Diabetes what we are doing

Transcription

1 Diabetes what we are doing Structured Education Bid Funding Pot: 800k Developing an elearning tool to educate primary care clinicians of value of education for patients, and incentivising GPs to refer more patients Extending role of Diabetes Champions and mentors to embed understanding. Commissioning a structured education hub deliver education, promote service and benefits, provide online, SPoR, signposting to other services, utilise PAM, report back to GP Practices re: attendance/completion rates, provide script to Practice staff Trialling self-care applications Develop diabetes videos in non-english languages. Diabetes In-Patient Specialist Nurses 3 Treatment Targets Bid Funding Pot: 1.15k Providing additional support to primary care (GPs, Specialist nurses etc) to ensure essential diabetes care ( Tier 1) is robust and develop tier 2 diabetes clinics and joint working and sharing of best practice Providing monthly reporting dashboards to GP practices (BP,Chol, HbA1c) to reduce unwarranted variation Providing clinical skills training to all diabetes team members. Developing the integrated clinical model for diabetes, with one spec and contract Multi-Disciplinary Footcare Bid Funding Pot: 0 Bid Funding Pot: 397k Exploring additional funding for in-patient specialist nurses Improving hospital safety Improving discharge and making it more timely Establishing NW London STP Diabetes Foot Network aligned to vascular hub Standardising diabetes foot data/metrics for dashboard/outcome measures Recruiting 6 additional band 7 podiatrists across the STP for weekend MDFT clinics at vascular hubs and Mon-Fri 9-5 MDFT clinics at all local hospitals and outreach dialysis MDFT clinics Recruiting MDFT pathway coordinators (band 3 and 4) PATIENT ENGAGEMENT asset mapping/ evaluation framework/ patient engagement plan 1

2 Project 1: Diabetes Self Care Group - Structured Education bid Lack of understanding around the value of structured education ( amongst clinicians) leading to low levels or poor quality of referrals. Inconsistent information and engagement with patients, leading to variation in take-up Patient choice is limited to what s available in their place of residence. Ad hoc provision for additional languages All people with diabetes Those with diabetes who don t have capacity for structured education ( this should be documented on shared care record, so they can be excluded in the denominator) Increase referrals and attendance at structured education. Improve GP practices knowledge and understanding of the value of structured education to increase referrals into structured education programmes. Education to be seen as essential part of treatment Increase options of videos and education in non-english languages Reduce clinical input to organising structured education (hub) Provide proof of concept for the structured education hub for CCGs to sustain INCREASE ATTENDANCE Video for GPs and practice nurses on importance of structured education Design and deliver an education programme with strong consideration given to patientled sessions and/or e-learning INCREASE REFERRALS Commissioning a structured education hub Attendance at 80% Service User Benefit Chairs Name/Title More choice in type, format and place of education face to face and digital Reduction of inequality in structured education delivery for working-age population Staff / Organisation Benefit Milestones Grace Vanterpool, Diabetes Nurse Consultant Margaret McLennan, Head of Pathways Dr Buchi Reddy, Programme Manager and Operational Clinical Lead People who understand their condition will seek healthcare support less, and more appropriately. Increase understanding in the health service workplace around the importance of self-management for diabetes. Videos developed Website elearning hub Increased variability, accessibility and availability of Structured Education Nov 2017 Nov

3 Project 2: Integrated Diabetes Care Group - 3 Treatment Targets bid NWL NICE diabetes results show unwarranted variation in care of the three treatment targets Blood Pressure, Cholesterol and HbA1c (long term blood sugar level) reducing these figures will improve health of patients and reduce morbidity of complications and mortality, and NHS and social care costs. / Lack of single source of truth for diabetes care across NWL / Significant improvements in care achieved through CWHHE diabetes dashboards but not universally available / No current interoperability across primary/acute pathways / Lack of patient access to own data / Poor understanding of patients flows and outcomes Everyone with diabetes in NWL 140,000 people Includes children. Those with pre-diabetes (covered in prevention project) A shared record viewable to all clinicians involved in diabetes care. Prioritise delivery of improvements based on need CCG IAF know results across NW London / variation and why / focus on case management to improve/ ensure staff ( at all levels) are supported to case-find via virtual clinics, to develop a targeted case management approach to improve treatment targets a focus on up-skilling. We will implement the Type 1 commissioning pack. Population health / ACP views/ Understand finance, activity, key diabetes performance metrics across whole patient pathway Financial information, per patient costing Electronic patient held record Supported self-care apps Monitor improvements in care and outcomes, including reporting requirements for NHSE and developing Accountable care systems Achieve a baseline of 3TTs as part of dashboard of care across NW London to identify who has treatment targets out of range. Dashboard of care across / focus care on patients not achieving targets / identification of Targets and Outcomes / Aware of all 3TTs for full cohort achieve 52% of people at target for all three treatment targets. / Implemented Type 1 pack DIGITAL [4 key tasks achieved] 1) Real-time interoperability of diabetes care records across primary/secondary care 2) Patients accessing and making use of digital care records 3) Advanced analytics per patient costing, actuarial predictions, segmentation and risk stratification 4) Electronic pathways used across providers for referrals, virtual consultations, etc Service User Benefit Project Role Name/Title Effectively manage patients with diabetes in primary, secondary and community care / Workforce skills mapping, training and development of primary care / community care /Secondary Care to ensure competencies in diabetes delivered to patients / Proactive case finding to support people more / Ability to segment patients by need and risk stratify by disease status, engagement and duration of diagnosis enabling targeting of more proactive case management / Detection of patients at risk of diabetes / Benchmarking of organisations / Virtual working bringing greater efficiency s Dr Koteshwara Muralidhara, Consultant Physician in Endocrinology & Diabetes, Central Middlesex Hospital Lesley Robertson ( Programme Director) Dr Tony Willis, Clinical Director, NWL Diabetes Programme ( digital) Staff / Organisation Benefit Integrated clinical record across all providers and commissioners. Provision of Staff Education / workforce development to support this: mentoring / coaching / education/ development support CCG IAF & NDA results improve Pin point variation and understand why results differ and then focus on process change for practices/ clinical settings. Improves skill-mix in primary care by adding support staff ( Lifestyle coaches / health coaches / Milestones ( see Appoint clinical staff Implement linkages to IAPT pathway Workforce Development of Level 1 and 2 training ( PIT stop) Whole Systems IT work Patient access to their data Care Planning fully implemented DIGITAL End January 2018 April

4 Project 3 - Diabetes Foot Group (MDFT bid) Significant performance variation across the NW London STP Includes best performing CCG but with 3 fold variation in amputation rates across the STP Poor foot outcomes for dialysis patients MDFTs not aligned with the 2 NW London vascular hubs with variation access across the STP and inefficent patient flow Daily 9-5 MDFT access for 5 of 7 MDFTs. No weekend MDFT service across STP Multiple foot pathways across STP hinders navigation, delays access All diabetes foot pathways in NWL collaboration of CCGs Community Podiatry services other than those dealing with people with diabetes Provide same day MDFT access for all patients so all pathways are NG19 compliant Implement extended networked MDfT in each STP; linked to Vascular hub centres Facilitate navigation and improve patient flow and patient experience through Pathway coordinator and standardising pathways Create NW London network for promoting best practice through sector wide approach to clinical governance, quality improvement and training and education Create NW London network for promoting best practice through sector wide approach to clinical governance, quality improvement and training and education Appoint project lead, care navigators and podiatrists Provide same day MDFT access for all patients once all pathways are NG19 compliant Service User Benefit Project Role Name/Title Understand diabetes foot care Clarity on diabetes foot pathway know who to contact when Self-referral to appropriate services Staff / Organisation Benefit Milestones Dr Wing May Kong Weekend MDfT clinics at vascular hubs / Weekend virtual MDFT access to local vascular spoke hospitals / Baseline of what structure is in each hospital / access gaps in team in each hospital / Identify new staff and appoint / Single point of advice and self referral to be in place for inner and outer London MDFT networks / 7 day service needed not just go to A&E Improved patient flow to and from vascular hubs. Bring local MDFTs to 5 day 9-5 capacity as best way to avoid hospital admssions / Pathway coordinators - Improve patient flow and facilitate pathway navigation / Outreach MDFT clinics to dialysis patients / Sector wide approach to sharing best praciice, clinical gvernance, patient safety, quality improvement and workforce development / Link communication across existing MDfT and to all tier 4 members / Link communication across from MDfT to all tier 3 members / Link communication across from MDfT to all tier 2 and 1 members - event to launch the service so that primary care understand the pathway / Develop the MDfT aspects of the pathway Improved patient experience Improved communication between all parties in pathway Self referral throughout pathway Reduced Amputations Reduced length of stay April 2019 April

5 Project 4 Type 2 Diabetes Prevention Large numbers of citizens with elevated risk of Type 2 diabetes., for whom diabetes can be delayed or prevented Large numbers of those at elevated risk remain undetected Significant variability across practices in detection rates and subsequent care Overseeing NDPP implementation in NWL Liaison with NDPP team and providers Digital prevention pilot?addressing wider determinants of health?access to exercise, etc Infrastructure Diabetes prevention dashboard on WSIC will help identify citizens at risk Provide consistent care for patients with Non-diabetic hyperglycaemia (NDH) Standardise pathway for people with NDH and previous gestational diabetes Appoint project lead 4 key tasks achieved: 1) Digital prevention available to all at risk in NWL 2) National targets for NDPP referral met locally 3) At least 75% of at risk population being reviewed annually in primary care 4) Work well underway with local councils to address wider determinants of health Service User Benefit Project Role Name/Title Identify citizens with NDH Reduce risk of progression from NDH to Type 2 diabetes Provide patients with NDH with consistent advice and care to promote lifestyle change and achieve earlier detection of those progressing to Type 2 DM Co-chair Dr Imran Choudhury TBD Staff / Organisation Benefit & Approximate Cost Milestones Lower cost digital prevention available to more people Reducing burden of Type 2 DM in NWL Achieve further uplift in NDPP allowance to 300% Diabetes prevention dashboard on WSIC NDPP Digital pilot Type 2 diabetes prevention information and video content on NWL Diabetes elearning BHH join NDPP as Wave 3 Large scale digital expansion End July 2017 August 2017 November 2017 November 2017 June/July

6 NWL Diabetes Transformation Programme Governance Structure CCG // Provider Diabetes Implementation Groups (Chair Various // CCG Admin support) NWL STP Right Care Programme Board (DA2) NWL Diabetes Executive NWL DIABETES PROGRAMME LEADERSHIP GROUP s Dr Tony Willis / Lesley Robertson Programme Managers Sola Afuape / Dr Buchi Reddy Project support Deepa Somerchand NOTE: People with diabetes and those representing community groups will be represented in each group. Diabetes Care Advisory Board Project 1. Diabetes Self Care Delivery Group (SE bid) s: Grace Vanterpool / Margaret McLennan Programme Manager Dr Buchi Reddy Project support Simone Hurley Project 2. Integrated Diabetes Care Delivery Group (3TTs & DISN bid) s: Dr Koteshwara Muralidhara / Lesley Robertson Programme Manager Sola Afuape Project support Deepa Somerchand Project 3. Diabetes Foot Delivery Group (MDfT bid) s- Dr Wing May Kong,/Avni Amlani Programme Manager Sola Afuape Project support Simone Hurley Project 4. Type 2 Diabetes Prevention Delivery Group (incl NDPP) Chair- Dr Imran Choudhary Programme Manager - Ibrahim Khan Project support Simone Hurley Type 1 Diabetes Subgroup (All bids) s :Prof Nick Oliver / Maureen McGinn Programme Manager Ruth Miller Project support Simone Hurley Diabetes Digital Subgroup (All bids + Prevention) (s Dr Tony Willis /John Kelly) Programme Manager Diabetes Digital Programme Manager (vacant) Project support Deepa Somerchand) Diabetes Commissioning Subgroup (All bids + Prevention) s Dr Raj Chandok / Dr David Gable Programme Manager Lesley Robertson Project support Deepa Somerchand Diabetes and Wellbeing Subgroup (All bids + Prevention) s?? Programme Manager Buchi Reddy Project support?? Updated December2017