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The model of care
 

The model of care

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    The model of care The model of care Presentation Transcript

    • The Model of Care Stephen Thomas 18 July 2008
    • Basics Of A Diabetes Service
      • Identification of those at Risk
      • Identification of those with Diabetes
      • Registration / Recall
      • Surveillance / Treatment
      • Care right place with appropriate skills
      • Support self – management
      • Access Structured education
      • Personal Care Planning
      • “ We know what optimum care looks like
      • We know sub-optimal care has high personal costs for patients and high financial costs for the NHS”
    • Principles supporting the Diabetes Care Model
      • Coordinated Integrated Services - easy direct access to specialist services
      • Recognition skills primary care and specialists
      • Commissioners work with Primary Care & Specialists overseeing whole of the care pathway
      • Neighbouring PCTs, collaborate
      • Communication Standard -
      • Standardised referral forms
      • Documentation along the care continuum.
      • (electronic records / patient held records?)
    • “ Strong leadership for the delivery and organization of services ….. are essential. This should be supported through the appointment of adequately resourced clinical champions, user champions and network managers.”
    • Settings for care Hospital Based Specialist Led Primary Care GP / Practice Nurse & Others Community Based Specialist & Primary Care Lead
    • Patient at the centre of care Complications Kidney / Eye / Foot / ED Individual with Diabetes Insulin Start Routine Care Screening Complications / Diagnosis Education / Support Type 1 Diabetes Sub-optimal control / Hypos In-patient Care Complications Heart / Stroke / PVD Institutional Care / Housebond Pregnancy
    • Diabetes Service Model Training Support Development Level One Primary Care GP Led Level Two / Level Three Community Diabetes Team GP & Specialist Led Multidisciplinary Level Four Secondary Care Consultant Led Routine Care undertaken with specialist support by phone/email Patients can access advice by phone/email GPs and practice nurses training Joint Specialist Clinics T1D Patient Education Programmes Insulin initiation Insulin Pump telephone/email advice Inpatient assessment and management Extended care in community settings Dietetics Podiatry Patient Education Programmes Multi-disciplinary clinics Specialist clinics Dieticians, Podiatrists, DSNs and Psychologist Insulin initiation
    • From the consultation
      • ‘ GPs and nurses can provide a more 'personal' service and develop a relationship with people and hopefully make it easier to persuade them to change’
      • Female aged 55-64 
      • “ Moving too much into community can result in reduction in quality of care - and before you say "skill mix" I have seen what can happen when skills spread too thinly”
      • Male age 55 -64 
      • “ I think the combination (specialist / community) is very important.”
      • Female 45 -54
    • Settings for Care (2) Inpatients Urgent cases Type 1 diabetes Children Pregnant women Those at risk: renal, foot Specialist Clinics Management of Eye Screening Staff training / development Patient education Care Pathways Insulin For Type 2 Diabetes Routine management of most Type 2 patients Psychological support / Screening for complications / Treatment of complications Diagnosis of diabetes Management Obesity Diabetes Risk Factors Advice for staff / patients
    • Settings for Care (3) Progression CKD Anaemia Bone Disease Joint Kidney / Diabetes Services if nephrotic / eGFR <30 Preparation for ESRF Case review e-mail / telephone / virtual clinic support. Specialist clinic – including dietetic support Poor Control e.g. BP > 150 despite 3 anti-hypertensives Hyperkalaemia / Advice on use oral hypoglycaemics Patient Education / Support Blood Pressure treatment / Management of Risk factors Use of RAS inhibitors Microalbuminuria / eGFR Screening More regular follow up enhanced screening eyes / feet FBC / Renal Bone Disease
    • Newly Diagnosed Diabetes / Diabetes Screening No diabetes but at risk Primary Care / Community Secondary Care setting Diabetes confirmed Optimisation of blood glucose control with insulin or oral therapies Tailored education programmes Inpatient - insulin therapy and initial training Adults with DKA or HONK – URGENT referral to hospital specialist team Diabetes suspected – initial assessment Lifestyle advice Adults under 30 with signs/ symptoms of Type 2 to specialist-led team for triage Community / Specialist ketones in urine, blood glucose >25mmol/l URGENT referral to specialist service for triage All other adults – initiate management within primary care Criteria Optimisation of blood glucose control with oral therapies or lifestyle changes Indicators of quality numbers emergency admissions / numbers (proportions) completing education Estimated prevalence / prevalence on Register / Qoff Numbers with retinopathy
    • Quality Indicators - Diabetic Kidney Disease
      • • Percentage of adults and children with diabetes with a record of testing for proteinuria or microalbuminuria.
      • • Percentage of adults and children with diabetes with proteinuria or microalbuminuria who are treated with ACE inhibitors or A2 antagonists.
      • Late identification / referral
      • End stage renal failure - Monitoring
    • Quality Indicators - Diabetic Eye Disease
      • Number (Percentage) Diagnosed with Sight threatening retinopathy
      • Number (Percentage) needing Laser Treatment
      • Percentage who have had retinal screening
      • Registrations for blindness (Sight Impairment and Severe Sight Impairment
    • Quality Indicators – Self Management
      • Percentage Offered Structured Education
      • Percentage who have received structured education
      • Measurement of Satisfaction
      • Percentage of people with diabetes who agree a care plan to manage their diabetes
    • The Community Team Specialist Nurses Dietetics Podiatry Mental Health Diabetes Specialist Primary Care Lead Pharmacists Learning From Users
    • Community Diabetes Team / Diabetes Network Rapid Access Practice based joint clinical consultations Community Insulin starts Health Professional Education Community Nurse support Patient Education Telephone Advice Patient Participation Running Diabetes Clinics in Some Practices Governance / Practice Assessment
    • Governance / Quality Assurance
      • How to Ensure Quality Care within
      • Primary Care / Community Care
      • Secondary Care / Tertiary Care
      • Suggestions
      • PCT Performance Team
      • Local Enhanced Service: Diabetes Incentive Scheme
      • Peer Review Intermediate Care Team
      • What should we measure?
      • Clinical quality
      • User surveys
      • Financial
    • Specifically, does the model address…?
        • Local needs
        • Mobility of Population
        • Ethnicity of Population
        • Mobility of Healthcare professionals
        • Health inequalities?