Service Specification. Diabetes Integrated Service NHS Southern Derbyshire CCG

Transcription

1 Service Specification Diabetes Integrated Service NHS Southern Derbyshire CCG DRAFT: Version 8 27 th May 2014

2 Contents 1. Population Needs National/local context and evidence base Outcomes NHS Outcomes Framework Domains & Indicators The Diabetes Integrated Service addresses the following domains within the NHS Outcomes Framework: Local defined outcomes Scope Aims and objectives of service Service description/care pathway i Potential Contracting and Sub-Contracting of Services (General condition 12) ii Integrated IM&T iii Branding iv Intellectual Property Rights v Staffing Population covered Any acceptance and exclusion criteria and thresholds Interdependencies with other services/providers Review and Audit Applicable Service Standards Applicable national standards Applicable local standards Applicable quality requirements and CQUIN goals Applicable CQUIN goals & Local Incentive Scheme (Schedule 4) Location of Provider Premises Appendix A: Footcare pathway Appendix B: Health Outcomes Appendix C: local Incentive Scheme. 17 Appendix D: Local Quality Requirements.. 19 Page 1 of 25

3 SCHEDULE 2 THE SERVICES A. Service Specification Service Specification No. 001 Service Commissioner Lead Provider Lead Period Diabetes Integrated Service NHS Southern Derbyshire CCG Joint Commissioning To be determined Date of Review November 2015 Three years in the first instance with an annual review November 2014 to November Population Needs 1.1 National/local context and evidence base National context Diabetes is one of the biggest health challenges facing the NHS and has been recognised as becoming a significant priority both locally and nationally. There is unwarranted variation across the country relating to the level of care patients receive and disease outcomes. There are several publications that recommend better integration and standards of care for people with diabetes inclusive of: NICE Quality Standards for Diabetes (2011) Commissioning Diabetes without Walls (2009) Best practice for Commissioning Integrated Diabetes Services (2013) The National Service Framework for Diabetes Local context Locally there are currently in the region of 28,324 people diagnosed with either Type 1 or Type 2 diabetes (6.7% of the CCG population) based on 2012/13 QOF data. The national prevalence is 5.5%. There are 57 GP practices in Southern Derbyshire CCG (SDCCG) all involved in the care of patients with diabetes. There are also health professionals employed by Derbyshire Community Health Services and local Acute Trusts who provide services in the community for people with diabetes including specialist nurses, podiatrists, dieticians and consultants however these services are geographically variable across the CCG. There is variation in the number of patients with Type 1 and Type 2 diabetes who receive the nine recommended care processes with 40.5% of patients with Type 1 diabetes receiving eight out of the nine processes and 67.8% of patients with Type 2 diabetes receiving them (National Diabetes Audit 2011/12 eight processes audited omitting retinopathy due to unreliable data). Page 2 of 25

4 There is a recognised need to move away from disease specific pathways, where specialists treat only one disease, due to people often having multiple physical health conditions, along with mental health and social care needs. Whilst such specialists are highly skilled this does not reduce fragmentation of care. Locally, there is an agreed model for an approach to all Long Term Conditions. The aim of all provision in the community will be to ensure that as many people as possible maximise their ability to self- manage their conditions as early as possible and develop / maintain support networks to keep living the best life possible. This approach has been adopted across SDCCG and both Local Authorities. It is the expectation that the diabetes integrated service does not seek to operate in a vacuum but recognises it has a part to play in this wider health goal with partnerships and relationships which may easily fall outside of this specification. The integrated diabetes service will also be mindful of the implications of Personal Health Budgets for long term conditions Each GP practice has a Community Support Team CST Care Coordinator in place for the highest risk patients which may be required to be kept informed of progress for some of the people attended to in this diabetes integrated pathway. The CST Care Coordinators are not part of this contract. A representative may be required to participate in Multi-Disciplinary Meetings at the request of care coordinators to help meet the needs of patients with multiple long term conditions. Holistic care is at the heart of service delivery aiming to fully understand the root causes of patient s issues. To clarify, the model includes levels of care. Within each level it is anticipated that greater communication / co-ordination is achieved throughout each level and better integration is achieved across each level. The provider will need to remain a willing partner in this model. The integrated diabetes provision is likely to span all five levels at the point of full implementation. There will be a CCG wide approach to establishing a single point of access for all intermediate care Functions. As this is finalised and developed, to avoid duplication of resources the Integrated Diabetes service provider/s will be expected to participate in the function of this initiative. Community Model - Definitions of Levels Level1: Can be described as Self-Help, centred on the person and their support networks, both formal and informal. maintaining people in level 1 to have a Good Life is a primary aim. This level includes the use of assets, social capital, self-monitoring, prevention and education. Level 2: Is centred around Primary Care, delivered close to the patient in the community. Community Support Teams, including social care and other associated practice based staff around the GP form the core offer for this level. Level 3: Is community facing care delivered on a district wide basis. Groups of professionals delivering targeted and / or integrated interventions and rehabilitation, providing the correct amount of support alongside Level 2. Level 4: Describes care delivered across the CCG which may deal with more specialised need. Typically fewer professionals will serve a greater area for needs which fall into this category. Level 5: Refers to community-facing services delivered in, or from, a Hospital or a Care Home. Page 3 of 25

5 The Service will recognise that community focused delivery integrated with existing resources across levels 1-3 will be required for optimum results. 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators The Diabetes Integrated Service addresses the following domains within the NHS Outcomes Framework: Domain one Preventing people from dying prematurely Domain two Enhancing the quality of life for people with long term conditions Domain three Helping people to recover from episodes of ill health or following injury Domain four Ensuring people have a positive experience of care Domain five Treating and caringfor people in a safe environment and protecting them from avoidable harm Page 4 of 25

6 2.2 Local defined outcomes It is expected that an integrated diabetes pathway will result in: Better outcomes for patients and carers affected by diabetes. Reduction in inequalities. Reduction in secondary care activity. Improved coordination of care. Improved self-management of condition. 3. Scope 3.1 Aims and objectives of service The overarching aim of the integrated service is to coordinate, promote, embed and provide, via the usual integrated structures for access, a holistic care pathway that has self-care, preventative care and medical care as the key components to improve the overall quality of life for patients and carers affected by diabetes. The integrated approach shall encompass the whole pathway across all levels of care from prevention through to highly specialist care to streamline services. It shall empower individuals to make informed choices about their health by changing from a traditional medical model to one that is integrative and holistic that not only deals with symptom management but also addresses the root causes of the condition and associated problems. The objectives of the service are: To implement a standardised, evidence based pathway that is responsive to local need and represents good value. To offer simplified and responsive access into diabetes pathway. To implement coordinated, holistic assessments that ensures all patients have access to the right care when they need it. There is an on-going campaign to raise the awareness of diabetes. To embed a harmonised care planning approach that encourages health professionals to support patients to identify goals and empower them to self-care. To support an appropriately skilled workforce. To ensure that all patients are provided with timely foot care management. To work with existing screening services. To support the provision of joined up pre-conception care for women of child bearing age with diabetes. To provide support that meets the needs of vulnerable / hard to reach groups. To create and allow peer support networks to flourish. To optimise treatment through medicines management and regular treatment review. To work in a collaboratively integrated fashion within acute model designed by SDCCG. All elements of the service will be delivered in a fully supportive way and enhance intervention. Page 5 of 25

7 Develop and maintain excellent partnership working and relationships with acute providers to help ensure timely discharge. Regardless of place of residents in SDCCG area all people will have equitable opportunities to access the different elements of this service. Provision of services close to the patients home that meet patient s needs with as few medical hand offs or unnecessary re-referrals as possible. There is direct liaison with appropriate partners and providers to ensure that patients gets seen by the right person, at the right time and are referred and managed in accordance with CCG approved guidelines and protocols. 3.2 Service description/care pathway The integrated diabetes service shall be delivered in community settings across SDCCG. Through the provision of the service the Contractor shall ensure that it works within the levels of care model and offers an integrated approach to the management of diabetes across SDCCG area with all health professionals working in partnership to ensure that patients are seen by the right person, at the right time according to their needs. Personal Health Budgets (PHBs) for long-term conditions will mean that patients may choose to get aspects of their needs met outside of this pathway should this be assessed as appropriate. The Contractor will be responsible for working closely with commissioners in preparation for PHBs to identify the average unit costs for each element of the pathway delivered of which related costs will be adjusted in schedule 3a. The Contractor shall ensure that the service is delivered utilising a range of flexible options including: Locality based services that meet local patient s needs and individual GP practice needs. One stop shop appointments, where possible. Combined specialist nurse and practice nurse clinics in general practice for teaching and education. A triage service for GP practices to enable potential secondary care referrals to be appropriately managed within the community. Health professional education. Consultant to GP support for urgent advice. Smarter ways of working for example patient education groups for various aspects of their care that may routinely be offered in a one to one appointment. Services for black, Asian and ethnic minority groups are culturally appropriate and delivered in different community settings e.g. mosques, Gurdwaras and female only clinics. The contractor shall ensure that the following specific service elements are provided : Integrated, multidisciplinary diabetes community support An integrated approach is established with options to access medical, nursing, dietetic, podiatry and psychological care which are offered as core functions within the team. Simplified Access Page 6 of 25

8 Patients have access to consistent, coordinated care via a diabetic care coordinator. Patients are provided with a diabetes care plan which is agreed with them and reviewed annually. Where care co-ordination is already in place for an individual then this resource is fully informed of progress. Where it s feasible community clinics may be provided alongside diabetic eye screening community clinics (commissioned via Public Health, NHS England) to support implementation of one stop shop clinics for annual reviews, foot care and dietetics. There is a patient centred approach in place to minimise the number of diabetes related appointments in order to achieve the optimal care. Dedicated specialist diabetic advice is available to health professionals on a routine and urgent basis. Systems are in place for patients under this service to access responsive advice about their condition. Referrals, trends and demands on community and hospital services is captured and reported to commissioners. Combined clinics in primary care General practices are offered mentorship and support for annual reviews, case finding, personalised care planning and patients with difficult to manage disease via combined clinics. The focus within these clinics shall also be on identifying problems earlier to reduce the onset of complications. GP s and practice nurses are supported in their holistic assessment approach. Health and Social Care professional education There is a range of rolling, locality based education, e-learning and training workshops provided that offer an interactive learning environment. Training should address as a minimum the following areas: - Practice diabetes reward scheme - Setting and achieving HbA1c and blood pressure targets - Complication awareness - Cardiovascular disease risk assessments - Foot and eye health - Dietary management - Insulin initiation, titration, escalation and on-going management - Effective medication reviews - Personalised care planning, self-management and behaviour change - Motivational interviewing and mindfulness - Raise awareness of diabetes patients smoking and/or obese and the link to depression. - The use of CCG approved guidelines are universally embedded. There is a standardised level of diabetic related skills and knowledge for staff working in primary care in line with the Integrated Career and Competency Framework for Diabetes Nursing (Trend UK) and The Podiatry Competency Framework for Integrated Diabetes Foot care. Support and training is available for other professional working within healthy lifestyle Page 7 of 25

9 change initiatives. Support for those identified at risk of Pre-Diabetes The service promotes early intervention. Those at risk of developing diabetes are referred onto a local lifestyle change programme where eligible. The service supports and promotes national and local awareness campaigns. Patients who are smokers or obese are screened for depression. Those who are identified as being pre-diabetic or with a history of gestational diabetes are offered Impaired Glucose education and regular assessment of education requirements. Equipping patients to Self-Manage Patients and carers are equal partners in decisions about their care and have more control in the management of their own health, care and treatment. Primary responsibility of the development and implementation of the Care Plan shall be with the patient and it will be documented in a universally agreed format. There is a joint approach to the development and provision of individualised care plans which may involve GPs and CST care coordinators. There are interventions and programmes jointly agreed and aimed at helping individuals to achieve their personal goals. Structured education is equitably delivered across SDCCG in line with National guidance and at every stage of the pathway. Structured education that supports behavioural change for patients should broadly cover the same topic areas as professional education and should be delivered in an equitable manner delivered across SDCCG locality. Patients have annual education update offers. Pre-pregnancy awareness for women with diabetes of child bearing age is raised across Southern Derbyshire. Women with diabetes who are planning a pregnancy are provided with knowledge and support to prepare them for pregnancy. Peer/social support networks are established in localities and in communities with differing cultural needs across Southern Derbyshire to offer opportunities for people to meet others with diabetes to share knowledge and experiences. Such networks are delivered in different ways that are sensitive to need and locality. Psychological support Robust partnerships are in place to provide specialised Psychological support services. At the point of diagnosis patients psychological needs are screened and supported on an on-going basis according to need. Where risks indicate the patient is screened for depression. Specialised psychological support is integrated at every stage of the pathway. Dietetics Page 8 of 25

10 Robust partnerships are in place to provide specialised Dietetics services. Diabetic dietary advice and management is equitably available for all patients who require it. There are a variety of methods by which patients can be provided with dietary support. Podiatry Robust partnerships are in place to provide specialised Podiatry services. Patients with low, medium and high risk of foot are reviewed according to NICE. There is a proactive focus on prevention to reduce diabetic related amputations. There is a seamless pathway to a specialist multidisciplinary foot care team for patients identified with a foot care emergency and/or foot ulcers. Patients discharged from hospital following a diabetes foot care related admission are appropriately followed up. See appendix A for the diabetes foot care pathway. Retinopathy screening There is a seamless pathway to the Diabetic Eye Screening service to ensure that all people with diabetes who are eligible for screening are offered annual screening for diabetic retinopathy. Triage of secondary care outpatient referrals All referrals made to secondary care outpatient clinics are triaged to confirm appropriateness. Inappropriate referrals shall be returned with clinical advice. There is an increase in access to community outpatient clinics. Admission avoidance There is a proactive review of care plans for patients who frequently attend acute hospital services and that support is provided to manage their condition together with community and social care partners. A model is developed for the early identification of risks regarding diabetic related, unplanned admissions and accident and emergency attendances with a view to reducing avoidable non-elective admissions and facilitating early discharge. Patients with diabetes who are identified as being at risk of admission are provided with an enhanced care plan that offers additional support to help improve self-management to reduce hospital admission. Pathways and robust communication links are established with local care coordinators to support the reduction in non-elective hospital attendances/admissions, including patients who fail to attend diabetes annual reviews. Prescribing The service/provider will supply or prescribe medication where; A medication needs to be continuously prescribed by a specialist. Page 9 of 25

11 A medication needs to be initiated and stabilised for a patient before requesting primary care prescribing. A GP has concerns regarding competence about prescribing a requested medication or where a medication is needed urgently, in line with JAPC guidance. Urgent drugs are classified as those required within 5 working days; 28 days will be supplied unless a shorter course of treatment is indicated. The service/provider will comply with the Derbyshire Joint Area Prescribing Committee Specification which is available on: 3.2i Potential Contracting and Sub-Contracting of Services (General condition 12) Commissioners must be in full agreement of any contracting or sub-contracting agreements. 3.2ii Integrated IM&T There is a robust information technology infrastructure in place to allow for: - Timely communication between members of the integrated team and other health professionals. There is IT connectivity for all providers across the entire pathway. Any IT infrastructure developed allows care plans to be shared across all providers involved in diabetic care inclusive of patients. Information Governance (IG) Data sharing and reporting measures are in place within the life of the contract. 3.2iii Branding The Contractor will ensure that NHS Southern Derbyshire Clinical Commissioning Group is acknowledged in accordance with NHS contracting General Condition 23 (GC23). 3.2iv Intellectual Property Rights Please reference NHS contracting General Condition 22 (GC22). 3.2v Staffing The service shall be delivered by appropriately qualified, skilled and competent staff. As required in NHS contracting General Condition 5 (GC5). 3.3 Population covered The contractor shall ensure service availability to: Adults from the age of 16 with a diagnosis of Diabetes Mellitus (Type 1 and Type 2) registered within SDCCG. The Contractor shall liaise closely with paediatric diabetes services to ensure that there is a seamless transition of care between adolescent and adult services. The Contractor shall support all practices within the CCG and patients who are registered with a practice in the CCG. Page 10 of 25

12 3.4 Any acceptance and exclusion criteria and thresholds All diabetes related care inclusive of prevention, screening, Type 1 and Type 2 diabetes management shall be included within the integrated care model with the exclusion of: Diabetic retinal screening service. Children with diabetes under the age of 16. Antenatal diabetes. Initiation of Insulin pumps. In-patient care Other exclusions include: General practice Quality and Outcomes Framework across Southern Derbyshire GP practices. Local Enhanced Schemes. The service will need to establish robust links with the above services to ensure a seamless transition of care is provided for all diabetic patients. Equity of access to services The Contractor shall ensure that its service is accessible to all patients who meet the eligibility criteria regardless of race, age, gender identity, disability, sexual orientation, religion or belief and that it deals sensitively with all service users and potential service users their families/friends and advocates. Diversity There are relevant pathways and skills available to meet the cultural needs of people with diabetes such as older people, those with mental health conditions, housebound, learning disabilities, black, Asian and ethnic minority communities to ensure equity of opportunity and reduce health inequalities. The provider will be aware of local initiatives such as Local Area Co-ordination that supports community asset development. Settings will be culturally or gender appropriate as required. Operational hours The Contractor shall operate services flexibly to meet demand and be able to increase availability as appropriate to the needs of the people accessing the services delivered. There may be a need to incorporate services to deliver seven days a week according to demand and local developments. The Contractor shall be sensitive to future developments in care delivery, out of hospital care in the community and out of hour s services. 3.5 Interdependencies with other services/providers The integrated service shall be interdependent with the following other services: Public Health Health and Wellbeing Board and Local Authority Community and voluntary sector organisations Page 11 of 25

13 GP practices Community pharmacies Retinal screening service Wider inter-agencies e.g. orthotics, interpreter services Derby and Derbyshire County Council Social Care Services Derbyshire Diabetes Network Diabetes Sight Support Derbyshire Acute care service providers Local support groups / patient forums Community service teams Single Point of Access EMAS Community care coordinators Community matrons District Nursing Improving Access to Psychological Services (IAPT) The Contractor shall ensure that pathways and communication links are established with hospitals that are located outside of SDCCG boundaries (Burton, Kings Mill and Nottingham). Referrals Referrals can be taken by SDCCG SPAs (Single Point of Access solutions). Also, directly to this service from Primary Care, Acute and other Secondary Care providers, Community Health providers, Social Care partners and providers, relevant third sector partners, Self-referrals, and Family and/or Carers. 3.6 Review and Audit The Contractor shall have the overall responsibility for ensuring that the following key service outcomes are achieved and reported on in accordance with NHS contracting General Conditions (including GC 8, 15). The CCG reserves the right to audit and requires monthly quality report (schedule 6) The Contractor agrees to allow NHS Southern Derbyshire CCG: To have reasonable rights of audit and access to any of the Contractor s premises, personnel, The Contractor s systems, sub-contractors and their facilities and premises and the relevant records (including the right to copy) and other reasonable support as the commissioner may require whilst the service is being provided and for twenty four (24) months following the end of the contract in order to verify any aspect of the service or provider s performance. 3.7 Implementation There will be a phased implementation approach over the initial three years of the contract. The implementation of this service will need to broadly encompass the following aspects of the pathway: Year one Year two Year three Page 12 of 25

14 Equity of access. Health professional education. Integrated IM&T infrastructure. Admission avoidance. Patient education pathway. Dietetics. Specialist Nursing. Psychological support. Insulin initiation. Helpline. Care planning. Podiatry. Peer support networks. Triage of secondary care referrals. GP to consultant urgent and routine advice. Combined clinics. Pre-conception care. Medication reviews. Ethnic minority screening. Awareness raising. 4. Applicable Service Standards 4.1 Applicable national standards The service shall meet the National Standards within the following: NICE quality standards for Diabetes (2011) The National Service Framework for Diabetes (2001) The National Diabetes Audit NHS Diabetes Commissioning without Walls (2009) NHS Atlas of Variation in Healthcare for Diabetes (2012) NHS Commissioning Excellence in Diabetes (2012) Our Health, Our Care, Our say (2006) NHS Confederation Healthy Mind, Healthy Body (2009) 4.2 Applicable local standards NHS Southern Derbyshire CCG Integrated Care Strategies. NHS Southern Derbyshire CCG Strategic Objectives. Page 13 of 25

15 5. Applicable quality requirements and CQUIN goals 5.2 Applicable CQUIN goals & Local Incentive Scheme (See Schedule 4) In accordance with options within the NHS 14/15 standard contract, CQUIN will not be applied to this contract. However a local incentive scheme will be applied. Initially this will be at 10% of the total agreed contract value and up to 20% within the life of the contract. The Local Incentive Scheme indicators are expected to be varied over the life of the contract. The indicators for this incentive scheme in year 1 will be fully set out in schedule 4 based on: 1. Improved access to diabetes community services. The service will achieve equity of opportunity of access across SDCCG. 2. Improved clinical leadership and increase in the number of health professionals working in practices who have undertaken quality assured diabetes management training. 3. Development of robust integrated IM&T system and reporting processes. 4. Reduction in non-elective activity. 5. Increase in the number of patients having the nine basic care processes of care provided. Year 2 and 3 are to be determined dependant on performance and mindful of section in technical guidance. See appendix C for the full breakdown of the Local Incentive Scheme for year 1 and appendix D for the Local Quality Requirements Schedule. Consequences of breach See Schedule Location of Provider Premises The Contractor s Premises are located at: The Contractor shall have a centralised point of contact located in Southern Derbyshire. Localised patient access to the service across Southern Derbyshire CCG is a contractual expectation. Page 14 of 25

16 Rapid referral if risk increases Appendix A: Diabetes foot care pathway PRIMARY CARE ANNUAL REVIEW Fully trained, competent health professionals (via integrated team support) LOW RISK (Normal sensations, palpable pulses) Agree foot care plan including education INCREASED RISK (Neuropathy or absent pulses or other risk factors) Regular review every 3-6 months HIGH RISK (Neuropathy or absent pulses plus deformity or skin changes or previous ulcer) Frequent review every 1-3 months EMERGENCIES / FOOT ULCERS (New ulceration, swelling, discolouration, foot ulcers) Refer to multidisciplinary foot care team within 24 hours. Page 15 of 25

17 Appendix B: Health Outcomes People who have diabetes will be expected to achieve the following: Treatment and clinical outcomes expected to achieve 3 out of 5 Person centred outcomes expected to set between 2 and 4 outcomes and achieve at least 1 The Contractor is expected to demonstrate improvement to the short term interventions as set out below using validated measures or questionnaires in each case in at least 60% of patients. Reporting for the below outcomes needs to include the number of patients who have achieved the desired health related outcomes as follows: Has the patient achieved 3 or more of the treatment or clinical outcomes? YES Has the patient achieved 1 or more of their personal outcomes? NO YES NO Record as not achieved outcomes Record as achieved outcomes Record as not achieved outcomes Outcome Improved treatment outcomes Improved clinical outcomes Improved person centred outcomes Indicator Improvement in knowledge and understanding of condition using a validated measure Improvement in behaviour change and self-care using a validated measure Improvements in clinical management outcomes: HBA1c 6.5 to 7.5 % Blood Pressure Cholesterol egfr BMI Retinopathy As set by the individual and could include stopping smoking, weight reduction for example. Page 16 of 25

18 Appendix C: Local Incentive Scheme (Year one) 10% of contract value Personal Health Budgets (PHP): To accommodate personal health budgets there is a need to collect adequate data within year one of this contract, successful applications for PHP will be monitored by the CCG. If required and to avoid parallel payments the CCG reserves the right to under the national contract to renegotiate payment options to cost and volume. Local incentive scheme description Total Value Method of measurement Payment Q1 Q2 Q3 Q4 Improved equity of access to diabetes community services. 20% of LIS Agreement between commissioner and provider relating to the number of service access points across SDCCG prior to contract signature. 25% payment ( target set agreed between provider and commissioners). 25% payment ( target set agreed between provider and commissioners). 25% payment ( target set agreed between provider and commissioners). Reconciliation of payment based on an agreement of appropriate level of access reached. Improved clinical leadership, practice engagement, sign up and health professional quality assured training (one health professional per practice). 20% of LIS Provider report to include: - Details and evidence of practices who have signed up to the pathway. - Details and evidence of identified diabetes link lead per practice and standardised associated quality assured training undertaken in year one. Target: 25% practices signed up with identified link lead and training undertaken. Payment: 25% payable on achieving full target within the quarter. Failure to achieve the target will be at the discretion of the commissioner. Target: 50% practices signed up with identified link lead and training undertaken. Payment: 25% payable on achieving full target within the quarter. Failure to achieve the target will be at the discretion of the commissioner. Target: 75% practices signed up with identified link lead and training undertaken. Payment: 25% payable on achieving full target within the quarter. Failure to achieve the target will be at the discretion of the commissioner. Target: 100% practices signed up with identified link lead and training undertaken. Reconciliation of payment will be made on the basis that the provider has achieved the full target over the year. Page 17 of 25

19 Local incentive scheme description Total Value Method of measurement Payment Q1 Q2 Q3 Q4 Development of integrated IM&T systems and reporting processes 20% of LIS Evidence of agreement and sign up of IT infrastructure across 57 GP practices, the service and secondary care. Reporting template submitted by provider and agreed with commissioner. Following agreement the reports are to be fully compliant with the local quality requirements as defined in appendix D. Full payment for year will be made dependant on quality of data available to commissioner. A mid-year report will be required to provide the CCG with assurance on progress. A reduction of up to of 5% non-elective admissions with a primary and secondary diagnosis of diabetes. 20% of LIS Data will be obtained from SUS data (GEM). Reduction of 5% non-elective admissions overall for SDCCG for the period 01/11/14 31/10/14. Payment will be made for every 1% from baseline in reduction of nonelective activity up to a maximum of 5%. Increase in the provision of nine care processes as defined in the local quality requirements in appendix D. 20% of LIS MIQUEST query to be undertaken by 57 practices at the end of each quarter. Increase in 25% from 2011/12 baseline for nine care processes being undertaken for Type 1 and Type 2 diabetes. 2011/12 baseline: Type 1 diabetes: 40.5% Type 2 diabetes: 67.8% Target: 5% increase in the number of patients provided with nine care processes. Payment: 25% payable on achieving full target. Target: 10% increase in the number of patients provided with nine care processes. Payment: 25% payable on achieving full target. Target: 15% increase in the number of patients provided with nine care processes. Payment: 25% payable on achieving full target. Target: 25% increase in the number of patients provided with nine care processes. Reconciliation of payment will be made on the basis that the provider has achieved the full target over the year. Page 18 of 25

20 Appendix D: Local Quality Requirements Quality Standard 1. Improved case finding and an increase in the number of patients being diagnosed earlier. Measurement service quality report as in Schedule 6b The provider will report on: Percentage of high risk ethnic minority patients. Percentage of high risk ethnic minority patents. referred onto a lifestyle intervention programme. Percentage of patients who are smokers or obese who are screened for depression. Percentage of patients identified as being prediabetic who are offered access to Impaired Glucose education. Establish a number of awareness raising campaigns either alone or in partnership with others. Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach 8,947 ethnic minority patients (indicative figure). Monitoring targets to establish accurate 2 awareness campaigns within year 1. baseline with agreed increase. 4 awareness campaigns within year 2. baseline with agreed increase. 4 awareness campaigns within year 2. G.C 8,9. 2. Improved access to diabetes community services. The service will achieve equity of opportunity of access across SDCCG. The provider will report on: Available level of access to the service. Annual increase in the number of diabetic patients accessing the service. Helpline implemented and continual increased use. Achieve equitable access with increased access points. Increased equity of opportunity across SDCCG. Increased equity of opportunity across SDCCG. Year 1 Schedule 3 LIS G.C 8, Improved access to high quality structured diabetes education. The provider will report on: The number of qualified, competent educators that have delivered a minimum of two structured education programmes per annum. The innovative education methods employed e.g. online. Unknown Monitoring targets to establish baselines 75% educators deliver two programmes minimum PA 100% educators deliver two programmes minimum PA G.C 8,9. Page 19 of 25

21 Quality Standard 4. Improved provision of personalised advice on nutrition and physical activity. 5. Improved care planning / self-management culture adopted across the programme area. Measurement service quality report as in Schedule 6b The provider will report on: The number of people who receive personalised nutrition advice from an appropriately trained dietician or as part of structured education. The number of people who receive personalised advice on physical activity and smoking by professionals with specific expertise and competencies. The provider will report on : Percentage of patients with an agreed care plan in place that is regularly reviewed. Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach Unknown Monitor to establish At least 75 % patients with a care plan and agreed goals. 75% of patients provided with personalised nutritional, physical activity and smoking advice from professionals with specific expertise. 80% patients with a care plan and agreed goals. 100% of patients provided with personalised nutritional, physical activity and smoking advice from professionals with specific expertise. 100% patients with a care plan and agreed goals. G.C 8,9 Percentage of patients achieving individual health and quality of life goals within their individual care plan. Unknown 60% patients achieving goals 70% patients achieving goals 75% patients achieving goals Percentage of patients reporting improvements in behaviour change and self-care (PAMS international tool for measuring self-management behaviour). Unknown Monitor to establish baselines 70% patients reporting improvements in behaviour change 75 % patients with improvements in behaviour change Number of peer support networks established. Unknown Establish locality based support. Page 20 of 25

22 Quality Standard 6. Improved glucose control Measurement service quality report as in Schedule 6b The Provider will report on: The number of people with Diabetes who agree a HBA 1C and blood pressure target with their health professional and this is documented in their care plan. Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach Monitor to establish Year 1 G,C 8,9 Year 2 Schedule 3 LIS The number of people achieving their HBA 1C target. The number of people who have received a review of treatment to minimise hypoglycaemia in the previous 12 months, in line with local JAPC approved guidance. Monitor to establish Year 1 G,C 8,9 Year 2 Schedule 3 LIS 7. Improved medication usage The provider will report on: Percentage of people who have received a medication review in line with local JAPC guidelines. Monitor to establish Percentage of people who have received a medication review in the last 12 months in line with NICE and local JAPC guidance. The number of people adhering to medication regimes. To determine stretch target. Increase based on year one. Increase based on year two. 8. Improved management of insulin initiation The provider will report: The number of people with Diabetes starting insulin therapy that is initiated by a trained healthcare professional. The number of people with Diabetes who receive on-going structured support to manage insulin. The number of health professionals who have documented appropriate training and competencies for initiating and managing insulin. G.C 8,9 Page 21 of 25

23 Quality Standard 9. Improved management of pre-conception care for women with diabetes and reduction in still births/ abnormalities Measurement service quality report as in Schedule 6b The provider will report: The number of women with diabetes of child bearing age who receive advice regarding preconception glycaemic control and any risks including medication that may harm an unborn child. The number of women with diabetes planning a pregnancy who receive specialist preconception care from an appropriately trained health professional. The number of women of childbearing age with diabetes not planning a pregnancy who are offered advice in contraception. Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach G.C 8, Improved management of people with diabetes will contribute towards a reduction in admissions for incidents of complications. The Provider will report: The number of people with diabetes who are assessed annually for the risk and presence of complications of diabetes (retinopathy, neuropathy, nephropathy and cardiovascular disease) and managed appropriately. Monitor. Establish improvement targets. G.C 8,9 CCG figures: There will be a reduction in admissions arising from an emergency for diabetic patients 395 primary diagnosis admissions 816 secondary diagnosis admissions. 5% reduction from 2012/13 10% reduction from 2012/13 Review with an expectation of 15% reduction. Schedule 3 LIS year 1. There will be an overall reduction in diabetes related non-elective admissions for complications 2,909 complication associated admissions (angina, heart attack, heart failure, stroke and renal failure). 5% reduction from 2012/13 10% reduction from 2012/13 Review with an expectation of 15% reduction. Page 22 of 25

24 Quality Standard Measurement service quality report as in Schedule 6b There will be a reduction in non-elective admissions for Hypo and Hyperglycaemia / ketoacidosis from 2012/13 baseline Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach 200 non elective 5% reduction 10% reduction Review with ketoacidosis from 2012/13 from 2012/13 an admissions (primary baseline baseline expectation of and secondary 15% reduction diagnosis) 109 non-elective admissions for Hypoglycaemia. 11. Improved management of people with diabetes who require psychological support. The Provider will report on: The number of patients who are screened for psychological problems at the point of diagnosis and on an on-going basis. Monitoring targets to establish 100% patients screened for psychological problems. 100% patients screened for psychological problems. G.C 8,9 year 1 The number of people with Diabetes and psychological problems successfully referred to IAPT (IAPT for LTC attendances) Monitor to establish targets. The provider will equal the national best quartile for referral rate into IAPT for LTCs 12. Improved management of people with diabetes who have foot ulcers will help contribute to a reduction in lower limb amputations. The Provider will report on: The number of people at risk of foot ulceration referred to a qualified specialist podiatrist with a knowledge in diabetes. 2013/ 14 baseline 53 amputations for SDCCG area. Monitoring targets to establish all targets. There will be no less than a 10% reduction in diabetes related amputations. G.C 8,9 year 1 The number of people who receive a regular review by a qualified specialist podiatrist with a knowledge in Diabetes in accordance with NICE. Monitoring targets to establish targets. Page 23 of 25

25 Quality Standard 13. Improved offer rate for retinopathy screening. 14. Significant reduction in secondary care outpatient referrals. 15. Improved management of people with diabetes and increase in the number of people receiving the NICE recommended care processes. Measurement service quality report as in Schedule 6b The number of patients who are offered annual screening for diabetic retinopathy. The Provider will report on: The number of people attending all outpatient appointments. The Provider will report on: The number of people who have agreed treatment targets in place. The number of people receiving NICE recommended care processes. Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach 26,795 invited 80% 90% 100% appropriate appropriate appropriate patients in the patients in the patients in the service are service are service are offered offered offered screening screening screening 10,207 attendances within current system Unknown 2011/12 baseline (NDA) Type % Type % Develop triage / alternative system to reduce outpatient referrals to secondary care settings. Monitoring targets to establish expected baselines 25% increase on 25% reduction in outpatient referrals. Targets to be established. 50% reduction in outpatient referrals. Targets to be established. G.C 8,9 G.C 8,9 Schedule 3 LIS year 1. Page 24 of 25