Welcome to the Brent Intermediate Diabetes Care Services Launch




                        10th May 2006
                ...
Brent Diabetes Services


         Dr. Senan Devendra MD MRCP
Consultant in Endocrinology & Integrated Diabetes Care
     ...
The Team
•   Claire Lawler
•   Nina Patel, Julia Anthony & Lucy Ogida (DSN’s)
•   Sala Salih & Camelia Kirollos (Diabetes ...
www.brentpct.nhs.uk
Referral criteria to ECC

• Young adults with Type 1 diabetes (<35yrs)
• Poor glycaemic control despite on insulin
  (need...
Higher tariff set in Payment by Results system
for diabetes treatment
   New figures issued by the Department of Health sh...
Diabetes SPA total referrals per locality
     (according to GP post code)
     20.02.06 – 26.04.06 total = 207 x £241= £5...
Brent Diabetes Services
• Clinical support: MDT approach
 - Intermediate care clinics
 - Email consultations
 - Liaising w...
Brent Diabetes Services
• Education: MDT approach
 - patient education
 - health care professional education

• Research &...
100 years of
 hormones




               Photo Courtesy of Prof. G.Williams
               Dean of Medicine, Univ. of Bri...
Expected Standard of Care
& Microalbuminuria Pathway
Dr Encarna Fernandez
Diabetes GPWSI – Kilburn Locality
Weight Management in
Diabetes Intermediate Care

   By Helen Davies & Salma Butt
   Specialist Diabetes Dietitians
The business case !

•   Type 2 DM – overweight at diagnosis
•   Av. BMI = 28-29
•   Relationship with macrovascular disea...
Current services
•   Diabetes education sessions
•   MDT intermediate care clinics
•   Fit for Life programme
•   Obesity ...
MDT intermediate care clinic
•    Initial assessment
•    Readiness to change
•    Brent options
•    Refer to pathway
   ...
Fit for Life
•   12 week weight management programme
•   Nutrition education + exercise
•   Group support
•   Referral thr...
Obesity clinic at CMH
• Patients with complications/poor control +
  maximum oral therapy
• Failed at Intermediate care cl...
New package of care for
improving Glycaemic control
       in primary care


          Nina Patel
        DSN Brent tPCT
AIM
• To provide focused intensive input to
  improve HbA1c with a clear supportive
  plan and exit strategy
Referral criteria


• Patient on maximum doses of oral
  hypoglycaemic
  (see protocol for the use of oral
  hypoglycaemic...
Where will the patient be seen?
 DSN clinic in own locality
• Kilburn      Kilburn Square clinic
• Wembley      WembleyWCH...
First Review – Consultation 1
• Patient considered for education session
• Medication review – address compliance
• Dietet...
Consultation 2: (2 to 3 wks post
                      visit 1)
• Assess blood glucose results
• If not started, start ins...
Consultation 3: (4 to 6 weeks
                  post visit 1)
• Weight check/ WC            • Also consider
• Blood glucos...
Consultation 4: 3 month review
• Check HbA1c (1 week before
  appointment)
• Further titration of insulin
• Add pre-meal s...
Exit strategy
• Hba1c less than 7.5% (or desired goal
  achieved) return to the care of GP and
  Practice nurse.
• Maintai...
Joint British Societies Guidelines 2 on
prevention of Cardiovascular Disease in
        Clinical Practice (JBS2):
        ...
Introduction
• How will the new guidelines affect the
  management of people with diabetes in
  Brent
• What are the workf...
JBS – 2            2005

             High risk patients
• Established athero-sclerotic disease
• 1ry prevention CVD risk ...
JBS-2
 targets for high risk patients


Total cholesterol <4
             (25% reduction)
LDL-cholesterol <2
             ...
LDL-C reduction & cost across
     statin dose ranges
                   LDL-C: Mean change (%) from baseline at week 6

 ...
Next Steps
• What is the most effective way to
  implement the new guidelines ?
  In Primary care or Intermediary care
• G...
“Highest” Risk Group
    ( Diabetes + one of the following)
•   Previous CV event
•   Peripheral Vascular disease
•   Fami...
Treatment Pathway for
                 High Risk Group



CHOLESTEROL < 5.5 OR LDL < 3.8                    CHOLESTEROL > ...
Education
Diabetes Education
     Network
     Dr Camelia Kirollos
    Associate Specialist
  Central Middlesex Hospital


         ...
Brent Diabetes Education
        Network
Diabetes Education
             Network
• Professionals’ Education

• Nurses: Practice nurses, District
  nurses, Twilight...
Diabetes Education
              Network


• Patients’ Education
Short courses - 2 days
Long courses 6 weeks
Tailored Ethn...
Attendants of diabetes patient education
                 courses
    between July 2004 and March 2006
          Attendanc...
Patients’ self-management
            courses

• DAFNE: For Type 1 Diabetes (since 2002)
Alternate Months at JKDC (CMH)
Av...
DAFNE Improvement lasts



            9                                       30




                                    ...
Certificate in Diabetes Care:
       Warwick Courses
• Warwick Diabetes care
  – Run twice a year: February and September
...
Consultant led seminars

• Insulin for life programme (Insulin initiation)
• MERIT (Insulin initiation)
• Consultant notes...
Educational Needs
• The network needs to extend and invite
  the front line workers:
  – Eg: Health care assistants
  – Tw...
Competency & Skills
   “A Mandatory Requirement ”


         Ram Dhillon FRCS
    Consultant Surgeon, Northwick Park
     ...
No Mans Land
(Locus of Demand & Need for Capacity, Competency & Skills)
                                                2n...
What is Fundamental
                  for
 Acquisition of Competency & Skills



        1.   Knowledge & Skills
        2...
A Model for Competency/Skills Training &
       Accreditation in Respiratory Medicine for Primary
              Care ( Dr ...
PwSIs
                                with

                      Special Interests
                       ( competent & s...
Questions?


gm.e.diabetes.bre-pct@nhs.net

    www.brentpct.nhs.uk
Brent Diabetes Launch Day - Presentation
Brent Diabetes Launch Day - Presentation
Brent Diabetes Launch Day - Presentation
Brent Diabetes Launch Day - Presentation
Brent Diabetes Launch Day - Presentation
Brent Diabetes Launch Day - Presentation
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Brent Diabetes Launch Day - Presentation

  1. 1. Welcome to the Brent Intermediate Diabetes Care Services Launch 10th May 2006 Clay Oven , Wembley
  2. 2. Brent Diabetes Services Dr. Senan Devendra MD MRCP Consultant in Endocrinology & Integrated Diabetes Care Brent tPCT & Central Middlesex Hospital
  3. 3. The Team • Claire Lawler • Nina Patel, Julia Anthony & Lucy Ogida (DSN’s) • Sala Salih & Camelia Kirollos (Diabetes Edu. Network) • Salma Butt, Helen Davies & Farhat Hamid (dietetics) • Rakhee, Gaytree & E. Shillingford (podiatry) • Leena Sevak & Maggie McClelland (pathway managers) • Rowland Hughes (DPAG chair) • Silvia Sedeghian & G.Vafidis(retinal screening) • Ricky Banarsee & Azeem Majid (Imperial - research) • Kirsten Darylmple (Imperial – education faculty) • JKC – too many to mention
  4. 4. www.brentpct.nhs.uk
  5. 5. Referral criteria to ECC • Young adults with Type 1 diabetes (<35yrs) • Poor glycaemic control despite on insulin (needing insulin pump) • Hypoglycaemia unawareness • eGFR < 30 • Foot ulcers requiring intensive management • Women with diabetes who are pregnant • Very obese who failed therapy
  6. 6. Higher tariff set in Payment by Results system for diabetes treatment New figures issued by the Department of Health show that the tariff set for the treatment of people with diabetes under the payment by Results system has been increased. New tariffs for 2006/2007 are as follow Tariff 2005/06 New tariff 2006/2007 New adult (i.e. adult receiving their first treatment) £152 £241 Follow up appointment (adult) £61 £88 Diabetes UK 2006
  7. 7. Diabetes SPA total referrals per locality (according to GP post code) 20.02.06 – 26.04.06 total = 207 x £241= £50,000 80 70 60 50 40 total referrals 30 20 10 0 Wembley Kingsbury Harlesden Kilburn Willesden
  8. 8. Brent Diabetes Services • Clinical support: MDT approach - Intermediate care clinics - Email consultations - Liaising with District Nurses/out of hours - Up-skilling Primary Care colleagues - Telephone support clinics for patients
  9. 9. Brent Diabetes Services • Education: MDT approach - patient education - health care professional education • Research & Audit
  10. 10. 100 years of hormones Photo Courtesy of Prof. G.Williams Dean of Medicine, Univ. of Bristol
  11. 11. Expected Standard of Care & Microalbuminuria Pathway Dr Encarna Fernandez Diabetes GPWSI – Kilburn Locality
  12. 12. Weight Management in Diabetes Intermediate Care By Helen Davies & Salma Butt Specialist Diabetes Dietitians
  13. 13. The business case ! • Type 2 DM – overweight at diagnosis • Av. BMI = 28-29 • Relationship with macrovascular disease • Weight loss associated with survival • Does weight need to be managed “differently” in DM
  14. 14. Current services • Diabetes education sessions • MDT intermediate care clinics • Fit for Life programme • Obesity clinic at Central Middx
  15. 15. MDT intermediate care clinic • Initial assessment • Readiness to change • Brent options • Refer to pathway (enclosed in conference pack)
  16. 16. Fit for Life • 12 week weight management programme • Nutrition education + exercise • Group support • Referral through Diabetes SPA
  17. 17. Obesity clinic at CMH • Patients with complications/poor control + maximum oral therapy • Failed at Intermediate care clinic • Intensive weight management advice • Long term support if necessary • Bariatric surgery
  18. 18. New package of care for improving Glycaemic control in primary care Nina Patel DSN Brent tPCT
  19. 19. AIM • To provide focused intensive input to improve HbA1c with a clear supportive plan and exit strategy
  20. 20. Referral criteria • Patient on maximum doses of oral hypoglycaemic (see protocol for the use of oral hypoglycaemic agents*) • HbA1c > 8 % (age < 75) *www.brentpct.nhs.uk
  21. 21. Where will the patient be seen? DSN clinic in own locality • Kilburn Kilburn Square clinic • Wembley WembleyWCHC • Willesden Willesden CHC • Kingsbury Chalkhill Health Centre • Harlesden Monks Park CHC
  22. 22. First Review – Consultation 1 • Patient considered for education session • Medication review – address compliance • Dietetic assessment – weight management pathway • Assessment of motivation, health beliefs, readiness to change • Set realistic goals • Obtain a contract with agreed roles of DSN and patient (minimum 1.5% HbA1c reduction by 3 months) • Start Blood glucose monitoring • Insulin discussed or started
  23. 23. Consultation 2: (2 to 3 wks post visit 1) • Assess blood glucose results • If not started, start insulin e.g. once daily long- acting or twice daily mix. Insulin (this can be done with practice nurse/ district nurse) • Given algorithm to follow • Address weight gain issue with insulin Titration of insulin doses over telephone with daily or weekly contact.
  24. 24. Consultation 3: (4 to 6 weeks post visit 1) • Weight check/ WC • Also consider • Blood glucose control • Orlistat/Sibutramine • BP • Weight management • Injection sites clinic • Management of pen • Exercise classes device. • Patient support group • Hypo’s • Expert patient course • Consider prandial insulin • Titration of insulin doses over telephone with daily or weekly contact.
  25. 25. Consultation 4: 3 month review • Check HbA1c (1 week before appointment) • Further titration of insulin • Add pre-meal soluble insulin • Check weight gain/WC & dietitian review • Titration of insulin doses over telephone with daily or weekly contact.
  26. 26. Exit strategy • Hba1c less than 7.5% (or desired goal achieved) return to the care of GP and Practice nurse. • Maintain regular contact (telephone of link DSN or Diabetes SPA given) • If HbA1c goal not achieved – consider other options (eg. restart package of care, JKC - insulin pump therapy, novel therapeutic agents)
  27. 27. Joint British Societies Guidelines 2 on prevention of Cardiovascular Disease in Clinical Practice (JBS2): implications for Brent Dr. Joan St John Gpwsi Diabetes Wembley Locality
  28. 28. Introduction • How will the new guidelines affect the management of people with diabetes in Brent • What are the workforce and cost implications • What is the most effective way to implement the new guidelines ?
  29. 29. JBS – 2 2005 High risk patients • Established athero-sclerotic disease • 1ry prevention CVD risk >20% • Diabetics ALSO elevated risk due to a single risk factor BP >160/ >100 (or less if target organ damage) Elevated TC: HDL >6 or FH of hyperlipidaemia
  30. 30. JBS-2 targets for high risk patients Total cholesterol <4 (25% reduction) LDL-cholesterol <2 (30% reduction)
  31. 31. LDL-C reduction & cost across statin dose ranges LDL-C: Mean change (%) from baseline at week 6 0 -5 -10 -15 20 -25 -30 -35 -40 -45 -50 -55 -60 10mg 20 40 rosuvastatin £18.03 mg mg 10mg 20 40 80 £ 18.03 mg mg mg atorvastatin £22.64 £28.21 10 20 40 80 mg mg mg mg simvastatin £2.34 £4.23 £24.07 10 20 40 mg mg mg pravastatin  ‡ ‡  ***P<0.001 vs Rosuvastatin 10mg;  p<0.002 vs. rosuvastatin 10mg ^^^P<0.001 vs Rosuvastatin 20mg ‡ p<0,002 vs, rosuvastatin 20mg  p<0.002 vs. rosuvastatin 40mg
  32. 32. Next Steps • What is the most effective way to implement the new guidelines ? In Primary care or Intermediary care • Guidelines for Titration of Simvastatin or • Trying to treat to target with one drug one visit
  33. 33. “Highest” Risk Group ( Diabetes + one of the following) • Previous CV event • Peripheral Vascular disease • Family history of Premature (<60yrs) death from IHD • Renal Impairment (eGFR < 60) • Micro-albuminuric patients
  34. 34. Treatment Pathway for High Risk Group CHOLESTEROL < 5.5 OR LDL < 3.8 CHOLESTEROL > 5.5 OR LDL >3.8 Start Simvastatin 20mg Start Atorvastatin 20mg (titrate to 80mg) to 40mg if needed to achieve target or Rosuvastatin 10mg od Target: T. Cholesterol = 4 LDL = 2 Law, BMJ 2003
  35. 35. Education
  36. 36. Diabetes Education Network Dr Camelia Kirollos Associate Specialist Central Middlesex Hospital * Please refer to handout for details
  37. 37. Brent Diabetes Education Network
  38. 38. Diabetes Education Network • Professionals’ Education • Nurses: Practice nurses, District nurses, Twilight nurses, Residential homes, Nursing Homes • Doctors: GPs, GPwSI, Hospital Doctors • Health care Assistants
  39. 39. Diabetes Education Network • Patients’ Education Short courses - 2 days Long courses 6 weeks Tailored Ethnic or Cultural courses Eg. For Pakistani, Gujarati Communities
  40. 40. Attendants of diabetes patient education courses between July 2004 and March 2006 Attendance of diabetes education courses between July 2004 and March 2006 Total = 550 Harlesden 6% Willesden Wembley 20% 30% Kilburn 14% Kingsbury 30%
  41. 41. Patients’ self-management courses • DAFNE: For Type 1 Diabetes (since 2002) Alternate Months at JKDC (CMH) Available soon in intermediate care • DESMOND: For newly diagnosed Type 2 Diabetes (NSF requirement)
  42. 42. DAFNE Improvement lasts 9 30 Severe hypoglycemia HbA1c (%) 25 per 100 pt y 8 20 15 7 10 5 6 0 0 1 2 3 6 Years of follow-up
  43. 43. Certificate in Diabetes Care: Warwick Courses • Warwick Diabetes care – Run twice a year: February and September • Includes 4 units (Each is a whole day) • Understanding Diabetes • Therapeutic Options • Preventing & Managing Complications • Life Times
  44. 44. Consultant led seminars • Insulin for life programme (Insulin initiation) • MERIT (Insulin initiation) • Consultant notes review service (eg. HbA1c >7.5%)
  45. 45. Educational Needs • The network needs to extend and invite the front line workers: – Eg: Health care assistants – Twilight nurses – Pharmacist in the community and hospitals – Local initiatives for day release education. – Courses for Hospital staff. – Junior Doctors programmed trained.
  46. 46. Competency & Skills “A Mandatory Requirement ” Ram Dhillon FRCS Consultant Surgeon, Northwick Park Hospital, Harrow Hon. Professor, Middlesex University, London National Clinical Lead, Elective Care Team (m): 07 958 450 544 (e): ram.dhillon@talk21.com
  47. 47. No Mans Land (Locus of Demand & Need for Capacity, Competency & Skills) 2nd Opinion 100% No Mans Land Intermediate Tier Level Care Home to: (PwSIs) GPwSIs, NwSIs, AHPwSIs Patients (FCE ) 50% 0% P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 Practitioner
  48. 48. What is Fundamental for Acquisition of Competency & Skills 1. Knowledge & Skills 2. Knowledge & Skills 3. Knowledge & Skills 4. Knowledge & Skills Adequate Training & Accreditation
  49. 49. A Model for Competency/Skills Training & Accreditation in Respiratory Medicine for Primary Care ( Dr Vincent Mak & Prof. Ram Dhillon) Clinical activity * Local mentoring * Directed learning * REGn SEM M1 M2 M3 SEM + EX PGCert CPD Clinical Case Studies * Middlesex University, London Seminars # OSCE # Royal College of General (lectures, practical skills) VIVAS # Practitioners (RCGP) • NB. Further details on Postgraduate Training for Special Interests : www.pgdip.com
  50. 50. PwSIs with Special Interests ( competent & skilled ) Potential effects • NSFs • Retention/Recruitment • Demand • Clinical Pathways • Capacity • Clinical Governance • Access • Community Care • Integrate 1*/2* • Cost-Effective Care
  51. 51. Questions? gm.e.diabetes.bre-pct@nhs.net www.brentpct.nhs.uk

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