South Belfast Integrated Care Partnership Transforming Delivery of Diabetes Care 2014
Background Context: Aims: Reduction in T2DM Earlier recognition of Type 1 diabetes in children Reduction in risk and complications and avoidable hospital admissions Improvement in quality of life for those living with T2DM Process: Collaborative Project; Primary care, Secondary care, Community and Voluntary organisations Extend the use of the type 2 diabetes support pack throughout Belfast Enhancement of current staff with alignment to practices.
Aim of the T2DM pathway and Pack To support and ensure standardised high quality care for all patients with T2DM via a standardised pathway of care To raise awareness for referral for Structured Patient Education at onset of diagnosis of T2DM Additionally to be an information resource for services including: Dietetic Services, Healthwise / Active Belfast Diabetes UK
Aims & Requirements: To increase delivery of Diabetes care within primary care setting To strengthen strengthen pre-diabetic and preventative services. To involve BHSCT, Community Pharmacy and all other relevant stakeholders To include regular discussion of specific cases between primary and secondary care To involve to include community pharmacy, patients and community and voluntary groups
Project Aims 5 year plan Identification of undiagnosed Service evaluation Self- Management Type 2 Diabetes pathway Professional education Patient Education and ongoing support Case Management
Prevention and Risk Identification: Physical Education Programme for Patients at Risk of Type 2 Diabetes Strategic Need: Increasing prevalence of T2DM Outline: To identify people at risk of type 2 diabetes using a validated risk assessment tool Availability of structured patient education programme Walking Away from Diabetes from NHS Desmond Outcome: Post Walking Away invitation to participate in physical education activities provided by trained Community Staff in the South Belfast Community Partnership
Self Management and Peer Support Strategic Need: Delivery of the TYC agenda in the BHSCT area Reduce the reliance on secondary care services Increase the provision of care in a primary, community or home environment Support of high quality, effective and sustainable care leading to optimal health outcomes
Outline: Self Management and Peer Support Effective self management skills for type 2 diabetes Training of skilled volunteers to support patients with newly diagnosed type 2 diabetes Development of sustainable and self supporting patient support network across Belfast Creation of a sustainable Diabetes Patient Reference Group for the BHSCT Development of an active working partnership with the Voluntary Sector Outcome: Positive behaviour change and optimal adherence
Patient Education and Ongoing Support Strategic Need: TYC- the need to find methods of supporting Healthcare Workers deliver necessary changes Outline: Investment in DESMOND Structured Patient Education for newly diagnosed people with T2DM Outcome: Prevention of complications by supporting concordance/adherence Reduce patient use of attendance to healthcare facilities by supporting self management. Evidence Based: reduction in weight, smoking, depression, HbA1c; Increased in self care.
Case Management: Type 2 DM Integrated Shared Care Enhanced Service Strategic Need: Diabetes care costs NI More than 1,000,000/day 10% of healthcare budget (DUK, Programme for Government, Priorities for redesigning Diabetes Services 2011-2015) Current healthcare budgets are unsustainable Outline: Support integrated working between GP practices and Secondary Care Services Regular meeting to discuss: Detailed case review Clarification of review arrangements Escalation & de-escalation of care Education and Service update discussion Outcome: Streamlined use of the T2DM pathway Early identification of increasing or decreasing need for services Support education of healthcare provider Development and Optimisation of integrated working arrangements
Case Management: Extension of Diabetes Specialist Team Strategic Need: High deprivation in Belfast Increasing complexity with co-morbidity and T2DM Increase in number of vulnerable patient groups with T2DM High cost of a hospital admission with concurrent Diabetes Increase in numbers with diabetic foot complications Outline: Investment in Additional Community Staff 1 Consultant in Community diabetes 1 wte Band 7 Community DSN ( encompassing weekend cover) 2 wte Band 6 Community Diabetes Sister/Charge Nurse 2 wte Band 3 Health care Assistants Admin support 4 Podiatrists Outcome: Reduction in avoidable hospital admissions and discharge planning Reduction in hospital outpatient attendances Support in self management skills Reduction in complications Education of Community staff
Professional Education Identification of Need: GP Audit of Baseline Services 2011 >86% of Practices returning questionnaire indicated an interest in extending Diabetes education Outline: Education programme for healthcare professionals in an ICP area Opportunity to discuss service delivery Development of a clinical network Outcome: Education, engagement, and empowerment building to measurably improve T2DM care Increase provision of T2DM care in Primary care setting Support Shared care working Improved communication Audit of management activity
Current Pathway for Diabetes GP diagnosis Referral to Structured Patient Education GP managed GP / shared care Trust Outpatients Annual review -Foot check -Dietetic Review -Diabetic Retinopathy Screening Programme Children Type 1 Type 2 Unstable Outpatient Appointment Patient becomes ill Emergency Department Discharge to GP Admission to General Medical Ward Discharge to GP
Proposed New Pathway for Diabetes COMMUNITY PREVENTION HUB primary prevention RISK STRATIFICATION LES case findings & management Community Based Risk Identification & Prevention Programme Identification of Pre-Diabetics @ GP level & management in line with agreed pathway Identification of at risk group OFFER Diagnosed Type 2 Diabetes DESMOND Walking Away from Diabetes Programme or similar approved educational resource Onward referral to Physical Activity Scheme Annual QOF assessment Complex case review meeting with GP, Community Diabetes Service Nurse and Community Diabetologist -Referral to NICE approved Structured Patient Education Programme -Referral to Diabetic Retinopathy Screening Programme -Referral for foot assessment Patient becomes ill / develops foot complication 24 hours Hospital admission and assessment within 48 hours and management plan Community Diabetes Specialist Nursing Team Access to Community Diabetologist to avoid ED admission COMMUNITY PREVENTION HUB secondary prevention
Service Evaluation Proposed outcome markers to include: Diabetes UK 15 care proposals HbA1c Patient satisfaction Patient knowledge Number of GP visits each year for diabetes QOF indicators (including lipids and blood pressure) Diabetes Prevalence data Number of patients having SPE at diagnosis Unscheduled care activity Others: Number of GP/Consultant joint meetings and details of reconfiguration Number of people trained within SPE programme Number of educational meetings and evaluation Number of risk assessments performed Numbers of volunteers trained etc
Next Steps Consolidation of resource Confirmation of Business Case Staff Recruitment Roll-out Service evaluation