The Model of CareStephen Thomas18 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 – managementAccess Structured educationPersonal Care Planning

“We know what optimum care looks likeWe 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 LedHospital Based Specialist Led

Primary CareGP / Practice

Nurse & Others

Community BasedSpecialist &

Primary Care Lead

Patient at the centre of care

ComplicationsKidney / Eye /

Foot / ED

Individual with

Diabetes

Insulin Start

Routine CareScreening

Complications / Diagnosis

Education / Support

Type 1 DiabetesSub-optimal

control / HyposIn-patient Care

ComplicationsHeart /

Stroke / PVD

Institutional Care /

Housebond

Pregnancy

Diabetes Service Model

Level One

Primary Care

GP Led

Level Two / Level Three

Community Diabetes TeamGP & Specialist Led

Multidisciplinary

Level Four

Secondary Care

Consultant Led

Routine Care undertakenwith specialist support by phone/email

Patients can access advice by phone/email

GPs and practice nurses training

Extended care in community settingsDieteticsPodiatry

Patient Education ProgrammesMulti-disciplinary clinics

Specialist clinics

Dieticians, Podiatrists, DSNs and Psychologist

Insulin initiation

Joint Specialist Clinics T1D Patient Education ProgrammesInsulin initiation Insulin Pumptelephone/email advice Inpatient assessment and management

Training Support Development

Progression CKD Anaemia

Bone DiseaseJoint Kidney / Diabetes Services if nephrotic /

eGFR <30 Preparation for ESRF

Case review e-mail / telephone / virtual clinic

support.Specialist clinic – including dietetic

supportPoor Control e.g. BP > 150 despite 3

anti-hypertensivesHyperkalaemia /

Advice on use oral hypoglycaemics

Patient Education / SupportBlood Pressure treatment / Management of Risk factors

Use of RAS inhibitorsMicroalbuminuria / eGFR Screening

More regular follow up enhanced screening eyes / feetFBC / Renal Bone Disease

Settings for Care (3)

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 educationEstimated prevalence / prevalence on Register / Qoff Numbers with retinopathy

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 Assessm

ent

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?