Practice Baseline Questionnaire/Practice development plan for Consultant/DSN meeting

Transcription

1 Practice Baseline Questionnaire/Practice development plan for Consultant/DSN meeting Name of Practice Contact details of practice staff who you would like a copy of this questionnaire to be sent to when completed. Name: Role: Address: Name: Role: Address: Lead Clinicians Lead GP (Name) Do any other GPs run Diabetes Clinics? Lead Nurse (Name) Does the Practice run designated Diabetes Clinics? How frequently are patients with Diabetes reviewed? Which aspects of the review are the GPs responsible for? Which aspects of the review are the Practice Nurse responsible for? Have you got an HCA involved in the Diabetes Clinic? And what is their role? Appendix D Commissioning Framework 13/14 1

2 Patient demographics (at date of questionnaire) 1. Diabetes Patient demographics 1. Total ADULT Practice Population: (> 17 yrs) 2 Number of ADULT patients with Diabetes: 3 What is current prevalence? (%) 4 DM QOF register growth since previous year? (%) 5 Numbers of QOF excluded patient with diabetes? 6 What is the practice policy for annually reviewing Q&O framework excluded patients? 7 No. of patients on Impaired Fasting Glycaemic register? 8 How does the practice follow up IFG patients? 9 What patient groups does the practice pro-actively screen for diabetes? E.g. patients on long term steroids? previous gestational diabetes? Severe PCO/metabolic syndrome? 10 Number of patient with diabetes in Nursing Homes? 11 Number of patient with diabetes housebound

3 2 Obesity register - current Have patients on the QOF obesity register been screened for DM with annual recall? Opportunistic or systematic What % of obesity register have record of screening within the last year How are the obese patients (existing and new) screened for diabetes? 3 High risk case lists A). Number of obese DM patients (BMI > 30 or above and < 60 years.) + Hba1c > 58 mmol/mol (within past 15 months only ) Please provide patient list B) Number of cases with Hba1c > 75 mmol/mol () within past 15 months only Please provide patient list or details below Separate Type 1 DM from Type 2 DM if possible Appendix D Commissioning Framework 13/14 3

4 C). Risk register of those aged < 40 **( within past 15 months only) Type 1 patients or Type 2 patients with complications either not under specialist care in community or secondary care clinics or those patients who serially DNA** Please provide patient list or details below (include children with DM as well here if appropriate) D). Number of patients with any retinopathy/ maculopathy aged < 60 and Hba1c > 58 mmol/mol (within past 15 months only ) Please provide patient list or details below (include children with DM as well here if appropriate)

5 4. Type 1 patients Number of patients with Type 1 diabetes (under and over 17) (within past 15 months only) Please provide patient list or detail below (include children with DM as well here if appropriate) 5. Hospital discharges to primary care (within past 15 months only) Hospital DNAs- discharged from service but of concern: **Patients who have either been actively discharged from Hospital caseload but pose management queries for the GP/PN, or serially DNA'ing patients of concern to the GP/PN?** please detail below: 6. Please have patients with complex needs/uncontrolled diabetes/bp/lipids etc for management advice (within past 15 months only )- Proformas below: Appendix D Commissioning Framework 13/14 5

6 1. Name Age Duration of DM

7 2. Name Age Duration of DM Appendix D Commissioning Framework 13/14 7

8 3. Name Age Duration of DM

9 4. Name Age Duration of DM Appendix D Commissioning Framework 13/14 9

10 5. Name Age Duration of DM

11 6. Name Age Duration of DM Appendix D Commissioning Framework 13/14 11

12 7. Name Age Duration of DM

13 8. Name Age Duration of DM Appendix D Commissioning Framework 13/14 13

14 9. Name Age Duration of DM

15 10. Name Age Duration of DM Appendix D Commissioning Framework 13/14 15

16 Practice Development Plan for Diabetes, 2013_14 As a result of the Consultant/DSN diabetes visit, the practice identifies the following learning points for improving patient care: The practice will translate this learning into improved real patient care in the next 12/12 by: This Practice Development Plan for Diabetes will be submitted to the Locality meeting by mid-march 2014 s part of the Commissioning Framework returns proforma in This returns proforma will require the practice to confirm that it has undertaken the individual case management changes discussed during the visit, and improved its screening/ practice policies for following up patients at high risk of developing DM (as appropriate).