Integrated Diabetes Care in Oxfordshire -patient's perspective. Avril Surridge

Transcription

1 Integrated Diabetes Care in Oxfordshire -patient's perspective Avril Surridge

2 Today How does diabetes care in Oxfordshire look like from a patient s perspective? Good things What could be improved? National Drivers improved self care and consequent money saving! What do we need?

3 Good Diabetes Care Patient centred round individual needs Holistic Variable Enjoyable Challenging Achieveable Shared

4 Knowledge! I don t know what I don t know! What would I like to know? The HCP I am talking with Knowledge? Experience? Qualifications?

5 Waiting Areas Board listing the clinicians working today by name and rank. Leaflets listing the Clinicians with a few sentences about each of them. EG Dr X joined us as a Consultant in April. He spent 20 years as He has a special interest in diabetes/copd/cardiology etc

6 Patient feedback public engagement events in 2015 Greater dialogue between patient and clinician to get holistic and individualised care Greater access to specialist advice in GP surgery Better access to psychological services Better information about what services are available Patients and all healthcare professionals involved in care, including pharmacists, having access to same electronic file

7 Year of Care My knowledge and experience of really good care comes from Year of Care Routine consultations between clinicians and people with LTCs would become truly collaborative through Care Planning

8 Care Plan A personalised Care Plan Signposts to all available services Where Access Education accredited education with refreshers!

9 Results Patients with more knowledge and expertise Patients take responsibility for their own care Improved medical outcomes Happier patients!

10 Good integrated care can reduce: confusion repetition delay duplication and gaps in service delivery people getting lost in the system

11 Holistic Care

12 Integrated Diabetes Care in Oxfordshire -Specialist s perspective Dr Rustam Rea Consultant in Diabetes Oxford Centre for Diabetes, Endocrinology and Metabolism

13 In this presentation: National drivers specialist care in the community Why integrated care matters in diabetes complexity of diabetes Local drivers specialist s perspective Timeframe Challenges to integration Facilitators of integration Studying care integration

14 National drivers

15 Whole person care

16 Why integrated care matters in diabetes

17 Inappropriate referrals Late referrals Local drivers Long waits for appointments to see a specialist psychological service Gaps in patient health records Didn t know who you weren t seeing Variability in outcomes

18 Single Delivery model Population of people with Diabetes Overview, prioritisation and monitoring of care outcomes by Locality Diabetes Group Type 1 patients Type 2 patients well controlled Type 2 patients who need extra medical support Type 2 patients who need extra logistical support Type 1 & 2 patients who are disengaged Single Clinical Decision point OPD face to face Remote consultation with Specialist Case management / MDT Psychology support / MDT Primary care, Community Care, Self-Care

19 Timeframe local context Sustainability and Transformation Plan Diabetes Prevention Programme funding Clinical Advisory Group Diabetes Cocommissioning Pilot Integrated Diabetes Project Team Sub-groups Personal Medical Services Re-investment Transformation Fund Diabetes Project Board Diabetes Task and Finish Group 1st team of commissioners 2nd team of commissioners 3rd team of commissioners changes 1 st GP lead 2 nd GP lead No 3 nd GP lead GP lead for pilot locality secondary care leads community care leads new manager Business case 1 Business case 2 Business case 3 progress Public engagement events Engagement with pilot locality Pilot in one locality Developing new contract

20 What were the challenges Uncertainties about service reorganisation Personnel changes on the programme Keeping stakeholders engaged in a long lasting process Uncertainty over roles and responsibilities Unclear leadership Variable engagement from hospital management Agreeing on shared outcomes

21 What were the facilitators Making case for integration at all levels of the organisations involved Building a shared vision and developing common goals Engaging with primary care through MDT meetings to build mutual understanding of needs and resources available Knowledge sharing Strong cohesive clinical leadership across organisations A GP champion Widely agreed need for better IT communication system

22 Integrated IT system Single patient record: provider communication Patient view : - upload data - link to health apps - enter priorities / interact with record Integrated IT system Population Governance: reduce variation Enable research: - Consent for studies / search - Search for recruitment - Longitudinal studies

23 Studying service integration leadership for integrated care mental health training for healthcare professionals working with patients with diabetes development, optimisation and evaluation of virtual clinics barriers to and enablers of integration

24 One thing I would do differently Update hospital management regularly and routinely to ensure they are kept up to date and to bid for resources

25 Integrated Diabetes Care in Oxfordshire -primary care s perspective Dr Amar Latif GP and Clinical Lead Long Term Conditions Oxfordshire Clinical Commissioning Group

26 In this presentation: National drivers central role of primary care Local drivers in primary care Challenges to integration Facilitators of integration

27 National drivers

28 Local drivers Better collaboration with specialists Fast access to specialist advice Staying up to date with changes in diabetes care Better collaboration between surgeries Pooling and sharing of resources Workforce/Practice challenges Development of federations

29 Additional Risk of Mortality

30 Additional Risk of Heart Failure

31 Patients receiving 8-care processes

32 Risk of Complications

33 Variation 43.6% A 22-fold variation in % diabetes patients who have all 9 processes of diabetes care Oxfordshire Diabetes Audit, 2014

34 Causes? Deprivation? Patient Demographics? NDA Report 2015/16 Statistical modelling has found that most of the variation seen in treatment target achievement cannot be explained by patient demographics

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36 Pilot in the North East Locality Gradual introduction of the interventions working on the clinical model and building contracting model to support it Virtual clinics (multidisciplinary team meetings in the community) Skype clinics Diabetes dashboard Joint governance Joint ownership Evaluation

37 Challenges to integration Buy-in from six localities and 70+ practices Representing hundreds of GPs Representation of primary care nurses Current pressures in primary care Uneven uptake of training in primary care The unknown unknowns

38 Facilitators of integration Previous successful collaboration initiatives Primary care hubs Early visiting service Ongoing presence of specialists in the community Diabetes clinics DSNs Integrated IT EMIS Viewer

39 One thing I would do differently Revisit the case for change when new stakeholders engaged

40 Integrated Diabetes Care in Oxfordshire -commissioner's perspective Paul Swan Commissioning Manager - Long Term Conditions and End of Life Care Oxfordshire Clinical Commissioning Group

41 In this presentation: National drivers Local drivers commissioner s perspective Diabetes population and diabetes services Developing the local model of care Challenges to integration Facilitators of integration

42 National drivers

43 Diabetes care in Oxfordshire Population More than 28,000 adults diagnosed with diabetes (4.92%) with possibly more than 12,000 undiagnosed (QOF, 2015/16) Expected to rise to 34,000 in 2025 OUH NHS FT OH NHS FT Primary care Services

44 Vision

45 Local drivers Vision To provide the highest quality of care for people with diabetes across Oxfordshire (28,000) Aims To deliver high quality diabetes care To reduce variation in diabetes care To provide efficient and sustainable diabetes care

46 Developing the local model of care Additional Professional Advice Lifestyle and exercise Patient Education Patient with Diabetes needs help Peer support Psychological support Medication

47 Pillars of integration (Best practice for integrating diabetes care) 1. Integrated IT systems 2. Aligned finances and responsibility 3. Care planning 4. Clinical engagement and partnership 5. Robust shared clinical governance

48 Oxfordshire model for integrated diabetes care Prevention Person-centred and personalised care care planning patient education care close to home integration of mental and physical health Population health Integration across primary, community and specialist care with earlier specialist intervention Integration across organisations under one commissioning contract joint budget with shared responsibilities Joint governance Joint IT

49 Finance Diabetes Transformation Funding Personal Medical Services (PMS) Funding National Diabetes Prevention Programme (NDPP) Implementation Funding 15.5m approx. cost of current diabetes activity across the Oxfordshire system Primary care: prescribing Community care: diabetes specialist nursing, podiatry Secondary care: outpatients, inpatients, amputations, podiatry, retinal screening, drugs and devices

50 Initiating change NE Locality Pilot Joint GP and Consultant Skype consultations Practice MDTs underway Diabetes dashboard primary, community & secondary care data Primary Care Locally Commissioned Services (LCS) Year of Care Planning Insulin initiation Locality Diabetes Review Meetings Outcomes incentives Primary Care Local Investment Scheme (LIS) Diabetes MDTs in practices NDPP Oxfordshire mobilisation from July 2017 Diabetes Transformation Funding work streams Patient education Improvement of NICE treatment targets (HbA1c, blood pressure, cholesterol) Multi-disciplinary Foot Team (MDFT)

51 Outcomes based commissioning Outcomes based on: Care that is directly related to diabetes (Phase 1) Care for conditions likely to be related to a patient s diabetes (Phase 2) Contractual options: Multiple contracts with individual providers Single contract lead provider Single contract joint venture Single contract alliance

52 Outcomes

53 Challenges to integration Changing project leadership Multiple and changing priorities in healthcare locally and nationally Different objectives of organisations Keeping stakeholders informed and engaged in a long lasting process with a clear understanding of the model, project progress and eventual outcomes IT: data, integration and information governance

54 Facilitators of integration Using guidelines, evidence and patients feedback in developing integrated service Consulting a wide range of stakeholders Effective clinical engagement and leadership Fostering a collaborative team approach between commissioners, providers & CSUs Open and transparent: activity, finance and governance Pump-prime funding to initiate change

55 One thing I would do differently Engage the Local Medical Committee (LMC) earlier regarding diabetes transformation

56 Paul Swan Commissioning Manager - Long Term Conditions and End of Life Care Oxfordshire Clinical Commissioning Group paul.swan@oxfordshireccg.nhs.uk