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Rustam Rea: integrating diabetes care in Derbyshire
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Rustam Rea: integrating diabetes care in Derbyshire


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Dr Rustam Rea, Associate Clinical Director and Consultant in Diabetes, Derby Hospitals NHS Foundation Trust, talks about First Diabetes - an integrated diabetes service, delivering care in one place, …

Dr Rustam Rea, Associate Clinical Director and Consultant in Diabetes, Derby Hospitals NHS Foundation Trust, talks about First Diabetes - an integrated diabetes service, delivering care in one place, closer to patients’ homes. 

The health care professionals in the team are drawn from both the hospital and the community and include consultants, GPs, specialist nurses, health care assistants and dieticians. The team are able to communicate easily among themselves through a shared electronic patient record and work closely with the practices who are part of the First Diabetes service. As well as providing individual appointments for patients, team members also provide group education along the whole patient pathway, from prevention of diabetes to complex insulin regimes. They also go out to practices to see patients and provide professional training and advice.

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  • The prevalence of type 2 diabetes mellitus (T2DM) and its rate of rise has been a source of concern in the UK.There is also much evidence of gaps and challenges in the care of people with diabetes. Areas that stand out in particular include the lack of access to and uptake of structured education, the high level of variability of care in both primary and secondary care and feedback from people with diabetes that the care they receive appears fragmented. For people with type 1 diabetes mellitus (T1DM), the present evidence suggests high levels of poor glycaemic control and a low rate of care process achievement increases the likelihood of future complications that can be avoided with good care.The need for integrated care is present at every stage of the patient journey. It is particularly important for those individual whose needs are becoming more complex. This group of people includes the elderly and infirm, those with longer duration of diabetes and those with multiple morbidities and a plethora of medications. Integrated care is pivotal for this group as their care is provided by multiple groups of professionals, who may have conflicting priorities. This can result in fragmentation of care, poorer outcomes and complications as well as hospital admissions that may have been avoidable with better integrated care.Best practice for commissioning diabetes services - An integrated care framework was developed in response to the needs of new commissioners and of health professionals involved in diabetes care. The overarching goal of this framework is to provide practical guidance and key principles for these professional groups to better commission and provide integrated care for people with diabetes. It aims to ensure that people with diabetes have access to a joined up service from the time of diagnosis, through more complex management, complications, inpatient care to end-of-life care.
  • Transcript

    • 1. Integrating diabetes care in Derbyshire Dr Rustam Rea Consultant Diabetologist, Royal Derby Hospital Co-Chair First Diabetes
    • 2. Person centered integration BOB AGE 60 Practice Nurse for regular check-ups GP for regular BP and medication checks Foot calluses Podiatry Clinic at Village St Health Centre Referred by GP for New patient education classes DAY course at Coleman St Health Centre delivered by Nurse Consultant, Dietician and Podiatrist Referred by GP for retinopathy screen Retinopathy screening at the London Road Community Hospital Referred by GP for Podiatry Bob has obesity issues Referred by GP to dietician Dietician appointments at the Walk-in Centre Bob confesses he has erectile dysfunction Referred by GP to Erectile Dysfunction Clinic Diabetic Specialist Nurse at the erectile dysfunction clinic at RDH Podiatrist at Village St finds foot neuropathy Podiatrist refers to Diabetic foot clinic Diabetic Foot Clinic seen by Diabetic Specialist Nurse, Podiatrist, and Consultant at RDH Nurse Specialist at the Osmaston Surgery has recommended exenatide Referred by GP to RDH Consultant Diabetologist initiates exenatide GP eventually thinks Bob requires insulin Referred by GP to LES2 insulin initiation service Nurse Specialist at the Osmaston Surgery decides exenatide is a better option so refers patient back to GP for referral to Consultant Foot neuropathy discovered
    • 3. Integration across a community „Bringing together clinicians across the system with legal and financial autonomy to be responsible for the health outcomes of the community‟
    • 4. Whole system integration 1 care 2 careIntermediate care Specialist podiatrists Diabetes service Specialist dietitians Specialist doctorsSpecialist DSNs Practice nurses GPs
    • 5. First Diabetes – a very new model  Partnership  Shares held 50% by GPs and 50% by acute trust  Single budget, not-for-profit  Comprehensive  Outcome focused, not process driven  A network including primary care, community and hospital staff  No one directly employed – staff either seconded or sessional  Facilities rented
    • 6. Pillars of integration in First Diabetes  IT  Financial  Patient participation  Clinical engagement  Clinical governance
    • 7. SystmOne - the IT solution  Single real-time clinical record  Rapid access to decision making and referrals  Consent and confidentiality  Rolled out into tertiary hospital clinics  Patient access
    • 8. Programme budgeting – the financial solution  Single budget for diabetes, jointly owned by GPs and hospital  Set by PCT based on previous years spend, scope of specification and efficiency savings  Not-for-profit organisation  Re-invest surplus back into the service
    • 9. Care planning – the patient engagement solution  Care planning philosophy  Patients informed and educated before clinic appointment  Patient shadow clinical board  Diabetes prevention workshops  Education throughout the patient journey
    • 10. Clinical engagement  Keeping colleagues engaged – primary care and hospital  New style of leadership – collaborative, shared responsibility, acknowledging historical differences  MSc diabetes module for upskilling primary care  Practice visits, discussing difficult patients – 4 groups  Reporting outcomes and comparing practices
    • 11. Clinical governance  Underpinned by a legal partnership – Company limited by shares – Equally owned by hospital and GPs – Provides stability and confidence in long term future  Move from silo working to joint ownership – Board of directors – Clinical management board – Wider team working – in hospital, in general practice
    • 12. Cost of integration  50% lower DNA rate compared to non-integrated service Cost per patient Year First Diabetes £ National tariff £ 2009/10 109 112 2010/11 124 118 2011/12 121 122
    • 13. Reduction in prescribing costs £0.00 £500.00 £1,000.00 £1,500.00 £2,000.00 £2,500.00 £3,000.00 CostperPU Total diabetes costs First Diabetes Act Cost Per standard pu Derbyshire Act Cost Per standard pu National Act Cost Per standard pu £200M savings if figures were extrapolated nationally
    • 14. Biochemical outcomes  Sustained QoF improvements for diabetes  Reduction in HbA1c (1-2%) and weight (5-10kg) in patients starting new diabetes drugs  75% reduction in insulin doses and 1.25kg weight loss in patients on complex insulin regimes
    • 15. Admission with primary code of diabetes 0 20 40 60 80 100 120 140 160 180 2009/10 2010/11 2011/12 2012/13 County Practices First Diabetes
    • 16. Admission with a secondary code of diabetes 0 500 1000 1500 2000 2500 2009/10 2010/11 2011/12 2012/13 County Practices First Diabetes 21% reduction in admissions in First Diabetes 9% reduction in surrounding county practices
    • 17. Patient and professional satisfaction “The FD service from Stoneleigh House is excellent. They give excellent care and advise to any patients I have sent there and have always improved the diabetic measures of control as well as helping the patient with understanding their condition. The patient satisfaction is very high. They have also helped with my own understanding of diabetes as well as being a considerable support to our nursing team”
    • 18. Recognition  Winner of Quality in Care Awards 2012 for Best Cross Boundary Working and Best Primary and Community Initiative  Finalist in HSJ Awards 2012 in Managing Long Term Conditions category  Finalist in HSJ / Nursing Times Care Integration Awards 2012 in Diabetes Care  Finalist in Health Enterprise East Innovations Awards 2012
    • 19. Challenges ahead  Providing diabetes care for Southern Derbyshire  Integrating with other long-term conditions  Integrating with social services and mental health  Ongoing clinical engagement
    • 20. Acknowledgements  Dr Garry Tan  Dr Kyran Farrell  Staff and patients at First Diabetes  GPs, hospital management  PCT / CCG
    • 21. Thank you Commissioning for Integrated Diabetes Care