Fylde Coast Integrated Fylde Coast Integrated Diabetes Care Diabetes Care

Diabetes Care PathwayDiabetes Care Pathway

Dr. Cruz AugustineDr. Cruz Augustine

Where we are Now!Where we are Now! Huge variations across NHSHuge variations across NHS

Services and outcomesServices and outcomes Socio-economic differencesSocio-economic differences

High Mortality in diabeticsHigh Mortality in diabetics 75,000.00 deaths with diabetes75,000.00 deaths with diabetes 1 1

1/3 can be prevented1/3 can be prevented 1 1

Cost to society and NHSCost to society and NHS 2.9 million UK population has diabetes2.9 million UK population has diabetes Total expenditure on diabetes could be up to Total expenditure on diabetes could be up to

10% of total NHS expenditure 10% of total NHS expenditure 22

1. Diabetes UK. Disease Prevalence, 20112. Commission for Healthcare Audit and Inspection, 2007

VISIONVISION : Bridging the secondary care and the : Bridging the secondary care and the CommunityCommunity

Fylde Coast Diabetes Care PathwayFylde Coast Diabetes Care Pathway

THE VISION: The Strategic Priorities!THE VISION: The Strategic Priorities!

CCG and Providers vision for CCG and Providers vision for integrated, unified services integrated, unified services balancing quality and cost-balancing quality and cost-effectivenesseffectiveness

Current variations in service Current variations in service provisionprovision

NSF principles of patient NSF principles of patient empowerment and self empowerment and self managementmanagement

THE VISIONTHE VISION““INTEGRATED DIABETES CAREINTEGRATED DIABETES CARE””

Patient centred not organisation Patient centred not organisation centredcentred

Care should be deliveredCare should be delivered

at the appropriate time, at the appropriate time, in the appropriate place, in the appropriate place,

by the appropriately trained by the appropriately trained professional, professional,

for that patient’s present needsfor that patient’s present needs

Objectives - Integrated Objectives - Integrated Fylde Coast Fylde Coast Diabetes CareDiabetes Care

fully integrated servicefully integrated service

avoid any gaps or duplication in serviceavoid any gaps or duplication in service

smooth and quick referral from primary smooth and quick referral from primary care for advice and management plancare for advice and management plan

increased specialist input into primary increased specialist input into primary care settingscare settings

consistent high quality patient centred consistent high quality patient centred carecare

To improve the quality of diabetic care To improve the quality of diabetic care provided by GP practicesprovided by GP practices

To improve capacity for diabetic To improve capacity for diabetic servicesservices

Manage more complex patients in the Manage more complex patients in the communitycommunity

To reduced unplanned diabetic To reduced unplanned diabetic admissions to secondary care admissions to secondary care

Pathway and GuidelinesPathway and Guidelines

To encourage care to be offered at the To encourage care to be offered at the most appropriate site by the most most appropriate site by the most appropriate method administered by the appropriate method administered by the most appropriate clinical most appropriate clinical professional(s)professional(s)

For care to be as near to the patient’s For care to be as near to the patient’s home and usual environment as home and usual environment as possiblepossible

To encourage patient involvement in To encourage patient involvement in their own caretheir own care

To foster professional development and To foster professional development and training about diabetes training about diabetes

PHILOSOPHY OF CAREPHILOSOPHY OF CARE

• All of the documents done by All of the documents done by multidisciplinary input from multidisciplinary input from community and secondary carecommunity and secondary care

• Seamless service where patients with Seamless service where patients with diabetes will be at the forefront of diabetes will be at the forefront of planningplanning

• Service will ensure equity of care for Service will ensure equity of care for everyone with diabetes, including the everyone with diabetes, including the housebound, those in care homes, the housebound, those in care homes, the mentally ill, and patients with learning mentally ill, and patients with learning disabilities disabilities

Hidden Health Care Hidden Health Care SystemSystem

Self-CareSelf-Care 80%80%

Professional CareProfessional Care20%20%

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Generalist Primary CareGeneralist Primary Care MAXIMUM ORAL TOLERATED THERAPY AS REQUIRED MAXIMUM ORAL TOLERATED THERAPY AS REQUIRED

Prevention/targeted Screening Prevention/targeted Screening of at risk groups of at risk groups

Follow up IGTT patientsFollow up IGTT patients

Diagnosis, assessment, Diagnosis, assessment, treatment & monitoringtreatment & monitoring

Patient education and provide Patient education and provide Continual education for Continual education for patients & practice staffpatients & practice staff

Provision of patient held care Provision of patient held care plan which includes the plan which includes the management of co-morbiditiesmanagement of co-morbidities

Screening for complications – Screening for complications – including foot, retinopathy, including foot, retinopathy, medicationmedication

Lifestyle management – Lifestyle management – including referral to exercise including referral to exercise referral programmes, referral programmes, structuredstructured

• Referral onto Tier 2 only when Referral onto Tier 2 only when all primary care interventions all primary care interventions exhausted exhausted

• Referral of T1DM for expert Referral of T1DM for expert assessment and intervention assessment and intervention either enhance primary care either enhance primary care service or specialist service if service or specialist service if symptomaticsymptomatic

• All of the above services to be All of the above services to be provided via appropriately provided via appropriately qualified staff qualified staff

• homes or housebound.homes or housebound.

• Maintenance of Diabetes Maintenance of Diabetes register through coding as register through coding as either T1DM or T2DM and either T1DM or T2DM and ethnicityethnicity

• Patient EducationPatient Education

• Management and review of *stable Adult T1DM Management and review of *stable Adult T1DM

• Poorly controlled T2DM on insulin Poorly controlled T2DM on insulin

• Initiation of insulin or GLP 1’sInitiation of insulin or GLP 1’s

• Ongoing Patient Education, and Enhanced Staff Ongoing Patient Education, and Enhanced Staff EducationEducation

• Continued care planning and promotion of self Continued care planning and promotion of self managementmanagement

• Appropriate care, as applicable to the enhanced Appropriate care, as applicable to the enhanced primary care service, of those patients in nursing and primary care service, of those patients in nursing and residential homes or houseboundresidential homes or housebound

• Management of those with poor healing/recurrent Management of those with poor healing/recurrent infections and raised HbA1cinfections and raised HbA1c

• Provide research and audit as requiredProvide research and audit as required

• Structured EducationStructured Education

Enhanced Primary Care

Acute site-Acute site-

• • Acute admissionsAcute admissions

• Emergency insulin Emergency insulin initiationinitiation

• HSS and DKAHSS and DKA

• Immediate Post MIImmediate Post MI

• Problematic management Problematic management

•Referral from retinopathy Referral from retinopathy screening servicescreening service

• specialist servicespecialist service

• Review of diabetic Review of diabetic inpatients inpatients

• PaediatricsPaediatrics

Complex patients

Management of complex Medical Problems:

•Neuropathy•Vascular & Pain•Retinopathy•Cardiology•Nephropathy•Endocrine•Mental health• Structured education

Consultant led Clinics

• Pre conception clinic• Young Persons clinic • Foot clinic• Pregnancy• Difficulties in initiation for type 1&2• insulin Pump therapy• Telephone advice and support for professionals and patients

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Specialist Care Inpatient care or specialist clinics not available in enhanced specialist services

Achieving Integrated CareAchieving Integrated Care

Source: Rosen et al (2011)

BarriersBarriersOwnershipOwnership

Organisational & Professional Organisational & Professional boundariesboundaries

Changing environmentChanging environment

Lack of understanding each other’s Lack of understanding each other’s perspectiveperspective

IT & Clinical recordsIT & Clinical records

GovernanceGovernance

ACTION: What we Need to Do next !ACTION: What we Need to Do next !

SERVICE DECISIONSSERVICE DECISIONSLet Patients & GPs decide on services to choose Let Patients & GPs decide on services to choose

SMART NOT JUST HARDSMART NOT JUST HARDWe must work smarter as local demand speeds We must work smarter as local demand speeds up.up.

PATIENT EDUCATION AND PATIENT EDUCATION AND ACCOUNTABILITYACCOUNTABILITY

We need to assist people to manage their own We need to assist people to manage their own illnessesillnesses

FOCUS ON PREDICT and PREVENTFOCUS ON PREDICT and PREVENTWe must move towards We must move towards ““predict and preventpredict and prevent””