dr nithya nanda clinical lead gp for diabetes 07/07/2016 ... · pre-existing work helped.. in...

Dr Nithya Nanda Clinical lead GP for diabetes

East Berkshire 07/07/2016

Taunton

Service provided by

Overview Existing locally enhanced service

Options for referral

Development of the ‘How to Guide’

Development of referral forms

Berkshire referral criteria

Description of progamme

Comments on cases referred to date

Pre-existing Work helped.. In Slough, we had started the process 2 years earlier. SilverStar charity partnership helped case identification in

public places—mosques, gurdwaras, temples and churches.

GP incentive scheme Pre-Diabetes LES helped create NDH Register.

£ 3 for creating a register and £23 for face-to-face reviews .

Hence Slough’s prevalance of Diabetes jumped from 7.5% to 8.4% and our estimated to actual prevalence proportion is nearly 95%

Options of Referral-pathways

Two pronged approach.

1. Referring NDH patients opportunistically at annual review as part of LES. High hit rate in terms of engagement, participation, and completion of the program. This results in gradual but good uptake of the program.

2. Data extraction using CHART query and digital invitation and referral thereof.

How To Guide - national audit

Referral forms for EMIS and Vision

Referral criteria • Aged 18 years or older • Be registered to a Berkshire GP practice (by

postcode) • Not diagnosed with Type 2 diabetes • Not pregnant at the time of referral • With a valid HbA1c of 42-47 mmol/ml (6.0-6.4%)

or an FPG of 5.5-6.9 mmol/l tested in last 12 months

910 patients on existing prediabetes audit

206 patients on NDH audit

Single

cases

Options for practices to refer

Road Show GP practice visitation by Reed Momenta provider

explaining the program and getting the buy in from the practice Staff.

Banners and promotional material in the waiting room.

Good timing as filming going on for ‘GPs behind closed doors’

In the second year, public place identification and self referral and digital offer needs robust implementation?

Programme Content

18 week local programme Free, nine month community-based behaviour change programme to help people prevent the onset of Type 2 diabetes

18 supportive, group-based sessions for up to 20 people delivered by trained, local staff

Programme designed by experts and underpinned by a decade of research into community-based diabetes prevention

Thank you