East London Community Kidney Service

Transcription

1 East London Community Kidney Service Sally Hull, Neil Ashman, Sec Hoong, Nicola Thomas, Helen Rainey April 2017

2 Haemodialysis/million population What is the Problem? Fast rising ESRD rates in East London ever more people needing dialysis Haemodialysis rates per million population, 3 East London Boroughs NHS City and Hackney NHS Newham NHS Tower Hamlets England Data from the UK Renal Registry 2015

3 What are we doing about this? 1. Community CKD eclinic Community-based Nephrologist doing e-clinic in EMIS Web Referrals ALL electronic (through e-referral)- unless urgent All reviews and opinions recorded in EMIS Web Locally relevant guidelines. 2. Practitioner and Patient education Practice based education for clinicians Patient one-on-one and group education 3. Community CKD overview CKD Prevalence searches to find un-coded patients CCG/Practice dashboards with KPIs Trigger tools to alert GPs to patients with a falling egfr E-referrals and local guidelines Community based education Find and code cases Practice safety alerts

4 Community CKD eclinic Who to refer to the community renal clinic? everyone previously referred to outpatients. How to refer to the community renal clinic? Write your question in the patient record. Ask for patient consent to view the record Use the e-referral service When will my patient be seen? Next week

5 Patient consent for shared record

6 GP opens shared record Nephrology opinion visible in GP record

7 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Change in clinic activity: Tower Hamlets 2015/ First appointments to vckd and Nephrology: Tower Hamlets CCG 2015/6 About 20% of patients require a face to face appointment 0 FA General nephrology vckd Clinic Outcomes 2016 No. % OP F2F Appointment Discharge to GP Review in vckd Other 5 1 Total

8 Early Wins for the service Waiting times for consultant advice slashed! In the six-week pilot period 19/35 practices referred into the community e- clinic. Over 70% of referrals are managed without the need for patients to attend a hospital appointment. During 2015 the average wait for a renal clinic appointment was 64 days. Using the e-clinic the average time to get nephrology advice is 5 days. GPs say A model for future care happening right now in Tower Hamlets! Consultants say We can provide comprehensive management advice whilst avoiding unnecessary duplication of tests.

9 Community CKD surveillance CKD practice tools CKD Prevalence searches to find un-coded patients CCG/Practice dashboards with KPIs Trigger tools to alert GPs to patients with a falling egfr

10 CKD Prevalence searches CKD Prevalence searches period Annual review code but not on CKD register ever egfr 1-29 but not on CKD register last two years egfr but not on CKD register last two years Renal codes but not on CKD register ever 8A6.. Renal function monitoring 6AA.. Chronic kidney disease annual review 66i.. Chronic kidney disease monitoring 1Z1.. Chronic renal impairment (exclude child codes) 7B00. Transplantation of kidney ZV420 [V]Kidney transplanted 7L1A0 Renal dialysis K0... Nephritis, nephrosis and nephrotic syndrome

11 East London CKD Dashboard Jan 2017 (21,560 CKD cases) METRIC CCG 1 CCG 2 CCG 3 CCG 4 1. Proportion of CKD cases coded 87% 80% 54% 49% 2. Proportion of CKD cases, with diabetes, coded 88% 83% 59% 60% 3. CKD with BP below 140/90 74% 71% 64% 55% 4. CKD and diabetes, with BP below 130/80 5. Adults with CKD on lipidlowering medication 43% 39% 36% 31% 80% 76% 73% 64%

12 Improvements to CKD coding Practice List size Patients aged 18+ Adults with egfr evidence of CKD Metric 1 egfr evidence of CKD - and CKD Read code Rate Adults with egfr evidence of CKD with diabetes Metric 2 egfr evidence of CKD, Diabetes and CKD Read code Rate Min 15.6% 17.9% Max 93.7% 96.4% F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % % F , % %

13 Practice trigger tools

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15 East London Community Kidney Service CKD managed in a single care record Coding improved to prevent medicines errors and enable CKD monitoring Trigger tools to find unknown at risk patients Patient self-management through education & information