A Whole Pathway Integrated Approach to Improving Foot Care

Transcription

1 A Whole Pathway Integrated Approach to Improving Foot Care Excellence in Action London Foot Care Network 4 th Feb 2016 Georgina Cunningham, Commissioning Manager LTC, Southampton City Integrated Commissioning Unit 1

2 Southampton City - our vision: A Healthy Southampton for all

3 About our city: Registered GP practice population of 276,257 Resident population of 248, GP practices 45 Pharmacies 1 Acute Hospital (DGH & Tertiary) Minor Injuries Unit 2 Community providers 2 National private providers South Central Ambulance Service Two Universities Strong marine industry and UK s leading vehicle-handling terminal Cruise ship port International airport and good travel links to London Major regional centre for retail

4 IMD 2015 Map of England Deprivation Deciles Southampton ranked 54 th most deprived LA based on average rank of LSOAs and 67 th most deprived LA on average score of LSOAs 4

5 Diabetes: Diabetes register size: (April 2015) Total = 11,854 Type 1 = 1,185 Type 2 = 10,669 Prevalence of 5.4% Drivers for change: 80-90% of patients are currently been managed in primary care Outcomes highly variable across primary care Southampton lagging behind in reported outcomes NDA bottom of comparable league table, higher than expected amputation rates Lack of pathway clarity Need for change - to improve outcomes for people with diabetes Diabetes Strategy Planned Improvement Programme commenced May

6 What we have achieved: Established Project Group, Diabetes Development Group and Clinical Reference Group Reviewed Hospital service provision Reviewed Community Service provision introduced new way of working Built co-ordination across pathway and between organisations Commissioned new local Insulin Pump Service Implemented new model of diabetes care (Oct 2014) Implemented new quality improvement scheme in Primary care Diabetes Accreditation Scheme (Oct 2014) 6

7 Southampton City CCG Integrated Model of Diabetes Primary Care On-going management of 80%- 90% of patients with diabetes including complex and Type 1 with support from specialists Providing the 9 care processes Participate in the Diabetes Accreditation Scheme (DAS) Intermediate Service Specialist Team including consultants and DSNs. (The team are also supported by Dietetic and Podiatry Teams) Professional Educator Role (Biannual visits to GP practices, provide education, virtual clinic for management of complex cases) Intermediate Team Facilitates the implementation of DAS Acute Service Specialist Care delivering the super six Patient Education Advice and Guidance for primary care through telephone and advice (Urgent and Routine) Face to Face Patient Contact as appropriate 1. Inpatient care 2.Insulin Pump Therapy 3. Pre Conception and Antenatal diabetes 4. Diabetic Nephropathy - diabetes & CKD stage 4 or worse 5. Type 1 diabetes with complex needs 6. Acute Diabetic foot care 80 90% on-going management in Primary Care Patient Pathway 7

8 Benefits of new model: Strategic fit in line with Diabetes Strategy Clarity of pathway Utilisation of specialist skills & increased skill levels Improved service and quality of care Improved outcomes NICE 9 key care processes Improved partnership working Proposed model expansion across LTC and other care pathways to be led by Primary Care 8

9 Diabetes Foot Care: Table shows the amputation rates for Southampton City that were published in 2014 and 2015 Extracted data from Foot Care Profile Amputations per 1,000 people aged 17+ with diabetes Major amputations per 1,000 people aged 17+ with diabetes Minor amputations per 1,000 people aged 17+ with diabetes Hospital footcare activity (April 10 to Mar 13) Published March 2014 Hospital footcare activity (April 11 to Mar 14) Published June 2015 SCCCG England avg. SCCCG England avg. 4.2% 2.6% 4.3% 2.6% (137) (148) 1.0% (32) 3.2% (105) 0.9% 0.8% (28) 1.7% 3.5% (120) 0.8% 1.8% Key observations are: Major amputations are similar to the national average for England Minor amputations are significantly higher than the national average for England We also know that Southampton patients spend higher than the national average number of nights in hospital 9

10 Diabetes Foot care Activity Profile June 2015 Diabetes Footcare Outcome vs. Peers Higher than peers Higher than peers Higher than peers Average Average Average Higher than peers Higher than peers Average Higher than peers Outcome Episodes of care in hospital for diabetic foot disease per 1,000 people aged 17+ with diabetes Number of days in hospital for diabetic footcare disease per 1,000 people aged 17+ with diabetes Average number of nights spent in hospital per episode of care for diabetic footcare diseases % of episodes of care for diabetic foot conditions accounted for by patients who had more than one inpatient stay % of patients who had more than one episode of care for diabetic foot disease within the three years % of patients who had more than four episodes of care for diabetic foot diseases within three years Amputations per 1,000 people aged 17+ with diabetes Number of days in hospital for amputations per 1,000 people aged 17+ with diabetes Major amputations per 1,000 people aged 17+ with diabetes Minor amputations per 1,000 people aged 17+ with diabetes Period Source Clare Young, Programme Management Office (PMO)

11 Diabetes Foot Care: Diabetes UK 1 st October 2015 Event at Bar Gate, Southampton city (148 shoes) A patients story 11

12 When I was first told I would lose my foot I was in total shock and told the doctors to go away. I didn t want to look at it and it was horrible going back home and not being able to do simple things like walk up the stairs. It was a lot to come to terms with and I found it particularly difficult to learn how to walk again. If we can stop others from going through what I have then I think this is exceptionally important 12

13 Diabetes Foot Care: Some progress with Patient Group Directives for antibiotics and direct access to x-ray which has reduced the delays in patients being able to access treatment Southampton is not providing a level and quality of service that is sufficient to address the poor outcomes Provision and Pathway is not NICE compliant High level of dissatisfaction within Primary Care and from those patients who have Diabetes The case for change is clear to improve quality of care 13

14 Diabetes Foot Care: Commissioning for the whole population and meeting the needs for those with Diabetes at: Low risk 70% (8,297) Medium to high risk 25% (2,962) Acute 5% (592) NB: % split of population based on NICE recommendation 14

15 What have we done: Worked collaboratively with our community podiatry service and hospital provider since September 2014 Revised our original plan to only implement combined foot care clinics and access to MDT (Jan 2015) to meet the needs of those with active / acute foot disease Detailed modelling to inform Business Case and commissioning plans Detailed audit of the podiatry caseload (July & August 2015) split Diabetic and Non-diabetic / risk stratification Renegotiated current commissioning arrangements Foot Care engagement with public and communication of intentions with patients group Engagement with SC Health, Overview and scrutiny panel 15

16 Level of risk Total pop. 11,854 Setting of Care Planned improvement Benefits Low risk 70% of the diabetes population (Approx. 8,000) Primary Care Improved quality of annual foot check Consistent foot care scoring of risk Better provision of education leaflets to raise awareness Improved signposting to services in the community Better patient awareness and improved selfmanagement for those at low risk to maintain status to prevent developing complications Improved management in primary care, through education, training Medium to high risk Medium risk 20% (Approx. 2,500) High risk 5% (Approx. 500) Community Diabetes Foot Protection team (DFPT) within Podiatry service Improved management of those at medium to high risk by the DFPT with regular review, assessment and management. Onward referral to new MDT and combined foot care clinics Improved advice and guidance to primary care Better focus on education for patients Improved access, more responsive and timely care Improved patient satisfaction Prevention of foot disease Improved management of ulceration by the foot protection team to prevent further complications Acute (active) Foot Disease and Ulceration 5% of the diabetes population (Approx. 600) Acute Multi-disciplinary team (MDT and Combined clinics) With access to podiatrists, diabetologist, vascular surgery, tissue viability nursing, orthopaedic surgery, orthotics, diabetic specialist nursing, radiology, microbiology) Dedicated specialist provision for those with active foot disease Joint working with community DFPT More effective use of resources Improved care and management for active foot disease Improved access to MDT and Combined Foot Care clinics to provide expert assessment and intervention Reduction in unplanned and emergency admissions A move towards improved patient experience and outcomes through more planned admissions Reduction in major and minor amputations over the next 3 years Improved outcomes for the city to align with similar cities 16

17 Key elements of the new pathway: To build capacity for the podiatry service to deliver a DFPT low risk patients both diabetic and non-diabetic will be discharged Podiatry service will continue to provide for non-diabetic moderate / increased and some low risk patients Podiatry service will start working 6 days a week Access to combined clinics and MDT will be through the DFPT SPA 17

18 Our Aims: To provide an integrated co-ordinated foot care pathway that covers primary care, community and secondary care with all areas of the pathway working together to improve outcomes for patients with diabetes. Improve quality of provision across all settings Over time improve amputation rates Reduction in NEL admissions 18