Mangere Diabetes Hub

Transcription

1 Mangere Diabetes Hub Mangere COMMUNITY HEALTH Trust Stephanie Emma BSc Trust Philosophy Community Focused Patient Centred patient journey is very important Patient Advocacy 1

2 Looking Back 2002 Community Retinal Screening 2004 CMDHB DRS Service Delivery Review 2005 CMDHB Rolls Out Community Screening Model 2006 All Screening Divulged from Manukau Super Clinic Patients seen YE June2012 Anecdotal Observations DRSS Education & Understanding of Diabetes limited Re-occurring Poor control Obvious poor foot condition 2

3 Integrated Services Eye Clinic GP? Practice Nurse Diabetes Nurse Specialist Podiatry Quit Smoking Dietitan Referral & Access Access Patients who Have Diabetes and Live in or Attend a GP in Mangere Referral Ideally via Referral Walk-in Facility GP Directly Book 3

4 Location Various rooms inside the Mangere Health Centre - Not ideal! From October Level 1 Of MCHC Level 1 Diabetes Hub Purpose Built Clinical Space 3 Eye Consulting Rooms Ophthalmology (Laser, Failed Photo & Paediatrics) Retinal Screening Foot Clinic with Separate Sterilisation Space Oral Health clinic Group Education Space 4

5 9 Hot Clinic Rooms Dietitian(s) Mental Health Nurse Quit Smoking Counselling Diabetes Nurse Specialists Gout Clinic Diabetes Auckland DNE Midwives 5

6 Resources Developed 6

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8 Foot Clinic 816 Patients Seen Jan-Aug 2012 Attendance Referrals Screened DNA/ No contact Referrers to Foot Clinic Internal From Eye and Dietitian Primary Care Manukau Super Clinic 8

9 Food Clinic Ethnicity Breakdown NZ European NZ Maori Pacific Islanders Indian Asian Other Podiatry Screening Nails Routine palliative management of nails and initiating care for onychomycosis, tinea pedis (fungal nail and fungal skin pathologies) Strapping therapy Plantar fasciitis, achilles tendonitis and various muscular injuries relating to the lower limb. Wound care & dressing Surgical and mechanical therapy Management of anhydrotic skin conditions, deep fissuring and crack heels using Moore s orbital sander 9

10 Referral for Orthotic Centre - accommodative footwear, insoles, offloading/biomechanical correcting devices Vascular surgery- PAD interventions Ulcer clinic- active foot complications Minor surgery Chemical matrixectomy- partial/full nail avulsion with phenolisation - for chronic onychocryptosis (ingrown nail) Verruca removal treatment Heloma durum (corn) removal Hyperkeratosis (callus) debridement Diabetic Foot screening Tool Risk Category Risk Levels Low Risk At Risk At Risk High Risk Active Foot Complication Definition No LOPS NO PAD No deformity LOPS +/- deformity PAD +/ - LOPS Hx of ulcer or amputation Active ulceration Charcot foot Foot Presentation Treatment Suggested Follow-up No neuropathy ABI > 0.9 Pedal pulses palpable No deformity No Hx ulceration, Charcot joints, or amputation Patient education including advice on footwear. Annual review with Get Checked screening Neuropathy ABI > 0.9 Pedal pulses palpable Foot deformity with signs of pressure i.e callus/ corns. No Hx ulceration, Charcot joints, or amputation Consider prescription of accommodative footwear Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes. Continue patient education Every 3 to 6 months (by specialist podiatrist) Neuropathy ABI < 0.8 Absent Pedal pulses with possible symptoms of PAD Possible Hx of vascular intervention Foot deformity may be present. No Hx ulceration, Charcot joints, or amputation Consider prescriptive accommodative footwear Consider vascular consultation for combined follow-up Continue patient education Every 2 to 3 months (by specialist podiatrist) Neuropathy PAD Hx ulceration, Charcot joints, or amputation Same as category 1 Consider vascular consultation if PAD present Continue patient education Every 1 to 2 months (by specialist podiatrist) Neuropathy PAD Active diabetic foot complication Same as category 1 Multidisciplinary team management of foot complication Specialist wound care Consider vascular consultation if PAD present Consider surgery for foot deformity Continue patient education As required until resolved 10

11 ABI Feb Mar Apr May June July Aug Totals Low Risk(0) At Risk(1) At Risk(2) High Risk(3) Active Complication(4)

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13 1/10/2012 Age: Gender: Ethnicity: Occupation: 50 Male Samoan Driver Transporting disabled patients to and from their appointments. Initial Date of Patient Consult/Treatment: April 20th 2012 The right big toe is severely infected with a strong odorous yellow discharge from under the nail. Throbbing pain and tenderness in big toes Unable to drive properly as the toe hurts when I push on the pedal Painful when I wear shoes Pain rated 9/10 on patient pain scale 13

14 Objective Findings: Hypergranulation tissue surrounding both hallux nails, more so on the right Malodorous pus and blood discharging from right hallux subungally Right hallux nail is surrounded by erythema, swelling and inflammation The right big toe had excessive tissue forming beyond the nail edges with a strong smelling yellow discharge coming from under the nail. There are signs of inflammation occurring with the toe being red hot and swollen. Treatment and intervention: Short term goals agreed with patient- to clear infection, reduce swelling and relieve pain from big toes. Long term goals agreed with patient- to prevent re-infection, pain and maintain healthy feet and nails. 14

15 Removed nail spikes from both edges of the each nail from the big toes. Each spike looked like fish hooks which were digging into the skin causing the infection process to occur. Spoke to his GP regarding antibiotics to help reduce infection tracking. GP says he has also referred Mr Sione to the Manukau Superclinic for nail surgery which he is still awaiting an appointment. Outcome Podiatry visits $55 each consult x9 $495 Chemical matrixectomy $500 Total podiatry intervention $995 Amputation and secondary care-$11,000 minimum Other factors associated with loss of limb: Loss in quality of life Loss in income Shorter life expectancy Depression and other psychological issues (All quotes are based on the guidelines from Diabetes NZ, 2005) 15

16 Patient Comments I am very pleased with the results after suffering with a sore toe for the last eight months. I did not know about the foot clinic or about the foot specialist, I wish I was told to come here earlier I used to sit at the back row at my church because of the (infected) smell from my toe, but now I sit up in the front row because it doesn t smell anymore, I m so happy Mr Sione at his latest review at the foot clinic 15/08/

17 Aims Increase Patient Understanding of Diabetes Reduce BMI Improved Control of Diabetes Increase Awareness of Patients Own Results January-August Total appointments scheduled Total DNA Non-Contact or Did Not Want Examination 17

18 Average Weight 102.9kg Average BMI 36.3 Average HbA1c 33.2 mmol/mol Note: Low HbA1c is surprising, many patients did not have recent (within last 12 months) HbA1c results Referrers to Dietitian Internal From Eye and Podiatry Primary Care Midwives Self Referral/Walk-in 18

19 Ongoing Issues DNA Rate is High Language is a Significant Barrier Increasing number of patients with low egfr Patients with Renal Concerns for August <90mL/min/1.73m2 7 <80mL/min/1.73m2 7 <70mL/min/1.73m2 8 <60mL/min/1.73m2** 9 Case Studies David: Referred Form retinal Screening Concerned that he had lost 20kg in 6/12 Leg Pain ++++ Duration Ethnicity Treatment SMOGB 18yrs NZM Insulin No 19

20 egfr 58mL/min/1.73m2 (L) Micro Alb 31mg/L (H) Alb:Cr 3.7 mg/mmol (H) Taking Podiatry Care Tramadol & Neurofen for Leg pain Neuropathy & Significant PVD referred Secondary Care Continue insulin Start to SMOBG CHO Awareness Education around Fat/Salt Content Assistance with Meal Planning From Here? Consolidate in the New facility Review Group Education Options Support Local Employers with their Health Programs Continue to Offer Training for Other HCP s More/better Integration with Primary care 20

21 Thanks To The Team at Mangere For their Support and Insight Karen Pickering & Eileen Howard - Diabetes Projects Trust Stephanie Emma- Mangere Community Health Trust 21

22 Service Overview Diabetes Projects Trust Diabetes Care Support Service (DCSS) Quality Improvement Audit since 1994 Collects data from Primary care, including Retinal Screening data, with feedback to GP Mangere Community Health Trust Introduced community Retinal Screening to CMDHB in 2004 Operate retinal screening services throughout CMDHB from 18 sites Process Review of DCSS Audit Results from 3 GP practices in different demographic & socio economic areas. DCSS Audit looked at clinical records of patients with diabetes from Exploratory study looking at Audit results of No Record for Diabetic eye screening in CMDHB area. Cross referenced No Record DCSS data with Diabetic Retinal Screening (DRSS) data -Ophthalmology and Photo Clinics. 22

23 Questions NHI Data search of Diabetes Eye Screening data to identify: False Negative How many patients current to diabetes eye screening services had no documentation in GP PMS? Action on DCSS Audit Results How are the lists of no record for eye screening followed up at Practice level? Have they been actioned? Characteristics of No Record Are there commonalities among those patients who have no record of eye screening? Data At Time of Audit Total patients with diabetes No Record of Screening (DCSS Audit data) Referred But No Results (DRSS Cross Reference) Referred Referral Rejected NET % patients still needing referral PRACTICE 1 Low SES High Risk PRACTICE 2 High SES Low risk PRACTICE 3 Mixed Practice TOTAL % 37.3% 34.8% 31.4% 3.5% 0 2.5% 3.0% 2.8% 0 3.7% 2.2% 15.7% 37.3% 28.6% 27.2% 23

24 Results 6-12 months post Audit PRACTICE 1 PRACTICE 2 PRACTICE 3 TOTAL Total Patients with Diabetes Referral Sent Post Audit -Seen and Not Seen Referred and Seen - Current to Service % 4.9% 9.9% 6.1% 2.1% 2.9% 6.2% 3.7% Still No Referral (Not seen) 12.2% 32.4% 18.7% 21.1% Patients Not Referred Demographics (n=165) Gender Male Female 30% 25% Age of patients 25% 28% 35% 30% 27% 27% Ethnicity 30% 20% 15% 10% 5% 0% 16% 15% 8% 5% 2% < Age (years) 25% 20% 15% 10% 5% 0% 4% 12% Asian Indian Maori Pacific Island 1% Pakeha Other 24

25 Patients Not Referred Clinical State (n=165) HbA1c (mmol/mol) Number of Medications < No Record Patients Not Referred Clinical State (n=165) Medications Diabetes Medications

26 Co-Morbidities (n=165) Conclusion 31.4% of diabetes patients had no recordof retinal screening at time of DCSS Audit 21.1% still had not been referred 6-12 months post audit 3% Results Not Documented Within GP s PMS Screened but no record of result in patients clinical notes Practice still did not refer once Audit completed 26

27 Patients were notlow risk & diet controlled as hoped. No significant differences between the 3 practices in terms of patient clinical characteristics. Many patients are also in Outpatient Clinics, especially Cardiology and Renal. Many patients also had regular Emergency Department visits. Volumes Referred to DRSS are not as projected is this the reason? Thoughts How do we get the missing 21.1% referred (and seen)? How can we improve processes particularly initial referral? Whose responsibility is it? Would a National Advertising Campaign help? Place for consumer advocacy group? National Diabetes Register Automatic Enrolment to Retinal Screening Services? 27

28 Thoughts more Opportunity for all disciplines/services to encourage eye screening when patients present. Patients are going blind due to failure of timely referral. This was a very limited snapshot designed for quality improvement. More work could be done to look at this area. There is a story about four people named: Everybody, Somebody, Anybody, and Nobody. 28

29 There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry because it was Everybody's job. Everybody thought that Anybody could do it, but Nobody realized that Somebody wouldn't do it. It ended that Everybody blamed Somebody when Nobody did what Anybody could have done. Thanks to: Diabetes Project Trust Sara Morton DPT for Audit Data Extraction MangereCommunity Health Trust 29