diabetes care pathways - newham ccg · • diabetes renal clinics and inpatient care • in patient...
TRANSCRIPT
Building Healthy Communities
Diabetes Care Pathways Workshop-1
7 July 2016
Agenda and Approach
• Introductions
• Programme update and context
• BHC Future model and generic care pathway
• Diabetes care in Newham - Current state
• Considerations for the Future State • Scope and exclusions
• Outcomes to achieve- National, regional and local
• Guidelines/ Protocols/ Standards we should meet
• Best practice examples from other NHS sites
• Services that need to be included at each level of care
• Base lining and activity modelling
• Future diabetes pathway- Enhancements to the BHC pathway
• Pathway documentation template and timelines
• Service specifications
listen and engage
design and test
procure service
mobilise & go-live
Feb-Aug 2016
Mar- Sept 2016
Oct 2016-July-2017
Feb
2018
• Patient Public engagement
• Needs analysis • Provider events • NCCG programs
• Vision and scope • Delivery models • Financial analysis • Pathways
Building Healthy Communities - Overview Plan
Risk Stratification/ Care Navigation
Single Point of Access-Health and Social care
Single Joint Assessment Framework- Health and Social care
Building Healthy Communities Integrated Future Care Model
Well Person
Minor Illness
Primary care condition
Urgent Care /111/ OOH
Emergency/ A&E
Outpatient / Inpatient
care
Supported discharge
End of Life
Chronic Care
Prevention and Well
being
Care close to home
Care Co-ordination
and extended
primary care
Rapid response
Case management
Specialist services in community
Intermediate care
services- Pre-
hospital/ In-hospital care
Post-hospital care
Supported Discharge
End of Life Care
Integrated Health and Social Care Functions
Redesigned Estates and infrastructure
Integrate multidisciplinary team- new workforce model
Shared Care Record / Technology enabled care platforms
Core and Specific Pathways including mental health- Step Up and Step Down Care as required
MOHAMMED’S Future Pathway
Mohammed –
50 yrs old has
diabetes with
renal disease
Wife &
Carer
Telehealth Skype Home monitoring Carer Support Homecare Self -Care Prevention Well- being Advice Patient education
Access
SPA
M
ult
i Age
ncy
Hu
b
He
alth
& S
oci
al C
are
DO
S SI
NG
LE A
SSES
SMEN
T
Hub
Diagnostics
Social Care
Voluntary service
Foot care/
Physio
111/ Urgent Care
Integrated workforce model – MDT Team, Case Management, CPN
Virtual Specialist Support from Acute
Facilities/ Services Provider
Single Shared Record- Integrated care plan
Locality
GP hub
Neighborhood team
Prevention and Well being
Care Navigation Extended primary
care
Rapid response Care coordination Case management
Specialist services in community
Intermediate care services- Pre-hospital/ In-hospital care
Post-hospital care Supported Discharge
End of Life Care Step up / Step
down care
EPCS
Referrer
SPAR Clinical Hub
Navigation Risk Stratification
Triage H&SC Care co-ordinator
Referral Criteria
Does not meet criteria for Case
management
Does not meet criteria for SPAR
YES
Cri
tica
l > 2
hrs
No
n C
riti
cal
Ro
uti
ne
Tas
k
Rapid Response
Intermediate Care/Re-ablement
DN team
Community Delivery MDT
Team
DIAGNOSTICS TELEHEALTH
Manage for required period Manage for up to 6 weeks H
eal
th
Soci
al C
are
Discharge/Refer Appropriate for Case management ?
YES NO
NO NO
Practice Social Care
Community Delivery Team
Rehab/Supporting Services/ Mental Health
Personalised Budgets
For Assessment
Case Manager
DN Team
Specialist Services
Social care
Self Referral
Planned Expected/proactive
Unplanned
Prevent ion/ Wellbeing/ Self Care
Hospital at Home /Care Homes /Community Beds
Acute Services
GP/ EPCS
Supported Discharge/ In-Reach Services
Specialist consultation
Level 1 Referrals Navigation
Level 2 Care Co-ordination
Level 3 MDT Care Planning Proactive case management
Level 4 Reactive Case Management Advanced Community Care
Level 5 Step Up/ Step Down
NEWHAM BHC GENERIC HEALTH AND SOCIAL CARE PATHWAY
Acute Hub
Urgent Care pathway/ OOH GP
EHCC- Dementia/ EOL/ Rehab/ Day Hosp
UCC/ A & E
Community hub
Primary care
Ambulatory Care
Enablers
Single point of access
Care navigation
Shared electronic patients record
Joint health and social care assessment
Patient Transport Services
Prevention and Well being
Multidisciplinary assessments (MDT)
Goal oriented MDT Care planning
Patient education services
Screening services
Selfcare and monitoring
Self referral
Falls prevention service
Day Hospital
Care close to home
Community Outpatient Consultations
Anticoagulation service
Ophthalmology
AQP Contracts/ EPCS
Dermatology
Community Diagnostics
Community procedures
Wound care
Community Therapies (OT, PT, Podiatry)
Specialist Palliative care
Home health monitoring (telehealth) & telecare
Home care & Home Social Care
Rehabilitation services including SLT
Re-ablement services
Specialist services in community
Continence
East Ham Care Centre & Falls Prevention Clinic
Specialist Opinion in Community / Community Geriatrician
Foot health services
Tissue Viablity
Patient Appliances/ orthotics
Wheelchair services
Lymphedema
LD
MSK
AQP contracts
CVD
Diabetes
Dietetics
Haemoglobinopathies/Sickle Cell Adults
Intermediate care services- Prehospital/ In-hospital care
Rapid response services (Immediate/ urgent/ Routine)
Supported care- step up/step down care (known as Bed Based Intermediate Care)
Proactive Case management
Phlebotomy
Post-hospital care
Early supported discharge
CHC AND PHB - assessments, care plan and referral only
End of Life Pathway
Respite care
Neuro & Stroke rehab
Bereavement Services
HIV rehab
BHC- service lines in scope- draft
Services in red are proposed new services not in current community contract
Diabetes care in Newham Current state understanding
The changing face of diabetes in Newham
• High prevalence of diabetes (> 5%) in general population (high genetic loading for T2D, socio-economic deprivation)
• Relatively ‘young ‘ population structure - rising prevalence of Type 2 diabetes in children and young adults; large ante-natal diabetes clinic
• The shift in emphasis of diabetes care towards primary care
• High diabetes risk: 38,940 (17.6%) subjects are at high risk of developing T2D (risk of 20% or more);
8781 known to have pre-diabetes
9542 have not had any blood test in the last 5 years
( UCLP/Newham CCG pre-diabetes programme 2014-16)
Geospatial maps of people at high risk based
on QD Scores
Diabetes is a complex problem: there are significant challenges all along the pathway
Safer healthier people
Vulnerable people
Afflicted without
complications
Afflicted with complications
Reduce vulnerability
• Reduce obesity &other lifestyle factors
• Culturally tailored public health
•Targeted screening
Reduce or delay progression
• Improve awareness and attitude in population
• Accessible and high quality screening and initial assessment
Improve routine management
• Improve quality and accessibility of self-management support
• Improve quality and accessibility of routine care
Improve management of complications
• Quality and integration of care for people with complex needs
• Improve support for particular vulnerable groups
• Improve end of life care
• Integrating health & social care and spreading best practice across different providers
• Securing adequate resources and excellent staff to meet growing need
• Using and directing limited resource to have a major impact
What can we do?
Underlying challenges:
•Community Prescription
•Mapping/Risk stratification
•JSNA
• Healthier You/ NDPP • Pre-diabetes screening /EPCS
•Structured education/ self-management programme •Cluster MDT model
What is happening?
The Super Six
Primary/ Community Care Services –
Low/Medium Risk
GP Cluster Diabetes MDT initiative • Started in January 2013 across all
clusters of Newham CCG
• Attended by lead GP and/or practice nurse for diabetes for each practice, linked consultant diabetologist (Barts Health: NUH), linked community DSN (ELFT) +/- clinical psychologist from the Psychology and Health team
• The MDT meetings take place bi-monthly, lasting 2 – 2 ½ hours
• The meeting venues are mostly community based e.g. GP practice (only one MDT is held at NUH)
• Typically one patient case per practice is discussed (6 – 8 per meeting) with group discussion, and agreed action plan, steered by the consultant diabetologist and community DSN
• Of 142 planned MDT meetings since April 2013, only 16 (11%) have been
cancelled, and diabetologist attendance has been 100%
• Of the 59 Newham CCG practices, 40 (68%) have provided at least one representative at 75% or more of the meetings;
• These 40 practices represent 15284 (69%) of the 22065 people with diabetes living in Newham
• (These early outcomes from the GP Cluster Diabetes MDT initiative were presented at the forthcoming Diabetes UK Annual Professional Conference to be held at The Excel Centre. March 2015)
• Opportunity to get specialist advice on their patients, directly face to face with
consultant, and other members of the diabetes specialist team
• Transfer of learning and skilling up of primary care
• Sharing experience with fellow health professionals, especially challenges faced
• Increased confidence with management decisions and treatment choices
• Better understanding of the psychology of long term conditions
• Increased planned discharges from specialist to primary care
• Referral avoidance
• Education and dissemination of information
Specialist Care Services – High Risk • Young adults (16-25 yrs) and Insulin Pumps: Currently 212
(16-25) active follow up with increasing number of young people with T2 DM (1/3rd to 1/4th of the case load): Probably the highest prevalence in the UK and a big concern.
Insulin Pumps (48 current) • Diabetes in pregnancy service (antenatal, pre and post-
partum clinics and inpatient care) >800 pregnancies per year;
• GDM numbers: Newham: 2271, City & Hackney: 604 , T Hamlets: 1987
• Women with GDM locally have a 1 in 3 conversion to t2D (UCLP/NCCG pre-diabetes programme)
• Multidisciplinary diabetes foot clinics • Diabetes renal clinics and inpatient care • In patient diabetes care (diabetic emergencies, and input
into the care of any inpatient with diabetes, as required) at NUH > 30 % of all inpatients have DM
• NADIA ( national in-patient audit usually in top 3 for inpatient diabetes)
• Complex diabetes care (long term follow up) about 1500 patients at any one time
Other Specialist Input • Strategic input –
service re-design, Diabetes Partnership Board etc
• Primary care
health professional education and training
• Joint research e.g.
UCLP/Newham CCG programme
Challenges
Rising demand on services: estimated rise 13.5% in 2030
Pressure to cut costs/ improve efficiency
Lack of shared patient records
Inflexible and inaccessible services
High non attendance rates in some (vulnerable ) groups
Poor patient self-management, related to poor engagement with service and lack of flexibility of services (Local MORI survey ‘09)
Poor health outcomes e.g.
Repeat admissions via the emergency department, particularly for young adults
Increased complications – cardiac, renal, foot disease
Poor pre-pregnancy care, late booking into antenatal services
Poor end of life care
Diabetes care in Newham Future state planning
Considerations for the future state
• Scope and exclusions
• Outcomes to achieve- National, regional and local
• Guidelines/ Protocols/ Standards we should meet
• Best practice examples from other NHS sites
• Services that need to be included at each level of care
• Base lining and activity modelling
• Future diabetes pathway- Enhancements to the BHC pathway
• Pathway documentation template and timelines
• Service specifications
Diabetes-What should be commissioned?
Principles of Integrated Diabetes Care
• Provide services as close to where
people with diabetes live as possible
• Provide coordinated services without
duplication or gaps and employ
coordinators to do this
• Work in an integrated way (between
primary care and specialists) and in
partnership with social care and
other providers
• Ensure the workforce is trained
(competency based) and care is
delivered via multidisciplinary teams
• Provide services that support self
management for people with
diabetes
How does BHC generic model address the Integrated Clinical Model for Diabetes? 1. Prevention and self
care 2. Care close to home 3. Service lines
a) Foot care b) CVD pathways c) EOL care d) CYPS
procurement e) Patient education
4. Shared care record 5. MDT teams 6. Hubs with diagnostics
and specialist care 7. Care Planning 8. Virtual Consults
BHC Diabetes Care pathway – levels of care
Level of care
Type of care Patient profile
Locations / Organisation
Care Activity
Roles
Level 1 Prevention and Well being- Navigation
Well person, minor illness
Home, Virtual Primary care SPA hub
Level 2 Care coordination
Moderate risk Primary care EPCS, Home, Locality hubs
Level 3 Proactive case Management
Moderate and high risk
Locality hubs Community hubs
Level 4 Reactive Case management
Very high risk Community hubs, EHCC, Home, Care homes
Level 5 Step Up and Step Down Care
Very high risk Community hubs, EHCC, Home, Care homes
Outcomes
• Those outcomes as defined in the five domains of the NHS Outcomes Framework
• An improved patient experience of their care, including moving between different parts of the healthcare community
• Screening and prevention of diabetes
• Achieving the nine key care processes for type 1 and type 2 diabetes
• Achieving treatment targets for patients with diabetes by acting upon the findings of care processes
• Achieving a reduction in complications of diabetes by acting on the findings of care processes
• Reducing admissions and use of inpatient services for patients with a primary code of diabetes
• Compliance against NICE Diabetes in Adults Quality Standard25
Indicative Outcomes/ KPIs/Quality • Statement 1. People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed
criteria from the time of diagnosis, with annual review and access to ongoing education.
• Statement 2. People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.
• Statement 3. People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.
• Statement 4. People with diabetes agree with their healthcare professional a documented personalised HbA1c target, and receive an ongoing review of treatment to minimise hypoglycaemia.
• Statement 5. People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.
• Statement 6. Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes.
• Statement 7. Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered preconception care and those not planning a pregnancy are offered advice on contraception.
• Statement 8. People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately.
• Statement 9. People with diabetes are assessed for psychological problems, which are then managed appropriately.
• Statement 10. People with diabetes at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance.
• Statement 11. People with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services, and the multidisciplinary foot care service is informed of this.
• Statement 12. People with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the multidisciplinary foot care service or foot protection service within 1 working day and triaged with 1 further working day.
• Statement 13. People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.
• Statement 14. People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team.
• Statement 15. People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.