Commissioning for Outcomes in Diabetes Joanne Taylor Primary Care Commissioning Manager
Current Diabetes Model in Dudley
History and Current Diabetes Pathway Primary Care 46 2 no LIS practices Annual review of 9 key care Processes 29 advanced practices Provide complex management including insulin and GLP1 initiation 15 enhanced practices Provide enhanced diabetes management including annual review of at risk of diabetes
Community Diabetes Team Specialist podiatry services Structured diabetes patient education Multidisciplinary Team (DSN and dietician) Community Based Clinic at BHHSC Domiciliary service for Housebound patients Support to Non - LIS practices providing practice based clinics advanced diabetes management including insulin and GLP1 initiation for practices who do not provide themselves Diabetes Specialist Nursing Service /Diabetes Podiatrist /Specialist Diabetes Dietician Complex Diabetes Management requiring more intensive input On-going clinical CPD support Clinical Education to support delivery of LIS Specialist dietetic support
Secondary Care (All currently based at Hospital) Diabetes of unknown origin Complications of Retinopathy Renal complications Referral for psychology support Type 1 ongoing management Multidisciplinary OPD clinics for complications of Feet / Vascular Multidisciplinary OPD clinics for Antenatal Initiation and ongoing management of Insulin pumps Diabetologists/Hospital OPD Diabetes Specialist Nurses/ inpatient outreach team Adolescent Transition OPD Clinics Paediatric Consultant for Advice and support Inpatient outreach team Pre-surgical assessment
Why? Spend on prescribing vs Outcomes Yorkshire and Humber Public Health Observatory - Diabetes outcomes versus expenditure (DOVE) tool
What did we do? Patient engagement and consultation GP membership consultation including survey Provider engagement Data gathering Collaborative working with Diabetes UK Development of service specification
New Model of Care Diabetes Pathway Primary Care 46 2 no LIS practices Annual review of 9 key care Processes Care coordination of the diabetes population Shared care arrangements reviewed and agreed on a regular basis Improved access to diabetologist facility for virtual consultations 29 advanced practices Provide complex management including insulin and GLP1 initiation 15 enhanced practices Provide enhanced diabetes management including annual review of at risk of diabetes
Multidisciplinary Community Diabetes Team Specialist podiatry services Structured diabetes patient education Support to Non -LIS practices providing practice based clinics Advanced diabetes management including insulin and GLP1 initiation for practices who do not provide themselves Type 1 on-going management Facilitate patient discharge to primary/community Integrated hospital and community Diabetes Specialist Nursing Service /Diabetes Podiatrist /Specialist Diabetes Dietician/ Diabetologists / psychology support psychology support On-going clinical Complex Diabetes CPD support Management requiring more intensive input Multidisciplinary Team (Diabetologist/ DSN /dietician / psychologist) Community Clinics based in each locality Domiciliary service for Housebound patients Clinical Education to support delivery of LIS Named DSN for advice and support to each GP practice Specialist dietetic support
Secondary Care (all patients are under a shared care arrangement) Single point of access for all referrals with advice & guidance and triage Complications of Retinopathy Multidisciplinary OPD clinics for Renal complications Multidisciplinary OPD clinics for complications of Feet / Vascular Inpatient outreach team Multidisciplinary OPD clinics for Antenatal Initiation and ongoing management of Insulin pumps Diabetologists /Integrated hospital and community Diabetes Specialist Nurses/ inpatient outreach team Multidisciplinary Adolescent Transition OPD Clinics Pre-surgical assessment Paediatric Consultant for Advice and support
Vascular complications Renal Dietician Podiatry/ Feet Retinopathy screening complications GP/Community Multidisciplinary Team provider Type 1 Primary Care annual Management check Enhanced / Advanced Advice and support Inpatient care Patient Structured patient Education Community Specialist multidisciplinary Team Psychological support Virtual Clinics Insulin Pumps Adolescent Integration Specialist care provision under a shared care arrangement (following prior agreement with GP) Antenatal Care 1. Patient Education 2. Annual Care Planning 3. Health Care Professional Education
Shared Care and Outcomes Hospital Incentives: Better outcomes Appropriate patients in specialist care Transfer patients -Community or Primary Care Care plans GP Better outcomes keep in Primary care Appropriate referrals Care plans
Potential Contractual structure Consistent with the CCG s new model of care with all providers working collaboratively to a set of shared clinical outcomes Capitated outcomes based contract 70:30% upfront :outcomes 10% shared care arrangement 10% transferring up to 40% of the current outpatient activity into a primary / community 10% of the contract clinical outcomes
Clinical Outcomes Indicator Target Threshold Undertake personalised care planning Ensure a HbA1c measurement has been recorded Rates of admissions for Diabetes Ketoacidosis, hypo/hyperglycaemia Rates of major amputations Increase the proportion of service users with diabetes reporting positive experiences of care 75% achievement 75% achievement 59mmol/mol or less Service Users without complications expected 90% discharge rate Reduction in Dudley CCG 15% reduction non-elective admission rates Maintain the Dudley CCG Less than 1.0 per 1,000 patients incidence for major amputation to below National average 75 90% 75 90%
Progress to date Integrated Specialist Nursing Team Consultant outreach commenced Agreement to work collaboratively Focus on prevention Phase 1 National Diabetes Prevention Programme Improvement in outcomes - 47.19% achievement for 3 clinical targets (National Diabetes Audit 2015/16)