Building Healthy Communities. Diabetes Care Pathways Workshop-1 7 July 2016

Transcription

1 Building Healthy Communities Diabetes Care Pathways Workshop-1 7 July 2016

2 Agenda and Approach Introductions Programme update and context BHC Future model and generic pathway Diabetes in Newham - Current state Considerations for the Future State Scope and exclusions Outcomes to achieve- National, regional and local Guidelines/ Protocols/ Standards we should meet Best practice examples from other NHS sites Services that need to be included at each level of Base lining and activity modelling Future diabetes pathway- Enhancements to the BHC pathway Pathway documentation template and timelines Service specifications

3 Building Healthy Communities - Overview Plan Patient Public engagement Needs analysis Provider events NCCG programs Vision and scope Delivery models Financial analysis Pathways listen and engage design and test procure service mobilise & golive Feb-Aug 2016 Mar- Sept 2016 Oct July-2017 Feb 2018

4 Building Healthy Communities Integrated Future Care Model Well Person Minor Illness Primary condition Urgent Care /111/ OOH Emergency / A&E Outpatient / Inpatient Supported discharge Chronic Care End of Life Single Point of Access-Health and Social Single Joint Assessment Framework- Health and Social Risk Stratification/ Care Navigation Prevention and Well being Care close to home Care Coordination and extended primary Rapid response Case management Specialist services in community Intermediate services- Prehospital/ Inhospital Posthospital Supported Discharge End of Life Care Integrated Health and Social Care Functions Core and Specific Pathways including mental health- Step Up and Step Down Care as required Integrate multidisciplinary team- new workforce model Shared Care Record / Technology enabled platforms Redesigned Estates and infrastructure

5 Multi Agency Hub Health & Social Care SPA DOS SINGLE ASSESSMENT MOHAMMED S Future Pathway Mohammed 50 yrs old has diabetes with renal disease Access EPCS Facilities/ Services Diagnostics Provider Locality GP hub Neighborh ood team Foot / Physio Hub Social Care Wife & Carer Voluntary service Telehealth Skype Home monitoring Carer Support Home Self -Care Prevention Well- being Advice Patient education 111/ Urgent Care Virtual Specialist Support from Acute Single Shared Record- Integrated plan Integrated workforce model MDT Team, Case Management, CPN Prevention and Well being Care Navigation Extended primary Rapid response Care coordination Case management Specialist services in community Intermediate services- Prehospital/ Inhospital Post-hospital Supported Discharge End of Life Care Step up / Step down

6 Critical > 2hrs Non Critical Routine Task NEWHAM BHC GENERIC HEALTH AND SOCIAL CARE PATHWAY Health Social Care Urgent Care pathway/ OOH GP Does not meet criteria for SPAR Unplanned Triage Referrer SPAR Clinical Hub Navigation Risk Stratification Self Referral Planned Expected/proactive H&SC Care coordinator Prevent ion/ Wellbeing/ Self Care GP/ EPCS Does not meet criteria for Case management Level 1 Referrals Navigation Level 2 Care Co-ordination Rapid Response Intermediate Care/Reablement Manage for up to 6 weeks Practice DN team Manage for required period Referral Criteria Community Delivery MDT Team YES DIAGNOSTICS TELEHEALTH Discharge/Refer Appropriate for Case management? Acute Hub Social Care Personalised Budgets Community Delivery Team For Assessment Rehab/Supporting Ambulatory Care Community hub YES Case Manager Services/ Mental Health NO DN Team Primary Specialist consultation NO Specialist Services NO Social EHCC- Dementia/ EOL/ Rehab/ Day Hosp Hospital at Home /Care Homes /Community Beds Level 3 MDT Care Planning Proactive case management Level 4 Reactive Case Management Advanced Community Care UCC/ A & E Acute Services Supported Discharge/ In-Reach Services Level 5 Step Up/ Step Down

7 BHC- service lines in scope- draft Prevention and Well being Multidisciplinary assessments (MDT) Goal oriented MDT Care planning Patient education services Screening services Self and monitoring Self referral Falls prevention service Day Hospital Enablers Single point of access Care navigation Shared electronic patients record Joint health and social assessment Patient Transport Services Care close to home Community Outpatient Consultations Anticoagulation service Ophthalmology AQP Contracts/ EPCS Dermatology Community Diagnostics Community procedures Wound Community Therapies (OT, PT, Podiatry) Specialist Palliative Home health monitoring (telehealth) & tele Home & Home Social Care Rehabilitation services including SLT Re-ablement services Specialist services in community Continence East Ham Care Centre & Falls Prevention Clinic Specialist Opinion in Community / Community Geriatrician Foot health services Tissue Viablity Patient Appliances/ orthotics Wheelchair services Lymphedema LD MSK AQP contracts CVD Diabetes Dietetics Haemoglobinopathies/Sickle Cell Adults Intermediate services- Prehospital/ In-hospital Rapid response services (Immediate/ urgent/ Routine) Supported - step up/step down (known as Bed Based Intermediate Care) Proactive Case management Phlebotomy Post-hospital Early supported discharge CHC AND PHB - assessments, plan and referral only End of Life Pathway Respite Neuro & Stroke rehab Bereavement Services HIV rehab Services in red are proposed new services not in current community contract

8 Diabetes in Newham Current state understanding

9 The changing face of diabetes in Newham High prevalence of diabetes (> 5%) in general population (high genetic loading for T2D, socio-economic deprivation) Relatively young population structure - rising prevalence of Type 2 diabetes in children and young adults; large antenatal diabetes clinic The shift in emphasis of diabetes towards primary High diabetes risk: 38,940 (17.6%) subjects are at high risk of developing T2D (risk of 20% or more); 8781 known to have pre-diabetes 9542 have not had any blood test in the last 5 years ( UCLP/Newham CCG pre-diabetes programme )

10 Geospatial maps of people at high risk based on QD Scores

11 Diabetes is a complex problem: there are significant challenges all along the pathway Safer healthier people Vulnerable people Afflicted without complications Afflicted with complications What can we do? What is happening? Reduce vulnerability Reduce obesity &other lifestyle factors Culturally tailored public health Targeted screening Community Prescription Mapping/Risk stratification JSNA Reduce or delay progression Improve awareness and attitude in population Accessible and high quality screening and initial assessment Healthier You/ NDPP Pre-diabetes screening /EPCS Improve routine management Improve quality and accessibility of selfmanagement support Improve quality and accessibility of routine Structured education/ self-management programme Cluster MDT model Improve management of complications Quality and integration of for people with complex needs Improve support for particular vulnerable groups Improve end of life The Super Six Underlying challenges: Integrating health & social and spreading best practice across different providers Securing adequate resources and excellent staff to meet growing need Using and directing limited resource to have a major impact

12 Primary/ Community Care Services Low/Medium Risk GP Cluster Diabetes MDT initiative Started in January 2013 across all clusters of Newham CCG Attended by lead GP and/or practice nurse for diabetes for each practice, linked consultant diabetologist (Barts Health: NUH), linked community DSN (ELFT) +/- clinical psychologist from the Psychology and Health team Of 142 planned MDT meetings since April 2013, only 16 (11%) have been cancelled, and diabetologist attendance has been 100% Of the 59 Newham CCG practices, 40 (68%) have provided at least one representative at 75% or more of the meetings; These 40 practices represent (69%) of the people with diabetes living in Newham (These early outcomes from the GP Cluster Diabetes MDT initiative were presented at the forthcoming Diabetes UK Annual Professional Conference to be held at The Excel Centre. March 2015) The MDT meetings take place bimonthly, lasting 2 2 ½ hours The meeting venues are mostly community based e.g. GP practice (only one MDT is held at NUH) Typically one patient case per practice is discussed (6 8 per meeting) with group discussion, and agreed action plan, steered by the consultant diabetologist and community DSN Opportunity to get specialist advice on their patients, directly face to face with consultant, and other members of the diabetes specialist team Transfer of learning and skilling up of primary Sharing experience with fellow health professionals, especially challenges faced Increased confidence with management decisions and treatment choices Better understanding of the psychology of long term conditions Increased planned discharges from specialist to primary Referral avoidance Education and dissemination of information

13 Specialist Care Services High Risk Young adults (16-25 yrs) and Insulin Pumps: Currently 212 (16-25) active follow up with increasing number of young people with T2 DM (1/3 rd to 1/4 th of the case load): Probably the highest prevalence in the UK and a big concern. Insulin Pumps (48 current) Diabetes in pregnancy service (antenatal, pre and postpartum clinics and inpatient ) >800 pregnancies per year; GDM numbers: Newham: 2271, City & Hackney: 604, T Hamlets: 1987 Women with GDM locally have a 1 in 3 conversion to t2d (UCLP/NCCG pre-diabetes programme) Multidisciplinary diabetes foot clinics Diabetes renal clinics and inpatient In patient diabetes (diabetic emergencies, and input into the of any inpatient with diabetes, as required) at NUH > 30 % of all inpatients have DM NADIA ( national in-patient audit usually in top 3 for inpatient diabetes) Complex diabetes (long term follow up) about 1500 patients at any one time Other Specialist Input Strategic input service re-design, Diabetes Partnership Board etc Primary health professional education and training Joint research e.g. UCLP/Newham CCG programme

14 Challenges Rising demand on services: estimated rise 13.5% in 2030 Pressure to cut costs/ improve efficiency Lack of shared patient records Inflexible and inaccessible services High non attendance rates in some (vulnerable ) groups Poor patient self-management, related to poor engagement with service and lack of flexibility of services (Local MORI survey 09) Poor health outcomes e.g. Repeat admissions via the emergency department, particularly for young adults Increased complications cardiac, renal, foot disease Poor pre-pregnancy, late booking into antenatal services Poor end of life

15 Diabetes in Newham Future state planning

16 Considerations for the future state Scope and exclusions Outcomes to achieve- National, regional and local Guidelines/ Protocols/ Standards we should meet Best practice examples from other NHS sites Services that need to be included at each level of Base lining and activity modelling Future diabetes pathway- Enhancements to the BHC pathway Pathway documentation template and timelines Service specifications

17 Diabetes-What should be commissioned? Principles of Integrated Diabetes Care Provide services as close to where people with diabetes live as possible Provide coordinated services without duplication or gaps and employ coordinators to do this Work in an integrated way (between primary and specialists) and in partnership with social and other providers Ensure the workforce is trained (competency based) and is delivered via multidisciplinary teams Provide services that support self management for people with diabetes How does BHC generic model address the Integrated Clinical Model for Diabetes? 1. Prevention and self 2. Care close to home 3. Service lines a) Foot b) CVD pathways c) EOL d) CYPS procurement e) Patient education 4. Shared record 5. MDT teams 6. Hubs with diagnostics and specialist 7. Care Planning 8. Virtual Consults

18 HC Diabetes Care pathway levels of Level of Type of Patient profile Locations / Organisation Care Activity Roles Level 1 Prevention and Well being- Navigation Well person, minor illness Home, Virtual Primary SPA hub Level 2 Care coordination Moderate risk Primary EPCS, Home, Locality hubs Level 3 Proactive case Management Moderate and high risk Locality hubs Community hubs Level 4 Reactive Case management Very high risk Community hubs, EHCC, Home, Care homes Level 5 Step Up and Step Down Care Very high risk Community hubs, EHCC, Home, Care homes

19 Outcomes Those outcomes as defined in the five domains of the NHS Outcomes Framework An improved patient experience of their, including moving between different parts of the health community Screening and prevention of diabetes Achieving the nine key processes for type 1 and type 2 diabetes Achieving treatment targets for patients with diabetes by acting upon the findings of processes Achieving a reduction in complications of diabetes by acting on the findings of processes Reducing admissions and use of inpatient services for patients with a primary code of diabetes

20 Indicative Outcomes/ KPIs/Quality Statement 1. People with diabetes and/or their rs receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education. Statement 2. People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained health professional or as part of a structured educational programme. Statement 3. People with diabetes participate in annual planning which leads to documented agreed goals and an action plan. Statement 4. People with diabetes agree with their health professional a documented personalised HbA1c target, and receive an ongoing review of treatment to minimise hypoglycaemia. Statement 5. People with diabetes agree with their health professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance. Statement 6. Trained health professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes. Statement 7. Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered preconception and those not planning a pregnancy are offered advice on contraception. Statement 8. People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately. Statement 9. People with diabetes are assessed for psychological problems, which are then managed appropriately. Statement 10. People with diabetes at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance. Statement 11. People with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services, and the multidisciplinary foot service is informed of this. Statement 12. People with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the multidisciplinary foot service or foot protection service within 1 working day and triaged with 1 further working day. Statement 13. People with diabetes admitted to hospital are d for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin. Statement 14. People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team. Statement 15. People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.