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 • 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

listen and engage

design and test

procure service

mobilise & go-live

Feb-Aug 2016

Mar- Sept 2016

Oct 2016-July-2017

Feb

2018

• Patient Public engagement

• Needs analysis • Provider events • NCCG programs

• Vision and scope • Delivery models • Financial analysis • Pathways

Building Healthy Communities - Overview Plan

Risk Stratification/ Care Navigation

Single Point of Access-Health and Social care

Single Joint Assessment Framework- Health and Social care

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

End of Life

Chronic Care

Prevention and Well

being

Care close to home

Care Co-ordination

and extended

primary care

Rapid response

Case management

Specialist services in community

Intermediate care

services- Pre-

hospital/ In-hospital care

Post-hospital care

Supported Discharge

End of Life Care

Integrated Health and Social Care Functions

Redesigned Estates and infrastructure

Integrate multidisciplinary team- new workforce model

Shared Care Record / Technology enabled care platforms

Core and Specific Pathways including mental health- Step Up and Step Down Care as required

MOHAMMED’S Future Pathway

Mohammed –

50 yrs old has

diabetes with

renal disease

Wife &

Carer

Telehealth Skype Home monitoring Carer Support Homecare Self -Care Prevention Well- being Advice Patient education

Access

SPA

M

ult

i Age

ncy

Hu

b

He

alth

& S

oci

al C

are

DO

S SI

NG

LE A

SSES

SMEN

T

Hub

Diagnostics

Social Care

Voluntary service

Foot care/

Physio

111/ Urgent Care

Integrated workforce model – MDT Team, Case Management, CPN

Virtual Specialist Support from Acute

Facilities/ Services Provider

Single Shared Record- Integrated care plan

Locality

GP hub

Neighborhood team

Prevention and Well being

Care Navigation Extended primary

care

Rapid response Care coordination Case management

Specialist services in community

Intermediate care services- Pre-hospital/ In-hospital care

Post-hospital care Supported Discharge

End of Life Care Step up / Step

down care

EPCS

Referrer

SPAR Clinical Hub

Navigation Risk Stratification

Triage H&SC Care co-ordinator

Referral Criteria

Does not meet criteria for Case

management

Does not meet criteria for SPAR

YES

Cri

tica

l > 2

hrs

No

n C

riti

cal

Ro

uti

ne

Tas

k

Rapid Response

Intermediate Care/Re-ablement

DN team

Community Delivery MDT

Team

DIAGNOSTICS TELEHEALTH

Manage for required period Manage for up to 6 weeks H

eal

th

Soci

al C

are

Discharge/Refer Appropriate for Case management ?

YES NO

NO NO

Practice Social Care

Community Delivery Team

Rehab/Supporting Services/ Mental Health

Personalised Budgets

For Assessment

Case Manager

DN Team

Specialist Services

Social care

Self Referral

Planned Expected/proactive

Unplanned

Prevent ion/ Wellbeing/ Self Care

Hospital at Home /Care Homes /Community Beds

Acute Services

GP/ EPCS

Supported Discharge/ In-Reach Services

Specialist consultation

Level 1 Referrals Navigation

Level 2 Care Co-ordination

Level 3 MDT Care Planning Proactive case management

Level 4 Reactive Case Management Advanced Community Care

Level 5 Step Up/ Step Down

NEWHAM BHC GENERIC HEALTH AND SOCIAL CARE PATHWAY

Acute Hub

Urgent Care pathway/ OOH GP

EHCC- Dementia/ EOL/ Rehab/ Day Hosp

UCC/ A & E

Community hub

Primary care

Ambulatory Care

Enablers

Single point of access

Care navigation

Shared electronic patients record

Joint health and social care assessment

Patient Transport Services

Prevention and Well being

Multidisciplinary assessments (MDT)

Goal oriented MDT Care planning

Patient education services

Screening services

Selfcare and monitoring

Self referral

Falls prevention service

Day Hospital

Care close to home

Community Outpatient Consultations

Anticoagulation service

Ophthalmology

AQP Contracts/ EPCS

Dermatology

Community Diagnostics

Community procedures

Wound care

Community Therapies (OT, PT, Podiatry)

Specialist Palliative care

Home health monitoring (telehealth) & telecare

Home care & Home Social Care

Rehabilitation services including SLT

Re-ablement services

Specialist services in community

Continence

East Ham Care Centre & Falls Prevention Clinic

Specialist Opinion in Community / Community Geriatrician

Foot health services

Tissue Viablity

Patient Appliances/ orthotics

Wheelchair services

Lymphedema

LD

MSK

AQP contracts

CVD

Diabetes

Dietetics

Haemoglobinopathies/Sickle Cell Adults

Intermediate care services- Prehospital/ 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

BHC- service lines in scope- draft

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 ante-natal 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

Afflicted without

complications

Afflicted with complications

Reduce vulnerability

• Reduce obesity &other lifestyle factors

• Culturally tailored public health

•Targeted screening

Reduce or delay progression

• Improve awareness and attitude in population

• Accessible and high quality screening and initial assessment

Improve routine management

• Improve quality and accessibility of self-management support

• Improve quality and accessibility of routine care

Improve management of complications

• Quality and integration of care for people with complex needs

• Improve support for particular vulnerable groups

• Improve end of life care

• 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

What can we do?

Underlying challenges:

•Community Prescription

•Mapping/Risk stratification

•JSNA

• Healthier You/ NDPP • Pre-diabetes screening /EPCS

•Structured education/ self-management programme •Cluster MDT model

What is happening?

The Super Six

Primary/ Community Care Services –

Low/Medium Risk

GP Cluster Diabetes MDT initiative • 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 bi-monthly, 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

• Better understanding of the psychology of long term conditions

• Increased planned discharges from specialist to primary care

• Referral avoidance

• Education and dissemination of information

Specialist Care Services – High Risk • 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 post-

partum 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

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

Care Activity

Roles

Level 1 Prevention and Well being- Navigation

Well person, minor illness

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 high risk

Locality hubs 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

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

• Compliance against NICE Diabetes in Adults Quality Standard25

Indicative Outcomes/ KPIs/Quality • 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.