OCCG Primary Care Contract Oxfordshire Long Term Conditions Locally Commissioned Service (LCS)

Transcription

1 OCCG Primary Care Contract Oxfordshire Long Term Conditions Locally Commissioned Service (LCS) Commencement date: 1 April 2018 End date: 31 March Year of Care Planning Oxfordshire CCG regards the implementation of Year of Care Planning 1 as key to the effective clinical management of people with long term conditions. Under the Diabetes LCS practices were funded to train one GP and one Practice Nurse in Year of Care Planning. Practices participating in this locally commissioned services are expected to complete the following. 1.1 Year of Care Planning implementation Each practice will implement Year of Care Planning (YOC) for the management of diabetes patients. The practice can extend this to all long term conditions patients, which will generate the most efficiencies and benefit. Each practice will need to do the following to achieve implementation and receive payment: a) Complete the Year of Care Planning Practice Checklist* b) Assign a named clinical champion for YOC in the practice. This YOC champion will: o lead implementation, o run practice meetings initially YOC specific then as a standing item on practice meeting, o disseminate YOC learning to whole practice team, o engage with OCCG YOC Coordinator c) Engage in evaluation of YOC using patient and healthcare professional (HCP) assessment tools*. Including YOC selfassessment tool for staff to check understanding/skills and to identify further skills development and refresh. d) Agree to engage in a review one year post-implementation. * The Year of Care Practice Checklist and Evaluation Tools are available on request to OCCG. 2. Diabetes Enhanced Care Delivery Practices participating in this locally commissioned service agree to deliver all elements of enhanced diabetes care Diabetes MDT Meetings Each practice will participate in 6-monthly meetings between individual practices and secondary care and community care clinicians specialising in diabetic care with the aim of improving the care of patients. Meeting & preparation/follow up time is expected to be up to 4 hours and 1 GP plus 1 Practice Nurse participating. The MDT is to review complex 1 Year of Care website: 1

2 diabetes patients with specialist diabetes clinicians to improve patient care Locality Diabetes Review Meetings The practice is responsible for running relevant searches in preparation for the meeting, administering the meeting, producing the minutes (patient identifiable information removed) and sharing the minutes with the diabetes specialists. The purpose of Locality Diabetes Review meetings is to support population health improvement for diabetes. Each locality will hold a Locality Diabetes Review meeting twice a year. Each meeting will be two hours in duration and include Diabetes Specialist Team representation. The meetings are to enable practices to; Review their Diabetes Dashboard Identify where improvements to diabetes care can be made Share best practice Develop strategies to ensure the best health outcomes for their diabetes population, which could include improved clustered working Care Process and NICE Treatment Target achievement for Type 2 diabetes patients Under this contract, each practice will ensure at least one GP and one Practice Nurse attend both Locality Diabetes Review meetings within the year and ensure implementation of any actions identified for individual practices from those meetings. National Diabetes Audit (NDA) 2016/17 will determine the England, Oxfordshire and Practice baseline for achievement for all 8 care processes (Appendix D) and patients meeting all three NICE treatment targets (triple target) of HbA1c 58mmol/mol (7.5%), BP 140/80mmHg, Cholesterol <5mmol/L) for Type 2 diabetes patients. Specific achievement requirements for each practice are set out in detail in Appendix A which will determine payment. The NDA will become a quarterly audit by NHS Digital by 2019; therefore practice achievement will be verified by the next NDA immediately after 31 March Practice achievement requirements have been broadly determined according to the following principles: Quartile 1 (bottom) practices: achieve the Oxfordshire average (56.4%) for 8 care processes and the Oxfordshire average (40.4%) for the Triple Target Quartile 2 practices: achieve the Oxfordshire average (56.4%) or improve performance by at least 1% compared to NDA 2016/17 for 8 care processes and achieve the England average (41.1%) for the Triple Target Quartile 3 practices: improve performance by 1% compared to NDA 2016/17 Quartile 4 (top) practices: maintain or improve upon NDA 2016/17 performance 2

3 Each practice should review their performance against these expected outcomes over the first half of the year (the Diabetes Dashboard 2 can help practices to track this) to assess whether they will achieve all targets. If a practice judges that they will not achieve all the outcomes, they should produce a plan of improvement through an MDT involving the Diabetes Specialist Teams. The plan should set out; an assessment of performance and any progress to date (including a review of progress against any 2017/18 diabetes improvement plan), barriers to achievement, how challenges will be overcome and targets achieved. The plan should include timescales and any implementation progress at point of submission. Completing the improvement plan with the diabetes specialist team and making progress against will enable to practice to be paid for this element if they miss the care process and treatment target achievement set out in Appendix A. The improvement plan needs to be submitted by 1 st Dec Insulin Initiation 2.5. Other essential items Each practice will provide initiation of insulin for all Type 2 Diabetes patients requiring conversion. Detailed criteria for the insulin initiation service are included in Appendix E. All patients with Type 1 Diabetes are to be either seen at OCDEM or stable patients discussed with an OCDEM consultant twice a year and actions implemented. Under this contract, each practice will: a) Apply complete coding for all diabetes structured education activity using nationally standardised codes 3. This is to include referral, declines, attendance, non-attendance and completion of structured education. b) Apply complete diabetic eye screening coding. c) Make their data available for the Oxfordshire Diabetes Dashboard. d) Ensure a lead GP and lead Practice Nurse for Diabetes are nominated as main points of contact for the CCG, with contact details provided. It is understood that not all diabetes care will be undertaken by just one Practice Nurse and GP in all practices. e) Ensure full submission to the National Diabetes Audit. 3. Respiratory Enhanced Care Delivery Practices participating in this locally commissioned service agree to deliver all elements of enhanced respiratory care Respiratory MDT Meetings Each practice will participate in 6-monthly meetings between individual practices and the Integrated Respiratory Team (acute and community specialists) with the aim of improving the care of patients. Meeting & preparation/follow up time is expected to be up to 4 hours and 1 GP plus 1 Practice Nurse participating. The MDT is to identify 2 Practices should be aware that the Oxfordshire Diabetes Dashboard will provide a good measure of performance however it does not perfectly replicate the National Diabetes Audit

4 undiagnosed COPD patients, respiratory patients at risk of admission and review complex respiratory patients with the Integrated Respiratory Team (IRT) to improve patient care. The practice is responsible for running relevant searches in preparation for the meeting, administering the meeting, producing the minutes (patient identifiable information removed) and sharing the minutes with the respiratory specialists. The MDTs will be scheduled according to the mobilisation of the IRT pilot, as and when the pilot commences across particular localities the MDTs will be arrange with practices. The number of Respiratory MDTs per practice for 2018/19 cannot be confirmed as it is yet to be determined. However the payment to the practice per MDT is set out at section Practice Respiratory Leads Each practice is to ensure a lead GP and lead Practice Nurse for Respiratory are nominated as main points of contact for the CCG, with contact details provided. It is understood that not all respiratory care will be undertaken by just one Practice Nurse and GP in all practices. 4. Payments The following payments require the practice to agree to deliver all activities and outcomes set out in this contract under sections 1, 2 and Year of Care Planning implementation Each practice will be paid a fixed payment of 600 to implement Year of Care Planning which includes everything set out in section 1.1 above. Each practice will also be paid 1.50 per registered diabetes patient (QOF 2016/17) to cover the costs of an additional letter to each patient. See Schedule of Payments by Practice (Appendix C) for exact payment per practice Fixed diabetes meeting payments The meeting payments set out in Table 2 are fixed for each practice, irrespective of practice size or diabetes register. These fixed payments will be paid at the start of the year on receipt of the Sign Up Form (Appendix F). Table 2 Activity Payment per practice Diabetes MDT Meetings x Locality Diabetes Review Meetings x Diabetes care process and treatment target (triple target) payment Payment for this element will be made after the year end on receipt of the End of Year Claim Form (Appendix G). Please refer to Schedule of Payments (Appendix C) for the anticipated values for each practice. Practice achievement targets are set out in Appendix A and achievement will be verified by the next NDA immediately after 31 March If the practice does not achieve all care process and triple target outcomes by the end of the year but has submitted an improvement plan by 1 st December 2018 and then makes progress against it, the practice will receive the payment. 4

5 To receive this payment all practices must also ensure delivery of essential items in section 2.5 by the end of the year. Table 3 Activity Payment per registered diabetes patient Care Process and Triple Target achievement Insulin initiation payment Insulin initiation payment will be paid on a per patient basis according to the following payment structure in Table 4. The amount practices are paid in total for insulin initiation will therefore vary according to the number of patients initiating insulin in the year. Practices must use read code 66Ap to be paid for insulin initiation under this contract and payment will be based on quarterly activity reported through a practice system search. As numbers are anticipated to be relatively low, payment for insulin initiation will be made as part of the final reconciliation process for locally commissioned services at the year end. Table 4 Activity Payment Per patient payment for insulin initiation Respiratory MDT Meetings The MDTs will be scheduled according to the mobilisation of the IRT pilot, as and when the pilot commences across particular localities the MDTs will be arrange with practices. The number of Respiratory MDTs per practice for 2018/19 cannot be confirmed as it is yet to be determined. The fixed per MDT payment for a practice is set out in Table 5. Table 5 Activity Payment per MDT Respiratory MDT Meeting Information reporting requirements Practice information reporting requirements are set out in Table 6 below. The Sign Up Form (Appendix F) and End of Year Claim Form (Appendix G) need to be completed and submitted to occg.primarycarecontracting@nhs.net to confirm participation and enable payment. Table 6 Year of Care Planning implementation Diabetes MDT Meetings Locality Diabetes Review Meetings Record of all implementation tasks set out in section 1.1. This should be provided in one by year end to: occg.primarycarecontracting@nhs.net A record of the meetings that documents: date/time of meeting, attendance, issues discussed and number of patients discussed (patient identifiable information not to be included). Record of meeting to be sent through to: occg.primarycarecontracting@nhs.net Minutes and attendance recorded at each meeting and ed on a per locality basis to: occg.primarycarecontracting@nhs.net 5

6 Diabetes Dashboard Care process and NICE treatment target outcomes Relevant data made available for pull into diabetes dashboard on a monthly basis. Submission of End of Year Claim Form and verification through National Diabetes Audit (NDA) immediately following 31 March If the NDA is not reported quarterly by this point, OCCG may use the Diabetes Dashboard to verify care process and treatment target achievement. If the practice deems necessary, a diabetes improvement plan is to be submitted by 1 st December Insulin Initiation Structured Education coding Read coding of all patients initiated on insulin. The read code to be used to ensure payment is: 66Ap. verification of attendance at insulin initiation training to: occg.primarycarecontracting@nhs.net Continuation of read coding of referral to structured education with the addition of read coding all outcomes of structured education with the following standard 4 read codes for EMIS and Vision. Outcome of referral to diabetes structured education Diabetes structured education declined Did not attend diabetes structured education Attended* diabetes structured education Diabetes structured education completed EMIS/Vision Read Code 9OLM 9NiA 9OLB 9OLF *Where a structured education course consists of more than one session, and the patient only attends some of the sessions then, enter a Read Code of attended. If the patient attends all the sessions and completes the course enter a Read Code of completed. Diabetic Eye Screening Respiratory MDT Meetings Coding will be monitored through the Diabetes Dashboard and NDA. Coding will be monitored through the Diabetes Dashboard and NDA. A record of the meetings that documents: date/time of meeting, attendance, issues discussed and number of patients discussed (patient identifiable information not to be included). Record of meeting to be sent through to: occg.primarycarecontracting@nhs.net 4 6

7 APPENDIX A: DIABETES REGISTER (QOF 2016/17) AND TYPE 2 CARE PROCESSES AND TRIPLE TARGET (NDA 2016/17) ACHIEVEMENT AND REQUIREMENT BY PRACTICE Practice code Practice name Locality Locality Plan Cluster Number on register (Diabet es) Prevalen ce (Diabete s) Practice % of Oxfordsh ire Diabetes Register 8 Care Processes performa nce (%) - NDA 2016/17 Required Care Processes achievem ent (%) for LCS payment Triple Target performa nce (%) - NDA 2016/17 Y02754 Banbury Health Centre North Banbury % 0.5% K84058 Bloxham Surgery North Rural North % 1.0% K84030 Chipping Norton Health North Rural North % 2.2% Centre K84056 Cropredy Surgery North Banbury % 0.6% K84055 Deddington Health Centre North Rural North % 1.4% K84059 Hightown Surgery North Banbury % 1.7% K84040 Horsefair Surgery North Banbury % 2.7% K84065 Sibford Gower Surgery North Rural North % 0.3% K84046 Wychwood Surgery North Rural North % 0.8% K84028 West Bar Surgery North Banbury % 3.0% K84024 Windrush Surgery North Banbury % 1.5% (Banbury) K84062 Woodlands Surgery North Banbury % 1.2% K84613 Alchester Medical Group North K84082 The Key Medical Practice North K84045 Gosford Hill Medical Centre North K84003 Islip Surgery North K84038 Montgomery House Surgery North K84052 Bicester Health Centre North Bicester % 2.3% Kidlington and Surrounds % 2.2% Kidlington and Surrounds % 1.4% Kidlington and Surrounds % 0.8% Bicester % 2.4% Bicester % 2.1% Required Triple Target achievem ent (%) for LCS payment 7

8 Practice code Practice name Locality Locality Plan Cluster Number on register (Diabet es) Prevalen ce (Diabete s) Practice % of Oxfordsh ire Diabetes Register 8 Care Processes performa nce (%) - NDA 2016/17 Required Care Processes achievem ent (%) for LCS payment Triple Target performa nce (%) - NDA 2016/17 K84042 Woodstock Surgery North Kidlington and Surrounds % 1.4% K84016 Beaumont St (19) Oxford Central Oxford % 0.8% K84049 Beaumont St (27) Oxford Central Oxford % 0.6% K84080 Beaumont St (28) Oxford Central Oxford % 0.5% K84021 Banbury Road (172) Oxford North Oxford % 0.6% K84032 Bartlemas Surgery Oxford Oxford % 1.8% K84025 Botley Medical Centre Oxford South and West Oxford % 1.2% K84009 Hedena Health Oxford Headington % 2.7% K84063 Cowley Road Medical Oxford Oxford % 0.8% Practice K84004 Donnington HC Oxford South Oxford % 2.4% K84048 Hollow Way Medical Centre Oxford South Oxford % 1.3% K84078 Jericho Health Centre Oxford North Oxford % 0.3% (Leaver) K84026 Observatory Medical Oxford North Oxford % 1.1% Practice K84005 Kennington Health Centre Oxford South and West Oxford % 1.0% N/A N/A N/A N/A K84605 King Edward Street Oxford Central Oxford % 0.2% K84066 Luther Street Medical Oxford % 0.0% N/A N/A N/A N/A Required Triple Target achievem ent (%) for LCS payment 8

9 Practice code Practice name Locality Locality Plan Cluster Number on register (Diabet es) Centre K84617 South Oxford Health Centre Oxford K84013 St Bartholomews MC Oxford K84060 St Clements Surgery Oxford K84011 Summertown Health Centre Oxford K84007 Temple Cowley Health Oxford Centre K84031 The Leys Health Centre Oxford K84044 Manor Surgery Headington Oxford K84008 Watlington & Chalgrove South Surgery K84071 Goring & Woodcote Health South Centre K84036 Mill Stream Surgery South K84014 Morland House Surgery South K84015 Nettlebed Surgery South K84020 Sonning Common Health South Centre K84035 Bell Surgery South K84001 Hart Surgery South Prevalen ce (Diabete s) Practice % of Oxfordsh ire Diabetes Register 8 Care Processes performa nce (%) - NDA 2016/17 Required Care Processes achievem ent (%) for LCS payment Triple Target performa nce (%) - NDA 2016/17 South and West Oxford % 0.4% Oxford % 1.2% Oxford % 0.6% North Oxford % 1.4% South Oxford % 1.5% South Oxford % 1.9% Headington % 2.2% Thame, Watlington and Wheatley % 1.2% Wallingford, Goring and Woodcote % 1.4% Wallingford, Goring and Woodcote % 0.7% Thame, Watlington and Wheatley % 1.4% Henley and Sonning Common % 0.5% Henley and Sonning Common % 1.2% Henley and Sonning Common % 1.1% Henley and Sonning Common % 1.1% Required Triple Target achievem ent (%) for LCS payment 9

10 Practice code Practice name Locality Locality Plan Cluster Number on register (Diabet es) Prevalen ce (Diabete s) Practice % of Oxfordsh ire Diabetes Register 8 Care Processes performa nce (%) - NDA 2016/17 Required Care Processes achievem ent (%) for LCS payment Triple Target performa nce (%) - NDA 2016/17 K84050 The Rycote Practice South Thame, Watlington and Wheatley % 1.6% K84037 Wallingford Medical Centre South Wallingford, Goring and Woodcote % 2.1% K84034 Clifton Hampden Surgery South Abingdon with Berinsfield and Clifton % 0.5% West Hampden K84002 Didcot Health Centre South Didcot % 2.7% West K84023 Berinsfield Health Centre South Abingdon with Berinsfield and Clifton % 1.1% West Hampden K84079 Long Furlong MC South Abingdon with Berinsfield and Clifton % 0.9% West Hampden K84041 Marcham Road Health South Abingdon with Berinsfield and Clifton % 1.8% Centre West Hampden K84019 Newbury Street Practice South Wantage % 2.3% West K84624 Oak Tree Health Centre South Didcot % 1.0% West K84054 Abingdon Surgery South Abingdon with Berinsfield and Clifton % 1.7% West Hampden K84033 Church Street Practice South Wantage % 2.2% West K84027 Malthouse Surgery South Abingdon with Berinsfield and Clifton % 3.1% West Hampden K84051 White Horse Practice South Faringdon % 2.3% West K84043 Woodlands Medical Centre South Didcot % 1.9% West K84010 Bampton Surgery West Rural West % 1.4% K84075 Broadshires Health Centre West Rural West % 1.3% K84047 Burford Surgery West Rural West % 1.1% Required Triple Target achievem ent (%) for LCS payment 10

11 Practice code Practice name Locality Locality Plan Cluster Number on register (Diabet es) Prevalen ce (Diabete s) Practice % of Oxfordsh ire Diabetes Register 8 Care Processes performa nce (%) - NDA 2016/17 Required Care Processes achievem ent (%) for LCS payment Triple Target performa nce (%) - NDA 2016/17 K84618 Cogges Surgery West Witney and % 0.9% K84006 Eynsham Medical Centre West Witney and % 2.2% K84072 Nuffield Health Centre West Witney and % 2.2% K84610 Charlbury Surgery West Rural West % 0.7% K84017 Windrush Health Centre West Witney and % 2.4% Oxfordshire Total 29, % Required Triple Target achievem ent (%) for LCS payment 11

12 APPENDIX B: COPD REGISTER (QOF 2016/17) BY PRACTICE Practice code Practice name Locality Locality Plan Cluster Number on register (COPD) Prevalance (COPD) Y02754 Banbury Health Centre North Banbury % 0.9% K84058 Bloxham Surgery North Rural North % 1.0% K84030 Chipping Norton Health Centre North Rural North % 2.9% K84056 Cropredy Surgery North Banbury % 0.4% K84055 Deddington Health Centre North Rural North % 1.5% K84059 Hightown Surgery North Banbury % 1.8% K84040 Horsefair Surgery North Banbury % 2.4% K84065 Sibford Gower Surgery North Rural North % 0.2% K84046 Wychwood Surgery North Rural North % 0.9% K84028 West Bar Surgery North Banbury % 2.7% K84024 Windrush Surgery (Banbury) North Banbury % 1.4% K84062 Woodlands Surgery North Banbury % 0.8% K84613 Alchester Medical Group North Bicester % 1.3% K84082 The Key Medical Practice North Kidlington and Surrounds % 1.8% K84045 Gosford Hill Medical Centre North Kidlington and Surrounds % 0.9% K84003 Islip Surgery North Kidlington and Surrounds % 0.7% K84038 Montgomery House Surgery North Bicester % 2.9% K84052 Bicester Health Centre North Bicester % 2.2% K84042 Woodstock Surgery North Kidlington and Surrounds % 1.0% K84016 Beaumont St (19) Oxford Central Oxford % 1.1% K84049 Beaumont St (27) Oxford Central Oxford % 0.3% K84080 Beaumont St (28) Oxford Central Oxford % 0.5% K84021 Banbury Road (172) Oxford North Oxford % 0.5% K84032 Bartlemas Surgery Oxford Oxford % 0.9% K84025 Botley Medical Centre Oxford South and West Oxford % 1.0% K84009 Hedena Health Oxford Headington % 3.4% K84063 Cowley Road Medical Practice Oxford Oxford % 0.8% Practice % of Oxfordshire COPD Register 12

13 Practice code Practice name Locality Locality Plan Cluster Number on register (COPD) Prevalance (COPD) K84004 Donnington HC Oxford South Oxford % 2.3% K84048 Hollow Way Medical Centre Oxford South Oxford % 1.4% K84078 Jericho Health Centre (Leaver) Oxford North Oxford % 0.3% K84026 Observatory Medical Practice Oxford North Oxford % 1.0% K84005 Kennington Health Centre Oxford South and West Oxford % 1.4% K84605 King Edward Street Oxford Central Oxford 7 0.1% 0.1% K84066 Luther Street Medical Centre Oxford % 0.2% K84617 South Oxford Health Centre Oxford South and West Oxford % 0.3% K84013 St Bartholomews MC Oxford Oxford % 0.9% K84060 St Clements Surgery Oxford Oxford % 0.3% K84011 Summertown Health Centre Oxford North Oxford % 1.6% K84007 Temple Cowley Health Centre Oxford South Oxford % 1.6% K84031 The Leys Health Centre Oxford South Oxford % 2.7% K84044 Manor Surgery Headington Oxford Headington % 2.0% K84008 Watlington & Chalgrove Surgery South Thame, Watlington and Wheatley % 1.4% K84071 Goring & Woodcote Health Centre South Wallingford, Goring and Woodcote % 1.3% K84036 Mill Stream Surgery South Wallingford, Goring and Woodcote % 0.6% K84014 Morland House Surgery South Thame, Watlington and Wheatley % 1.7% K84015 Nettlebed Surgery South Henley and Sonning Common % 0.6% K84020 Sonning Common Health Centre South Henley and Sonning Common % 1.1% K84035 Bell Surgery South Henley and Sonning Common % 1.2% K84001 Hart Surgery South Henley and Sonning Common % 1.0% K84050 The Rycote Practice South Thame, Watlington and Wheatley % 1.3% K84037 Wallingford Medical Centre South Wallingford, Goring and Woodcote % 2.8% K84034 Clifton Hampden Surgery South West Abingdon with Berinsfield and Clifton Hampden % 0.4% K84002 Didcot Health Centre South West Didcot % 2.8% K84023 Berinsfield Health Centre South West Abingdon with Berinsfield and Clifton Hampden % 1.2% K84079 Long Furlong MC South West Abingdon with Berinsfield and Clifton Hampden % 0.7% Practice % of Oxfordshire COPD Register 13

14 Practice code Practice name Locality Locality Plan Cluster Number on register (COPD) Prevalance (COPD) K84041 Marcham Road Health Centre South West Abingdon with Berinsfield and Clifton Hampden % 1.7% K84019 Newbury Street Practice South West Wantage % 2.2% K84624 Oak Tree Health Centre South West Didcot % 1.1% K84054 Abingdon Surgery South West Abingdon with Berinsfield and Clifton Hampden % 1.7% K84033 Church Street Practice South West Wantage % 1.7% K84027 Malthouse Surgery South West Abingdon with Berinsfield and Clifton Hampden % 4.4% K84051 White Horse Practice South West Faringdon % 2.9% K84043 Woodlands Medical Centre South West Didcot % 2.1% K84010 Bampton Surgery West Rural West % 1.2% K84075 Broadshires Health Centre West Rural West % 1.6% K84047 Burford Surgery West Rural West % 1.3% K84618 Cogges Surgery West Witney and % 0.7% K84006 Eynsham Medical Centre West Witney and % 1.8% K84072 Nuffield Health Centre West Witney and % 2.4% K84610 Charlbury Surgery West Rural West % 0.6% K84017 Windrush Health Centre West Witney and % 2.2% Practice % of Oxfordshire COPD Register 14

15 APPENDIX C: SCHEDULE OF CONFIRMED PAYMENTS BY PRACTICE Practice code Practice name YOC Implementation Payment (part fixed payment and part based on diabetes register) Diabetes MDT Payment (2 x MDTs per year) Locality Diabetes Review Meetings Payment (2 x meetings per year) Care Process and Triple Target Achievement Payment per Practice based on Diabetes Register Y02754 Banbury Health Centre ,812 K84058 Bloxham Surgery 1, ,274 3,691 K84030 Chipping Norton Health Centre 1, ,860 5,827 K84056 Cropredy Surgery ,027 K84055 Deddington Health Centre 1, ,827 4,436 K84059 Hightown Surgery 1, ,182 4,913 K84040 Horsefair Surgery 1, ,495 6,682 K84065 Sibford Gower Surgery ,556 K84046 Wychwood Surgery ,058 3,400 K84028 West Bar Surgery 1, ,771 7,055 K84024 Windrush Surgery (Banbury) 1, ,871 4,494 K84062 Woodlands Surgery 1, ,516 4,017 K84613 Alchester Medical Group 1, ,959 5,961 K84082 The Key Medical Practice 1, ,748 5,676 K84045 Gosford Hill Medical Centre 1, ,732 4,308 K84003 Islip Surgery ,295 K84038 Montgomery House Surgery 1, ,084 6,129 K84052 Bicester Health Centre 1, ,678 5,582 K84042 Woodstock Surgery 1, ,724 4,296 K84016 Beaumont St (19) ,080 3,429 K84049 Beaumont St (27) ,928 K84080 Beaumont St (28) ,748 K84021 Banbury Road (172) ,016 K84032 Bartlemas Surgery 1, ,229 4,977 K84025 Botley Medical Centre 1, ,568 4,087 K84009 Hedena Health 1, ,491 6,677 K84063 Cowley Road Medical Practice ,071 3,417 K84004 Donnington HC 1, ,080 6,124 K84048 Hollow Way Medical Centre 1, ,711 4,279 K84078 Jericho Health Centre (Leaver) ,544 K84026 Observatory Medical Practice 1, ,339 3,778 Total Payment to Practice 5 5 This is the confirmed payment per practice. The practice will receive a greater total payment depending on number of insulin initiations and Respiratory MDTs which take place. 15

16 Practice code Practice name YOC Implementation Payment (part fixed payment and part based on diabetes register) Diabetes MDT Payment (2 x MDTs per year) Locality Diabetes Review Meetings Payment (2 x meetings per year) Care Process and Triple Target Achievement Payment per Practice based on Diabetes Register K84005 Kennington Health Centre 1, ,331 3,767 K84605 King Edward Street ,306 K84066 Luther Street Medical Centre K84617 South Oxford Health Centre ,655 K84013 St Bartholomews MC 1, ,525 4,028 K84060 St Clements Surgery ,062 K84011 Summertown Health Centre 1, ,724 4,296 K84007 Temple Cowley Health Centre 1, ,944 4,593 K84031 The Leys Health Centre 1, ,436 5,256 K84044 Manor Surgery Headington 1, ,760 5,693 K84008 Watlington & Chalgrove Surgery 1, ,495 3,988 K84071 Goring & Woodcote Health Centre 1, ,737 4,314 K84036 Mill Stream Surgery ,126 K84014 Morland House Surgery 1, ,845 4,459 K84015 Nettlebed Surgery ,777 K84020 Sonning Common Health Centre 1, ,464 3,947 K84035 Bell Surgery 1, ,344 3,784 K84001 Hart Surgery 1, ,404 3,866 K84050 The Rycote Practice 1, ,052 4,739 K84037 Wallingford Medical Centre 1, ,722 5,641 K84034 Clifton Hampden Surgery ,754 K84002 Didcot Health Centre 1, ,473 6,653 K84023 Berinsfield Health Centre 1, ,395 3,854 K84079 Long Furlong MC 1, ,197 3,586 K84041 Marcham Road Health Centre 1, ,311 5,088 K84019 Newbury Street Practice 1, ,916 5,903 K84624 Oak Tree Health Centre 1, ,292 3,714 K84054 Abingdon Surgery 1, ,203 4,942 K84033 Church Street Practice 1, ,843 5,804 K84027 Malthouse Surgery 1, ,892 7,218 K84051 White Horse Practice 1, ,912 5,897 K84043 Woodlands Medical Centre 1, ,424 5,239 K84010 Bampton Surgery 1, ,724 4,296 K84075 Broadshires Health Centre 1, ,685 4,244 K84047 Burford Surgery 1, ,374 3,825 Total Payment to Practice 5 16

17 Practice code Practice name YOC Implementation Payment (part fixed payment and part based on diabetes register) Diabetes MDT Payment (2 x MDTs per year) Locality Diabetes Review Meetings Payment (2 x meetings per year) Care Process and Triple Target Achievement Payment per Practice based on Diabetes Register K84618 Cogges Surgery ,102 3,458 K84006 Eynsham Medical Centre 1, ,739 5,664 K84072 Nuffield Health Centre 1, ,778 5,716 K84610 Charlbury Surgery ,225 K84017 Windrush Health Centre 1, ,011 6,031 Total Payment to Practice 5 17

18 APPENDIX D: Diabetes Care Processes and QOF There are 9 care processes as outlined by NICE guidelines. One of these is retinal eye screening which is the responsibility of the Digital Screening Programme. This leaves 8 care processes as follows, which are covered as part of QOF as follows: Measurement of Blood pressure Measurement of Cholesterol Measurement of HbA1c Foot check Serum creatinine Urinary ACR Smoking Measurement of BMI QOF indicators DM002 and DM003 QOF indicator DM004 QOF indicators DM007, DM008, DM009 QOF indicator DM012 Not expressly covered in QOF likely to form part of routine patient care for most diabetic patients QOF indicator DM006 QOF indicators SMOK002 and SMOK003 Not expressly covered in QOF likely to form part of routine patient care for most diabetic patients. Obesity domain (OB002) within QOF also includes all patients with a BMI of over 30 for which practices receive a payment. 18

19 APPENDIX E: Insulin initiation service specification A. Definition of patients to be treated Primary Care patients: People over the age of 18 with diabetes Age: 40 + (under this age and with complications d/w Secondary Care) Ethnic origin: all (use of interpreters if required) The inclusion criteria for the client group of Type 2 patients will include: HbA1c 59mmol/mol (7.5%) for at least 3 months Intolerance of or inadequate response to maximised oral medication Intercurrent illness / steroids therapy exacerbating hyperglycaemia The exclusion criteria will be: Renal patients with chronic kidney disease including those undergoing CAPD Patient currently reviewed by Secondary Care & Community DSN service (unless otherwise discussed) Patients with complex complications (usually Secondary Care patient) B. Insulin Initiation - Over-arching Requirements Identification of those patients who meet the insulin conversion therapy criteria as specified in the guidance document available on NHS Oxfordshire CCG intranet at: Promote full understanding of the need for insulin to both patients and carers Provision of a safe and supportive environment in normal daily surroundings Initiation of insulin and stabilisation as per the specified local guidelines as above Referral to the multi-disciplinary team as required C. Insulin Initiation - Service Outline Patients are to have a regular appointment with a GP or Practice Nurse to discuss the need to be converted to insulin therapy. Referral to a GP or Practice Nurse (PN) for an appointment to discuss Insulin Therapy as per Local Insulin Conversion Guidelines (see link below): The Practice Nurse will review the patient and discuss: Current situation and reasons for Insulin Conversion. Social and psychological issues addressed. Issues relating to commencement of insulin eg. diet, hypo s and driving Blood glucose monitoring Insulin type and regime (first line use is NPH insulin if HbA1c < 75mmol/mol (9%) but should be either a basal-bolus regimen or twice daily biphasic regimen if HBa1C 75mmol/mol (9%)) as per guidance available on NHS Oxfordshire CCG internet at: diabetes/32324 Insulin pen device Agree time scale to commence the treatment Appropriate visits* with the GP/PN, monitoring and follow-up as necessary for individual patients Agreed written educational material will be used within the service. All staff to work within updated local clinical guidelines. 19

20 Close links with the Community Diabetes Nurse Specialists or MMT Diabetes Nurse Specialist to provide support and guidance throughout the process. *Appropriate visits recommend weekly titration reviews for at least one month and 2-4 weekly until target achieved. Some reviews could be by telephone. D. Accreditation and competencies The contractor will identify a GP or Practice Nurse who is the lead for insulin initiation for the practice. A named doctor or nurse, with insulin management knowledge, will be accessible within working hours to patients. GPs and Practice Nurses should be able to demonstrate a continuing sustained level of activity, conduct regular audits, be appraised on their competency level and take part in necessary supportive educational activities. They should have a responsibility for ensuring that their skills are regularly updated. The GP and/or Practice Nurse lead for initiating insulin must attend one of the following and provide evidence of attendance before initiating patients on insulin: Local insulin initiation course within the last 3 years Warwick courses in insulin initiation Intensive management in type 2 diabetes MSc in Diabetes Theory and Practice of Insulin Initiation Alternatively they may demonstrate equivalent competencies and experience to undertake insulin initiation safely. Regular educational updates such as local insulin management & intensification courses should be undertaken as recommended and the practice may be assessed annually for Competency using the competency assessment (Knowledge and Skills framework August 2004; HA11, HA12 HD3 & Trend Competency Framework) to include: Demonstrate an understanding of the physiological aspects of diabetes. Demonstrate an understanding the role of insulin during everyday life. Demonstrate competency in managing insulin therapy and to maintain their skills by regular clinical involvement. Demonstrate knowledge of all insulin devices and types of insulin E. Equipment minimum requirement Insulin/pen device/pen needles/sharps box/safeclip/hypostop Blood testing strips - all on prescription Blood glucose meter/ finger pricking device provided by the patient 20

21 APPENDIX F: Sign up Form Long Term Conditions Locally Commissioned Service Confirmation of intention to participate Name of practice: Practice Code: The practice confirms its agreement to implement Year of Care Planning and to carry out all other elements of the Long Term Conditions Locally Commissioned Service as set out in the Service Specification and summarised below. Activity Year of Care Planning implementation: By the end of the year, the practice will deliver the requirements set out in section 2.1 of the specification. Diabetes MDT Meetings: By the end of the year, the practice will ensure preparation, attendance and follow-up for 2 in-practice Diabetes MDT meetings. Locality Diabetes Review Meetings: By the end of the year, the practice will ensure attendance at two Locality Diabetes Review Meetings Insulin Initiation: Practice will provide initiation of insulin for all Type 2 Diabetes patients requiring conversion in line with the specification set out in Appendix E. Respiratory MDT Meetings: By end of the year, the practice will ensure preparation, attendance and follow-up for the number of in-practice Respiratory MDT meetings that may be scheduled for them according to IRT pilot (as set out in section 3.1 of the specification). Payment See Schedule of Payments by Practice per patient initiated on insulin per Respiratory MDT The practice also confirms that it will: a) achieve the following outcomes by the end of the year; or b) if achievement is not anticipated, provide a plan of improvement to OCCG by 1 st December Outcomes Eight Care Processes: Delivery of all 8 care processes to the percentage of Type 2 diabetes patients set out for the practice in Appendix A of the specification. NICE Treatment Targets: Achievement of the percentage of Type 2 diabetes patients meeting all three NICE treatment targets (HbA1c <59mmol/mol (7.5%), BP <=140/80mmHg, Cholesterol <5mmol/L) as set out for the practice in Appendix A of the specification. Name: Signed: Position in practice: Date: This form is to be sent to occg.primarycarecontracting@nhs.net along with confirmation of practice diabetes and respiratory leads and their contact details. Initial payment for the service will be made to the practice on receipt of this form. 21

22 APPENDIX G: End of Year Claim Form Long Term Conditions Locally Commissioned Service Confirmation of achievement of outcomes Name of practice: Practice Code: The practice confirms that it has achieved the following 8 care process and treatment target outcomes as specified in the service specification. The practice confirms it has also completed all essential diabetes items set out in section 2.4 of the specification. Y/N Please delete as appropriate. Eight Care Processes The practice has delivered all 8 care processes to the percentage of Type 2 diabetes patients set out for the practice in Appendix A of the specification. NICE Treatment Targets The practice has achieved the percentage of Type 2 diabetes patients meeting all three NICE treatment targets (HbA1c <59mmol/mol (7.5%), BP <=140/80mmHg, Cholesterol <5mmol/L) as set out for the practice in Appendix A of the specification. The practice confirms that it has not yet achieved the above outcomes as specified in the service specification but had provided an improvement plan to the CCG by 1 st December Y/N Please delete as appropriate. Name: Position in practice: Signed: Date: This form to be completed and returned to occg.primarycarecontracting@nhs.net by 30 th April Outcomes payment will be made to practice following receipt of this form. 22