Delivery of An Evolving Well Established Community Diabetes Service in South Sefton

Transcription

1 Delivery of An Evolving Well Established Community Diabetes Service in South Sefton Dr Nigel Taylor Clinical Lead for Diabetes South Sefton CCG Margaret Daley Lead Diabetes Specialist Nurse South Sefton Community Diabetes Service 6 th December 2017 Holiday Inn Haydock

2 Declarations of interest. Employers:- South Sefton CCG, Liverpool Community Health and Merseycare NHS Foundation Trust. Memberships:- Diabetes UK and the Primary Care Diabetes Society. Chaired meetings for a number of companies:bms; Schering; Pfizer; MSD; Sanofi; AstraZeneca; Lilly and Boehringer; Novonordisk; SB Communications. Received travel awards from Sanofi and Takeda and attended Pioneers in Diabetes meetings as a delegate

3 COMMUNITY DIABETES EARLY DAYS. Resources Identified (Aintree Catchment PCGs) Funding for Community Consultant Non-voting PCG representative on selection panel. Plan for similar service across Aintree Catchment area.

4 GPwSI in Diabetes Training

5 South Sefton Community Diabetes Service Introduction-Community Diabetes Services to be developed. April 2004 Diabetes team was established Aim to standardise diabetes care in South Sefton PCT Baseline assessment of practices and nursing and care homes. Plan for One Stop Shop Scoped Community Diabetes Team-Nurses- DSN and Diabetes Nurse Educators (3wte); Health Care Assistant (1wte); Dietitians (1.5wte); Podiatry (1wte). Admin support. Team involved in GPSI Training Programme Community Diabetes Litherland Town Hall 2005

6 Baseline assessment recommendations: Training Education Standardisation of information for patient and carers Care pathway Housebound patients with diabetes Nursing Homes and Residential care Referral criteria for LIFT diabetes services Resource pack on diabetes guidelines Develop close communication with secondary care Podiatry services to be accessible with good feedback Dietetics Data Collection

7 1) Retinal Screening 2) Community diabetes and NDA Community Oral Glucose Tolerance Tests Patient Education Hand held records Meter Training Link to Active Sefton Link to Access Sefton Staff Education 3) Diabetes Network Footcare Pathway Diabetes in Pregnancy Pathway Hypo Pathway Diabetes Dashboard

8 Retinal Screening In 2002 Eligible patients approx 5835 Community optometrists screened approx 46% 2684 Walton Hospital Screened further 22% approx 1284 Total uptake 68% 3968 Digital screening started early st December 2008 Eligible patients 5626 Screened 4712 Total uptake 83.72% 31 st December 2015 Eligible patients 7653 Screened 7195 Total uptake 94%

9 Research connections Pathway Development (Network Hypoglycaemia Pathway; Diabetes and More) Transition from GPwSI service

10 BENEFITS: Care closer to home (1400pts ACTIVE) Short wait to 1 st appointment (2WKS) First point of call for General Practitioner Patient turnaround (AV 30WKS) Training Nurses; GPs PBC-Purchase extra consultant sessions Improve surrogate CVD risk markers Clinics to complement Practices Patient satisfaction

11 Patient education Diabetes and You Programme (Abracadabra award winner)

12 Patient education Diabetes and You Programme

13 Primary care specialist support Locality based DSN Lead GPwSI & Consultant/Nurse Consultant support Supports General Practice Links with Secondary Care North Mersey Diabetes Pathway NICE North Mersey Diabetes 2011-suggested similar service across network.

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16 Patient Group Education Diabetes and You Financial year Referrals received Booked places Response Rate from invite letter Attended 1 st session Attended 2 nd session Total number of slots allocated to carers (63%) 233 (87%) 209 (79%) (62%) 203 (80%) 177 (71%) (63%) 215 (76%) 194 (80%) (55%) 206 (83%) 178 (76%) (67%) 166 (77%) 129 (62%) (63%) 148 (87%) 133 (82%) 69

17 Diabetes and You Participant Feedback and Evaluation participants completed the evaluation form. 85% reported they found the programme very useful. 98% stated they had a chance to ask questions 97% stated they received enough information. Since attending the programme 83% reported feeling more in control of their diabetes and 87% stated they felt more confident of asking questions about their diabetes. The majority stated they would make changes in their lifestyle since attending the programme, 140 people stated they were going to change their diet, 127 people were going to increase their activity, 68 would review their alcohol intake, 44 smoking and 33 other lifestyle changes. When asked if they would like to attend a further programme to learn more about their diabetes 60% stated yes they would like to attend another programme. People stated the main things they had learnt were diet, exercise, podiatry and general information.

18 Clinical service includes Consultant, DSN, DNE, Drop in and virtual clinics; Housebound caseload (10%). Number of discharges for a three month period (June-August 2016) = 193 Reasons for discharge: 84 (44%) Treatment completed 35 (18%) Treatment completed after one visit 36 (19%) Did Not Attend 26 (13%) No contact from invite letter to new referrals 12 (6%) Under another diabetes provider/transferred to another provider/admitted to hospital Treatment completed A Oral/GLP1 starts B Insulin starts C with Type 2 on insulin D. 5 - Type 1/secondary diabetes

19 A: Oral/GLP1 starts (42) 23 males/19 females average age 64 years (41-89 years) 5 People were housebound Treatments used: Average HbA1c loss 20.7mmol/mol (4-42mmol/mol) 41 improved the HbA1c 1 remained static (Microalbumin clinic) 29 lost weight average weight loss 5.5kgs (0.9-26kgs) 7 increased weight average weight gain 1.82kgs ( kgs) 1 weight remained the same 5 housebound; unable to weigh Average weight loss 5.5kgs (-26kgs to +5.4kgs). Treatments Number GLP1 13 SGLT2 10 Gliptin 13 Lifestyle alone 8 Sulphonylurea 7 Metformin 4 B) Insulin starts (21) 13 male/8 female average age 67 years old (41-94 years) 7 people were housebound Average HbA1c loss 25mmol/mol (-50 to +3mmol/mol) 19 improved the HbA1c 2 remained static (Started insulin due to renal function or medication stopped) 9 gained weight average weight gain 8.7kgs ( kgs) 5 lost weight average weight loss 4.5kgs ( kgs) Average weight gain for group 3.4kgs (-8.2 to +21.4kgs) 7 housebound; unable to weigh

20 C) Type 2 on insulin (16) 6 male/10 female average age 76 years (59-89years) 10 housebound 5 hypoglycaemic reviews 11 HbA1c improved average 12.1mmol/mol (8-18mmol/mol) 6 weights recorded average weight loss 2.8kgs (-9.3 to +2.0kgs) 4 lost weight/2 gained weight D) Type 1/secondary diabetes (5) 4 Male/1 female average age 53 years (23-74 years) 3 with Type 1, 2 with secondary diabetes 3 housebound Average HbA1c reduction 12.4mmol/l (-70 to +39mmol/mol).

21 BACKGROUND IN 2006 Approximately 2 million people in UKwith diabetes mellitus Increasing prevalence of both Type 1 and Type 2 diabetes Important to manage symptoms of diabetes and prevent long-term complications Local predicted prevalence of Type 2 diabetes 4.2% with 3.2% identified South Sefton

22 The Diabetes Challenge South Sefton Community Diabetes Service Key challenge: Increasing prevalence of diabetes South Sefton diabetes prevalence is 6.2% compared to 5.9% in similar CCGs and England as a whole 7,810 patients aged 17+ diagnosed with diabetes in South Sefton 90% have Type 2 diabetes But estimated a further 1,955 adults undiagnosed in SS Two fold variation in prevalence between our practices If current population and obesity trends persist, prevalence of diabetes projected to rise in Sefton to 8.7% by 2020 and 9.6% by 2030 (estimated average for England by 2030 is 8.8%).

23 The Diabetes Challenge South Sefton Community Diabetes Service Key challenge: At CCG level, in South Sefton the proportion of patients whose last HbA1c is < 59mmol/mol is 63%. This is higher than in other similar CCGs and higher than England People with diabetes in NHS South Sefton CCG were 39.1% more likely to have a myocardial infarction, 64.1% more likely to have a stroke, 96.4% more likely to have a hospital admission related to heart failure and 32.2% more likely to die than the general population in the same area. Spending on prescriptions for items to treat diabetes in 2012/13 cost per adult with diabetes in NHS South Sefton CCG compared to across England.

24 FUTURE: Delivery of An Evolving Well Established Community Diabetes Service 1) SEFTON DIFFICULT TO REACH-ELDERLY/HOUSEBOUND PROBLEMS ATTENDING HOSPITAL-COMMUNITY TEAM VIRTUAL CLINICS? (OTHER DIFFICULT TO REACH GROUP FOR EDUCATION-GPs AND PRACTICE NURSES????) 2) SEFTON FAB FOUR i) EDUCATION ii) INTEGRATION iii) COMMUNITY SPECIALIST SERVICE INCLUDING CONSULTANT OUTREACH AND VIRTUAL CLINICS iv) COMPLEX HOUSEBOUND PATIENTS (VIRTUAL CLINICS) 3) NHS DIABETES TRANSFORMATION PROJECTS.

25 Effect On Hospital Outpatient Clinic Attendance. A 33% reduction in hospital outpatients in the last 5 to 6 years representing a saving of approx to * plus ambulance conveyancing costs. *Based on National Tariff for First and Follow-up appointments for Diabetic Medicine.

26 CVD & Diabetes Patient Support Acute Complication/ DKA AHS? Psychology Foot Ulcer Ophthalmology Cardiology Click to edit Master title style Renal Vascular Transplant Obstetrics Retinal Screening Click to edit Master subtitle style Click to Respiratory edit Master Team subtitle style Community Midwife Lifestyle Services VIRTUAL WARD/Hospital Services Community Family Planning Community Heart Failure/Cardiac Nursing Team General Practice Patient CVS Community Diabetes Service/? diabetes IAPT District Nurse Palliative Care Support Services (DUK, BHF, Stoke Association, MacMillan) E D U C A T I O N

27 Click to edit Master title style Click to edit Master subtitle style Click to edit Master subtitle style Everest November 2017

28 South Sefton Community Diabetes Service Thank You. Any Questions?