Download Diabetes Care Pathways

Building Healthy Communities
Diabetes Care Pathways
Workshop-1
7 July 2016
Agenda and Approach
• Introductions
• Programme update and context
• BHC Future model and generic care pathway
• Diabetes care in Newham - Current state
• Considerations for the Future State
•
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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 care
Base lining and activity modelling
Future diabetes pathway- Enhancements to the BHC
pathway
• Pathway documentation template and timelines
• Service specifications
Building Healthy Communities - Overview Plan
• Patient Public
engagement
• Needs analysis
• Provider events
• NCCG programs
listen and
engage
Feb-Aug
2016
•
•
•
•
Vision and scope
Delivery models
Financial analysis
Pathways
design and
test
Mar- Sept
2016
procure
service
Oct 2016July-2017
mobilise & golive
Feb
2018
Building Healthy Communities Integrated Future Care Model
Well
Person
Minor
Illness
Primary care
condition
Urgent Care
/111/ OOH
Emergency
/ A&E
Outpatient /
Inpatient
care
Supported
discharge
Chronic
Care
End of
Life
Single Point of Access-Health and Social care
Single Joint Assessment Framework- Health and Social care
Risk Stratification/ Care Navigation
Prevention
and Well
being
Care close to
home
Care Coordination
and
extended
primary care
Rapid
response
Case
management
Specialist
services in
community
Intermediate
care
servicesPrehospital/ Inhospital care
Posthospital care
Supported
Discharge
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 care platforms
Redesigned Estates and infrastructure
End of Life
Care
MOHAMMED’S Future Pathway
Access
Mohammed –
50 yrs old has
diabetes with
renal disease
EPCS
Facilities/ Services
Provider
Wife &
Carer
SINGLE ASSESSMENT
SPA
Diagnostics
Locality
GP hub
Foot
care/
Neighborh
ood team
Physio
Hub
Social
Care
DOS
Telehealth
Skype
Home
monitoring
Carer Support
Homecare
Self -Care
Prevention
Well- being
Advice
Patient
education
Multi Agency Hub
Health & Social Care
Voluntary
service
Virtual Specialist
Support from
Acute
111/ Urgent Care
Single Shared Record- Integrated care plan
Integrated workforce model – MDT Team, Case Management, CPN
Prevention and
Well being
Care Navigation
Extended primary
care
Rapid response
Care coordination
Case management
Specialist services
in community
Intermediate care
services- Prehospital/ Inhospital care
Post-hospital care
Supported
Discharge
End of Life Care
Step up / Step
down care
NEWHAM BHC GENERIC HEALTH AND SOCIAL CARE PATHWAY
Level 1
Referrals
Navigation
Referrer
Self Referral
Does not meet
criteria for SPAR
Urgent Care
pathway/
OOH GP
Prevent ion/
Wellbeing/ Self
Care
SPAR
Clinical Hub
Unplanned
Navigation
Risk Stratification
H&SC Care coordinator
Triage
Level 2
Care
Co-ordination
Does not meet
criteria for Case
management
Planned
Expected/proactive
GP/ EPCS
Routine Task
Community
Delivery MDT
Team
DN
team
Manage for
required period
Manage for up to 6 weeks
Primary care
Ambulatory Care
DIAGNOSTICS
TELEHEALTH
Community hub
Discharge/Refer
Practice
Social
Care
Acute Hub
NO
YES
DN
Team
NO
Specialist
Services
NO
Social
care
EHCC- Dementia/ EOL/ Rehab/ Day Hosp
For Assessment
Hospital at Home /Care Homes /Community
Beds
Rehab/Supporting
UCC/ A & E
Appropriate for Case management ?
Case
Manager
Community
Delivery Team
Personalised
Budgets
Specialist
consultation
Social Care
Intermediate
Care/Reablement
Level 3
MDT Care
Planning
Proactive
case
management
YES
Health
Rapid
Response
Non Critical
Critical > 2hrs
Referral Criteria
Level 4
Reactive
Case
Management
Advanced
Community
Care
Services/ Mental Health
Acute Services
Supported Discharge/
In-Reach Services
Level 5
Step Up/
Step Down
BHC- service lines in scope- draft
Prevention and Well being
Care close to home
Specialist services in community
Multidisciplinary assessments
(MDT)
Community Outpatient
Consultations
Anticoagulation service
Ophthalmology
AQP Contracts/ EPCS
Dermatology
Community Diagnostics
Community procedures
Wound care
Community Therapies (OT, PT,
Podiatry)
Continence
East Ham Care Centre & Falls
Prevention Clinic
Specialist Opinion in Community /
Community Geriatrician
Goal oriented MDT Care planning
Patient education services
Screening services
Selfcare and monitoring
Self referral
Falls prevention service
Day Hospital
Enablers
Single point of access
Care navigation
Shared electronic patients record
Joint health and social care
assessment
Patient Transport Services
Specialist Palliative care
Home health monitoring
(telehealth) & telecare
Home care & Home Social Care
Rehabilitation services including
SLT
Re-ablement services
Foot health services
Tissue Viablity
Patient Appliances/ orthotics
Wheelchair services
Lymphedema
LD
MSK
AQP contracts
CVD
Diabetes
Dietetics
Haemoglobinopathies/Sickle Cell
Adults
Intermediate care servicesPrehospital/ In-hospital care
Rapid response services
(Immediate/ urgent/ Routine)
Supported care- step up/step
down care (known as Bed Based
Intermediate Care)
Proactive Case management
Phlebotomy
Post-hospital care
Early supported discharge
CHC AND PHB - assessments, care
plan and referral only
End of Life Pathway
Respite care
Neuro & Stroke rehab
Bereavement Services
HIV rehab
Services in red are proposed new services not in current community contract
Diabetes care in Newham Current state
understanding
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 care
towards primary care
• 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 2014-16)
Geospatial maps of people at high risk based
on QD Scores
Diabetes is a complex problem: there are significant challenges all along
the pathway
Safer healthier
people
Vulnerable
people
Reduce vulnerability
What
can we
do?
Reduce or delay
progression
• Reduce obesity
&other lifestyle factors • Improve awareness
and attitude in
• Culturally tailored
population
public health
• Accessible and high
•Targeted screening
quality screening and
initial assessment
•Community Prescription
What is
•Mapping/Risk stratification
happening? •JSNA
• Healthier You/
NDPP
• Pre-diabetes
screening /EPCS
Underlying
challenges:
Afflicted
without
complications
Afflicted with
complications
Improve routine
management
Improve management
of complications
• Improve quality and
accessibility of selfmanagement support
• Quality and
integration of care for
people with complex
needs
• Improve quality and
accessibility of routine
care
•Structured education/
self-management
programme
•Cluster MDT model
• Improve support for
particular vulnerable
groups
• Improve end of life
care
The Super Six
• Integrating health & social care 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
Primary/ Community Care Services –
Low/Medium Risk
GP Cluster Diabetes MDT
initiative
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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
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
•
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 15284 (69%) of the 22065 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)
•
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 care
•
Sharing experience with fellow health professionals, especially challenges faced
•
Increased confidence with management decisions and treatment choices
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Better understanding of the psychology of long term conditions
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Increased planned discharges from specialist to primary care
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Referral avoidance
•
Education and dissemination of information
Specialist Care Services – High Risk
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Young adults (16-25 yrs) and Insulin Pumps: Currently 212
(16-25) active follow up with increasing number of young
people with T2 DM (1/3rd to 1/4th 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 care) >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 care
In patient diabetes care (diabetic emergencies, and input
into the care 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 care (long term follow up) about 1500
patients at any one time
Other Specialist Input
•
Strategic input –
service re-design,
Diabetes
Partnership Board
etc
•
Primary care
health
professional
education and
training
•
Joint research e.g.
UCLP/Newham
CCG programme
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

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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 care, late booking into antenatal services
Poor end of life care
Diabetes care in Newham
Future state planning
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
care
Base lining and activity modelling
Future diabetes pathway- Enhancements to the
BHC pathway
Pathway documentation template and timelines
Service specifications
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 care and specialists) and in
partnership with social care and
other providers
• Ensure the workforce is trained
(competency based) and care 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
care
2. Care close to home
3. Service lines
a) Foot care
b) CVD pathways
c) EOL care
d) CYPS
procurement
e) Patient education
4. Shared care record
5. MDT teams
6. Hubs with diagnostics
and specialist care
7. Care Planning
8. Virtual Consults
BHC Diabetes Care pathway – levels of care
Level of
care
Type of care
Patient
profile
Locations /
Organisation
Level 1
Prevention and Well person,
Well beingminor illness
Navigation
Home, Virtual
Primary care
SPA hub
Level 2
Care
coordination
Moderate risk
Primary care
EPCS, Home,
Locality hubs
Level 3
Proactive case
Management
Moderate and Locality hubs
high risk
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
Care Activity
Roles
Outcomes
• Those outcomes as defined in the five domains of the NHS
Outcomes Framework
• An improved patient experience of their care, including moving
between different parts of the healthcare community
• Screening and prevention of diabetes
• Achieving the nine key care processes for type 1 and type 2
diabetes
• Achieving treatment targets for patients with diabetes by acting
upon the findings of care processes
• Achieving a reduction in complications of diabetes by acting on
the findings of care processes
• Reducing admissions and use of inpatient services for patients
with a primary code of diabetes
Indicative Outcomes/ KPIs/Quality
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Statement 1. People with diabetes and/or their carers 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 healthcare
professional or as part of a structured educational programme.
Statement 3. People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.
Statement 4. People with diabetes agree with their healthcare professional a documented personalised HbA1c target, and receive an
ongoing review of treatment to minimise hypoglycaemia.
Statement 5. People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose,
blood pressure and blood lipids in accordance with NICE guidance.
Statement 6. Trained healthcare 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
care 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 care 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 care 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 cared 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.