13 by provider

ROYAL FREE LONDON NHS FOUNDATION TRUST

UNIVERSITY COLLEGE LONDON HOSPITALS NHSFOUNDATION

Other

IMPERIAL COLLEGE HEALTHCARE NHS TRUST

THE WHITTINGTON HOSPITAL NHS TRUST

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What matters to patients?

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Terminology

Types of Innovation

A history of innovation theories

Recent Developments

Product development

Harnessing ideas

Innovative organisations

Supporting policy

Creative swipingScenarios

Scanning the environmentBenchmarking

Futures

The Commercial Environment

The Green Environment

The Ethical Environment

The EFQM Excellence model

The Quality Movement

ISO 9001:2000

Six Sigma

LeanReengineering

Entrepreneurs, inventors and innovators

Effective organisations

Leadership

Empowerment

Self-Organisation

Projects, departments and divisionsAlliancesOutsourcingThe supply chain

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Weighted referral rate to CICS (diabetes only) by practice April 2012 -December 2013

Variability - referrals to CICS

Variability in Prevalence

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Camden has the second lowest prevalence of diabetes in England in 2011/12.

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But, prevalence is increasing – 3.7%

Over 17 Population On DM registercoded with

Type 1 coded with Type

2 other DM codes

224695 8473 631 7797 45

7% 92% 0.5%

Prevalence 3.770889428

GAP STILL LARGE

- 7.6%

Total Practices 39

Report run on 18/06/2014

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Have we not done this before?

NO!

Other models are not the same!

Emergency Admissions

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Emergency diabetes admissions 2012/13Rate per 1000 weighted list size

Camden average

Why?

Camden Diabetes Admissions

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Diabetes admissions by age2012/13

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Diabetes admissions 2012/13 by ethnicity

Diabetes admissions 12/13 2011 Census - Camden

Who is admitted for Diabetes?There are more female admissions than male for diabetes up to the age of 45.

After age 45 there is a big leap in the level of diabetes admissions, with slightly more men being admitted.

There are fewer admissions for diabetes of people who are white than the 2011 census population data would predict. This is most likely due to the known link between ethnicity and prevalence in non-white communities.NB – the 2011 census data does not have an ‘unknown’ section and so some caution should be exercised when interpreting this as people identified from SUS data as not stated/unknown could be in any group.

Source: SUS

Source: SUS

But emergencies and Out Patients already decreasing.…

Emergency diabetes admissions to acute hospitals have been falling since the Camden Integrated Care (CICS) Diabetes service was launched.

Outpatient attendances in Diabetic Medicine at the Royal Free and UCLH (activity aimed to be reduced by the CICS business case) are also showing a downward trend since the new CICS diabetes service was introduced.

Source: SUS

Source: SUS

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Diabetes admission 6 per. Mov. Avg. (Diabetes admission)

Camden Integrated Care Diabetes service launched

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Camden Integrated Care Diabetes service attendances

Attendances 3 per. Mov. Avg. (Attendances)

Source: SUS

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Diabetic Medicine outpatient attendnaces at Royal Free and UCLH

DIABETIC MEDICINE 6 per. Mov. Avg. (DIABETIC MEDICINE)

Camden Integrated Care Diabetic Service launched

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Focus in first year

• POPULATION CHANGE• PREVALENCE• STAFF EDUCATION /COMPETENCIES• SKILL MIX• DIABETES FOOT• TIER 4• WEBSITE – GP website

www.camdendiabetes.co.uk• IT

Purpose built ITHospital

IT systems

EMIS

AHP’s

Labs

PharmacySocial Services

Investigations

Eye Screening

Where patient data is…

EMISHospital

Social Services

Pharmacy

LabsPurpose

Built

Investigations Eye Screening

AHPs

Where we are aiming ……CIDR : Right information to make the right clinical decision

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Patient Outcomes:Patient ExperienceClinical Outcomes

Patient safetyCost efficiency

Foot Care/Podiatry

Self-Management – patient education

Practice Education

Community Step-Up Service In-reach to

Primary Care - MDTsCase

Management

Risk stratification

Analysis & use of data for evidence-based improvements

Commissioning Framework (Camden CCG)Funded per person based on “Year of Care” Commissioning

Lead ProviderRoyal Free London FT

Haverstock Health

CNWL

UCLH

GP Practices Diabetes

UK

Camden DiabetesIntegrated Practice Unit

London Borough

of Camden(Social Care) Retinopathy

Screening

Funded through bundled package

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20 Objectives….1. The objectives of the project are as follows:2. Identify gaps in staffing and agree additional clinical and

admin staffing required and appoint staff by March 2014.3. Develop outcomes by March 2014.4. Agree minimum level of knowledge necessary for

competency at Tier 1 level. Develop competencies in all practices (by DSN led visits for case-note review and management plan creation / facilitation clinics and mentoring of staff)

5. Agree, assess and improve clinical competencies for district nursing staff dealing with diabetes patients thereby providing safer high quality care for some of the most vulnerable people with diabetes by December 2014.

6. Develop support for District nurses: A review of diabetes protocols/ Assessment sheets / DN care plans / Blood glucose records /creation of Aide memoir for staff /updated policy and implementation of Hypo boxes / MDT Home visits with GP and Diabetes Specialist staff and Consultant if appropriate.

7. Deliver accredited Foundation Course in Diabetes from July 2014.

8. Develop clinical governance arrangements across and between all providers by July 2014.

9. For very complex and vulnerable people with diabetes develop High risk MDTs in clinic settings, homes and/or practices by July 2014

10. Develop process to monitor outcomes by July 2014.

11. Review and streamline all pathways by end August 2014.

12. Standardise all patient-held and staff communication care plans by August 2014.

13. Implement Diabetes Foot work-stream that ensures all patients are risk stratified and seen in appropriate tier of podiatry by March 2016.

14. Improve diabetes care in hospital by March 2016 15. Develop PIT-stop training for Tier 2 practices who can

deliver a higher level of diabetes care including insulin and GLP-1 agonist management with 3-6 Tier 2 practices in place by March 2016.

16. Implement Mental Health work-stream by January 2015.

17. Year on year improve and standardise quality of diabetes care at all Tiers by March 2016.

18. Ensure each patient with diabetes is seen in appropriate Tier of Care (or at home if housebound) by March 2016.

19. Ensure all staff dealing with diabetes patients meet TREND competencies by March 2016.

20. Promote the use of QDiabetes to Improve prevalence to meet expected prevalence by March 2016.

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What is different? • Camden Diabetes IPU began on April 2014 • RFL responsible for a POPULATION CHANGE in

outcomes• Everyone working as ONE TEAM and being

patient not provider focused.• Agreed standards, pathways, outcomes• Clinical Model - Diabetes Guide for London

Clinical ModelDiabetes Guide for London

Aims Tier 4 – used more appropriately

Tier 3 – expanded to support primary care at Tiers 2 and 1.

Tier 2 – set up Hub practices (3)

Tier 1 – Better essential care in practices

Patients seen in correct tier

Move unobstructed through tiers

http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Diabetes-Guide.pdf

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TIER 1ESSENTIAL CAREDelivered by General Practices in primary care, community settings and the patient’s home - all Practices will deliver Tier 1 care•Annual review•Follow up of patients with Type 2 diabetes•Medications reviews•Complications Screening & Management e.g BP, HbA1c, weight, lifestyle factors•Patient education (excluding Structured Patient Education on diagnosis)•Telephone support for patients•Referring appropriately to other Tiers/specialist services•Care planning•Family planning advice and referral for pre-conception advice•Care for housebound patients (including maintenance of a register of housebound patients)•Maintenance of a register of patients with Diabetes, indicating place of care•Testing “at risk of diabetes” patients and maintaining register•Referral to IAPT

TIER 2ENHANCED ESSENTIAL CAREDelivered by General Practices in primary care, community settings and the patient’s home.As Tier 1, plus:•Injectable therapies •GLP-1 agonistsGP Practices may choose to deliver these services for their own patients only or as a ‘hub’ service for a number of Practices.

Note: There will be a process to identify the

Tier 2 practices in Camden.

TIER 3INTERMEDIATE CAREDelivered by Consultant-Led Multidisciplinary team(s) in community settings•Structured Patient Education for patients newly diagnosed with diabetes (Type 2)•Access to “At Risk” foot clinic•Access to specialist diabetes dieticians•Assessment, specialist advice and individual interventions for patients *, especially:•Hypo-unawareness•Recurrent Hypoglycaemia•Peripheral Neuropathy•Insulin & GLP-1 analogue initiation and management for Type 2•Pregnancy planning & pre-conception advice clinic – in development•Referral to Specialist Diabetes IAPT team•Joint clinics where competency is known e.g CKD and Diabetes Clinic at Mary Rankin •Same day diabetes clinic – self referral(to avoid A&E attendance) – TO BE DEVELOPED •Persistent BP>130/80 despite having 3 maximum tolerated antihypertensive agents•Persistent total cholesterol>4;LDL>2 despite maximum tolerated statins•Mentoring and coaching support for primary care

TIER 4HOSPITAL BASED CAREDelivered by Consultant-Led specialist teams in secondary care•Assessment of patients newly diagnosed with Type 1 diabetes•On-going management of Type 1•Type 1 Structured Education•Review of complex/atypical patients•Review of patients with suspected secondary diabetes•Management of active foot disease•Assessment of Autonomic Neuropathy•Joint clinics (e.g. Diabetes and CKD /CHD / CVD clinics)•Initiation of CSII/Pump therapy•Assessment and management of all pregnant women with diabetes•Review and management of patients with severe and/or unstable and/or new complications of diabetes*, especially:

Abnormal LFTsMalignant Hypertension

•Access to Clinical Psychologists•Genetic causes of diabetes•Young adult clinics (18 – 25)•Inpatient services

Retinal Screening

Camden Diabetes Integrated Practice Unit (ADULTS ONLY) - Tiers of Care Version 0.6

Population changeTier 1: Senior DSN Practice Support

• Visit practices in each locality team – 1/3 of practices been visited since Jan 14

• Diabetes QOF results of each practice • Virtual Clinics within the practice• Mentoring and Coaching clinics (nurses and doctors)• Deliver clinics for poorly controlled patients• Work with the practices to create an action plan for

improvement• MDT VISITS IN PRACTICES / HOMES• CONSULTANT VISITS PLANNED LATES SUMMER

What can you do? • Have a DSN practice visit• REFERRAL FORM• Act on lab results• Develop management Plans• Flu vac• Lifestyle changes• Nine Care Processes• Administration processes• Complete care plan

Encourage patient to attend structured patient education

• Blood Sugar• Blood Pressure• Blood Fats – cholesterol• Eyes• Feet• Kidneys• Weight • Smoking cessation• Care plan

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Population changeCommunity Nursing Support

• Caseload• 50 Joint visits ( DSN and District nurses) • Safety issues highlighted• Treatment changes• Collaborative working to transform diabetes

community nursing care• MDT visits• Ongoing support

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Population change Diabetes Foot Work-stream

• Review staffing – new Band 7 Podiatrist• Internal referral process between podiatrists; • Discharge back to GP (standardise Care Plan etc); • Foot Check Training; • Practice Nurse and District Nurse Support; • Implement Risk Stratification Tool; • Move appropriate patients to clinics dependent on foot risk;• Pathways; • Standardise Patient Leaflets;• Develop Foot Protection team in Community; • Develop MDT Diabetes Foot team in Community; • QOF Foot Data; Standardise data to deliver outcome Metrics;• Review DUK latest on foot post code lottery; • National Diabetic Foot audit 2014; CIDR - Camden Integrated Digital record – use

podiatry as example by March 2016

Foot protection teams in community & MDT in secondary care….

Putting feet first: national minimum skills framework NHS Diabetes/Diabetes UK

SIGN 116 - 11.5.1A multidisciplinary foot team should include:

• podiatrist• diabetes physician• orthotist• diabetes nurse

specialist• vascular surgeon• orthopaedic surgeon• radiologist

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Population change – increase competenciesTraining and Education – Camden Diabetes Foundation Course

• Detection, Diagnosis and Register maintenance• Complications screening• Personal Care Planning• Oral medications• Patient and Carer advice• Signposting to more support• Family planning and initial pregnancy planning

Local population change - Hub practices Advanced Level - PIT-stop

Programme for Injectable Therapy• Accredited with Greenwich University – 15 credits at level 5 (Diploma)• 2.5 day course trains primary care clinicians to support people with type 2 diabetes on

more advanced medication regimens, including injectables.• Meets NICE criteria

Three modules:1.Supporting people of insulin and starting GLP-1 receptor agonists.2.Starting & supporting people during first 6 months of insulin therapy.3.Reflect on progress and carbohydrate awareness for people on insulin.

Certification requires completion of Assessment, Patients Progress Log and Reflective Report.

UCLH / RFL Tier 4

• Emergency admissions• Elective admissions – pre / post• In-patient care - commitment to the principles

of “Think Glucose” • Elective procedures – diabetes a consideration• Discharged – diabetes reviewed to prevent

readmission

Impact on Tier 4….

• Emergency Admissions• Elective admissions• Cohort of patients will change

• Complex type 1 patients – see more often, focus on control

• Patients who are Type 2 and stable will be referred back to community services (Tier 3)or GP (Tier 1).

SummaryClinical Model

Aims Tier 4 – used more appropriately

Tier 3 – expanded to support primary care at Tiers 2 and 1.

Tier 2 – set up Hub practices (3)

Tier 1 – Better essential care in practices

Patients seen in correct tier

Move unobstructed through tiers

http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Diabetes-Guide.pdf