East London Community Kidney Service Neil Ashman – Kidney Physician Sec Hoong – Project Manager Sally Hull – GP and CEG lead Helen Rainey – Clinical nurse specialist for Kidney Disease Nicola Thomas – Kidney Nurse and Professor of Kidney Care October 2017

AMBITION/AIMS Long term goal is to reduce progression to end stage renal disease. Interventions build on successes in Camden, Birmingham and east London. Aim to improve management across the entire CKD pathway

IMPACT CKD managed in a single care record Wait times for renal consultant advice slashed from 64 to 5 days Only 20% of patient need to be seen in outpatients Outpatient costs falling Coding and management in primary care improved

SPREAD From the Tower Hamlets CCG pilot, the project has spread to 1.2M east London adults. 300 downloads of the falling eGFR trigger tool from the CEG website

KEY LEARNING Understand, and build on, local data sources for CKD. Work with CCGs to engage primary care in system change – relationships matter! Involve patients in co-designing educational materials

Why the NHS needs this innovation

What is the Problem? 1. Rising rates of End Stage Renal Disease (ESRD) in East London – with ever more people needing dialysis. The 4% annual growth costs the NHS about £6Million

2. Gaps in primary care identification, coding and CKD management. 3. No systematic CKD self management education for patients. 4. Long delays to see kidney specialists,

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NHS CityandHackneyNHSNewham

NHS TowerHamlets

Data from the UK Renal Registry 2015

What are we doing about this?

1. Community CKD e-Clinic Community-based nephrologist does e-clinics in EMIS Web. All reviews and opinions recorded in EMIS Web Locally relevant guidelines.

E-referrals Shared record

and local guidelines

3. Community CKD overview in primary care CKD Prevalence searches to find un-coded patients CCG/Practice dashboards with KPIs ‘Trigger tools’ to alert GPs to patients with a falling eGFR Practice safety

alerts

Community based education

Find and code cases

2. Education: patients and practitioners Patient one-to-one and group education Practice based education for clinicians

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First appointments to vCKD and Nephrology:

Tower Hamlets CCG 2015/6

FA General nephrology vCKD

Results from the e-clinic: Tower Hamlets 2015/6

Clinic Outcomes 2016 No. %

OP F2F Appointment 111 21.5

Discharge to GP 255 50

Review in vCKD 143 27.5

Other 5 1

Total 514 100

Waiting times for consultant advice slashed!

• In the six-week pilot period 19/35

practices referred into the community e-clinic.

• Over 70% of referrals are managed

without the need for patients to attend a hospital appointment.

• During 2015 the average wait for a

renal clinic appointment was 64 days. Using the e-clinic the average time to get nephrology advice is 5 days.

GPs say… A model for future

care happening right

now in Tower Hamlets!

Only 20% of patients

require a face to face

appointment

Patient Education

Innovative materials developed with patients including the ‘conversation map’ “Diabetes Conversation Maps™ are effective for diabetes self-management education and facilitate behaviour change in people with type 2 diabetes.” (Ghafoor 2015)

Primary Care Education

Supporting CPD

1. Presence at locality education meetings.

2. Community staff training– including diabetes teams and Health Trainers

3. Practice nurse group education:

Providing resources developed with patients

– booklets and films to self-manage kidney disease

https://bartshealth.nhs.uk/renal

Develop CKD practice tools CKD Prevalence searches to find un-coded patients Data entry CKD template CCG/Practice dashboards with KPIs QI practice tools to track progress ‘Trigger tools’ to alert GPs to patients with a falling eGFR

Results from Community CKD overview

Practice List size

Patients aged

18+

Adults with eGFR

evidence of CKD

Metric 1 eGFR

evidence of CKD - and CKD Read

code

Rate

Adults with eGFR

evidence of CKD with

diabetes

Metric 2 eGFR

evidence of CKD,

Diabetes and CKD

Read code

Rate

Min 15.6% 17.9% Max 93.7% 96.4% F84004 12,238 8773 342 236 69.0% 122 87 71.3% F84006 12,630 9537 297 164 55.2% 155 87 56.1% F84009 9,114 7407 140 99 70.7% 63 47 74.6% F84010 10,165 7874 255 144 56.5% 99 54 54.5% F84014 7,575 5741 200 152 76.0% 125 98 78.4% F84017 13,731 10365 274 222 81.0% 123 105 85.4% F84022 6,389 5317 119 79 66.4% 50 34 68.0% F84032 3,006 2223 49 21 42.9% 26 14 53.8% F84047 11,713 8472 239 146 61.1% 78 47 60.3% F84050 9,318 6522 122 55 45.1% 67 29 43.3% F84052 8,660 6734 198 44 22.2% 77 18 23.4% F84053 7,568 5801 155 51 32.9% 68 24 35.3% F84070 4,807 3751 146 53 36.3% 72 30 41.7% F84074 10,145 7701 287 214 74.6% 124 97 78.2% F84077 7,693 6280 142 99 69.7% 54 43 79.6%

CKD Practice Dashboard 2016

WE HAVE Improved average practice coding rates

AND Decreased variation between practices

http://www.blizard.qmul.ac.uk/ceg-home.html

Practice ‘Trigger Tool’ to identify patients with a falling eGFR