improving foot health proposal dmi programme board 19 th july 2013 dr carol gayle and monique...

Improving foot health proposal

DMI Programme Board19th July 2013

Dr Carol Gayle and Monique Ferdinand

19 July 2013 2

Foot health – DMI programme board

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Contents

• Our objectives• Work done to date• Conclusions from analysis• What we want to deliver and timescales• Measures of success• Risks and constraints

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Objectives of DMI foot health work

• Reduce variation in foot assessments across primary care

• Increase patient and provider understanding and confidence in the pathway, with clarity on when and how to refer to specialist podiatry services

• Ensure patients are seen in the most appropriate care setting

• Ensure capability and capacity of community podiatry service to manage cohorts of patients previously managed in secondary care

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Work done to date

1. L & S diabetes foot care pathway• Created for 1° care clinicians to clarify when and where

to refer patients

2. Primary care education events• Two events in Jan 2013 • Aimed to improve recognition of foot health problems,

launch pathway, provide practical support from podiatrists

3. Data collection and analysis• Used to inform next steps for improving foot health• Has been difficult to obtain, gaps in recording, unclear

coding

Foot intactNormal sensationPalpable pedal pulses

Foot intactNeuropathy or absent pulses

Foot intactNeuropathy or absent pulsesPLUSPrevious ulceration, skin changes or deformity

High

Moderate

Low

Lambeth & Southwark community podiatry (Foot Protection Team)

Southwark & Lambeth community podiatry (Foot Protection Team)

Primary Care

Risk level Service How to refer

Neuropathic foot + new onset blister / superficial ulceration (up to 48 hours)

KCH diabetic foot clinic or GSTT foot healthA&E if out of hours

Lambeth & Southwark community podiatry (Foot Protection Team)

What should happen

Advise patients of their risk level Advice and information for emergencies Discuss self management care plan & self management options. Refer as appropriate.

Advise patients of their risk level

Responsive to needs of patients

May include more specialised vascular assessment

Specialist advice about footwear and insoles

Arrange follow up care

Inform GP of intervention

See self management pathwaySouthwark: 020 3049 8863 / 8840Lambeth: 020 8655 7842

Southwark Community PodiatryTel 020 3049 7900Fax 020 3049 7901Lambeth community podiatry Tel 0203 049 4040 Fax 0203 049 6361/6362

Southwark Emergency clinics Mon,Wed, Fri Tel: 020 3049 7900Fax: 020 3049 7901Community podiatry:020 3049 7900Lambeth Emergency clinics Mon – Fri:Tel: 0203 049 4001/2/3Community podiatry 0203 049 4040 Fax 0203 049 6361/6362

Annual foot check• Test foot sensation• Palpate foot pulse• Inspect for

deformity / callus• Check for ulcers• Ask about history

of ulcers• Inspect footwear• Ask about pain• Stratify risk and

inform patient

Diabetic foot patient pathway for Southwark and Lambeth March 2013

Tailored intervention by community podiatry (Foot Protection Team)Referral to specialist hospital team if requiredInform GP of intervention

Tailored intervention by specialist teamInform GP of intervention

King’s Diabetic Foot ClinicTel: 020 3299 3223 Fax 020 3 299 4536 Guy’s Foot Clinic Tel: 0207188 2449 Fax 020 7188 2450St Thomas’ Foot ClinicTel: 020 7188 1983Fax: 020 7188 1991St George’s Foot Clinic 0208 725 1429 / 0232

Within 24 hours

Priority referral

Routine referral

As required

Holistic careAre diabetes & other risk factors well controlled?

At every appointment discuss self management care plan & refer if suitable to self mgnt pathway for options

Active

Foot ulcerationFoot intact BUT infectionIschaemic foot + infectionNeuropathic foot + infectionUnexplained foot inflammation ?Charcot

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Conclusions from analysis – foot assessments in primary care

• Foot checks recorded in primary care have increased in the last year, although the variation across GP practices is still wide

Lambeth Southwark England average

2011/12 83.7% (11,512)

81.5% (9,762)

83.6%

2012/13 85.6% (12,761)

84.4% (11,058)

QOF – DM29: percentage of patients receiving a foot check – values without exceptions

Practice level variation:• 2011/12 21.7% to 94.2% • 2012/13 44.4% to 96.8%

• Although this variation has narrowed in 2012/13, there are still some practices with low levels of foot checks being recorded

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Conclusions from analysis – community podiatry

• Referrals from specialist podiatry teams in secondary care to community podiatry are known to be low (none seen in audit performed)

• Source of referral most commonly from GP or Self

% of reasons for referral in patients presenting at Community podiatry in Jan 12

0%

10%

20%

30%

40%

50%

60%

70%

Nail care

CallusPain

OtherSkin

Diabetic foot check

Infection

Monitorin

g

Verrucae

Diabetic foot u

lcerWound

Up to 3 reasons for appointment allowed

Lambeth Southwark Total % of totalSource of referralGP 6 16 22 44%Self 9 8 19 38%St Georges Rheumatology 1 1 2%Other 1 1 2%Unknown 9 9 18%

Audit of 50 patients in community podiatry in Jan 2012 (25 from each borough)

Reasons for referral• Highest number of referrals were for nail

care (up to three reasons were allowed)• Eight per cent were referred for a foot

check

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Conclusions from analysis – hospital podiatry services

• There are potential cohorts of patients managed by KCH and GSTT podiatry teams who could be transferred to community podiatry

• KCH exploring if those who are high risk but stable needing ongoing surveillance could be managed within community podiatry

• There would be a need to conduct a similar exercise within GSTT

Analysis of appointment type

Appointment type No. appts % appts Ulcer management 1502 45.2% Follow-up - healed 1025 30.8% Vascular management 474 14.3% Charcot foot 116 3.5% Orthopaedic management 73 2.2% Casts 61 1.8% Other 72 2.2%

KCH to conduct audit of f/up healed

patients

Reason for appointment %Ulcer 47%Other 16%Diabetes foot check 10%Vascular 6%Amputation 5%Charcot 5%Nail care 5%Renal 3%BKA 2%Skin 2%Total patients 42Total reasons given 62

GSTT: audit of 42 L&S diabetic patients seen by podiatry in January

2012

• KCH diabetic foot clinic: Patient level data for 2011/12 and being analysed for 2012/13

• GSTT podiatry: The caseload includes inpatients at GSTT, as well as outpatients at St. Thomas. Difficulty in coding patients.

• GSTT diabetic foot clinic: Patient level data obtained for 2011/12, analysis not yet reviewed by clinical lead.

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Conclusions from analysis – primary care risk stratification compared to activity along pathway

• Mismatch between perceived levels of demand determined by primary care risk assessments and actual activity levels in specialist community and secondary podiatry services in 2011/12 analysis

Risk level GP assessed risk Patient count by service

Low 17,033 (81.48%)

Moderate 3,118 (14.92%)5,432 community podiatry unique patients

High 616 (2.95%)

Active 136 (0.65%) 577 KCH diabetic foot clinic + 1013 GSTT (estimated)

Total 20,903 (100%)

Not clear why discrepancy exists. Possibilities include:• Inaccurate / inappropriate risk stratification in 1°care• Breakdown in communication re: patient information and activity across pathway • Lack of confidence in managing low, moderate, high risk in community and 1°care

settings• Elements of clinical podiatry service are not provided in 1°care, i.e. nail cutting

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Proposed deliverables and activities

1. Identify cohort of patients from secondary care who could be managed in other appropriate settings, such as community podiatry services

• Determine guidance / criteria for patients to be discharged • Understand pathway required• Seek appropriate approvals• Understand capacity of community podiatry

2. Embed foot health improvements in primary care initiatives of the DMI

• Use DMI primary care initiatives• Target practices who are performing fewer

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Proposed deliverables and activities II

3. Improve communication for providers and for patients with diabetes who require foot care through tools, guidance and decision aids

• Further development of existing templates• Revisit methods to collect and share diabetes and foot health

patient information

4. Determine an appropriate “shared care” arrangements (secondary & community care)

• Agreement about what care means in each setting• Ensure clarity of pathway across providers

5. Promote and embed foot health pathway alongside development / distribution of legacy phase outputs

• Promote / develop methods to improve patient experience • Make available outputs from DMI work in accessible/known location

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Activities that are out-of-scope

1. Tertiary or super-specialist services• Likely to be in scope of the Changing Diabetes @KHP

programme• Work already underway at KHP to reconfigure integrated

vascular services

2. Improvement plans for Community Podiatry services• Initiatives in place to reduce wait-times, improve processes

around home visits and reduce variation between service provision in S & L

• Currently reviewing capacity, and will align with DMI work

3. Addressing nail care services in S & L • Community podiatry to begin initiative to understand the

capability of services provided by AgeUK (i.e. training required)• Will provide insight regarding the appropriate setting for those

who have diabetes and cannot manage their nail care

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Approach and Timescales

Stage Task J A S O N D J F Engage team

Engage stakeholders in foot health care pathway

Engage

Baseline and analyse current foot care data across pathway

Design, update and develop foot care pathway outputs to support patients and providers

Identify process adjustments ( esp. in community and secondary care) required, incl. measures to evaluate improvement

Design + Develop

Develop strategy to disseminate and promote deliverables

Seek appropriate approvals of new outputs developed

Promote existing and new tools, guidance, and criteria to providers and patients

Implement new protocol and shared care agreements

Implement + Promote

Ensure deliverables are available in accessible location for all providers

Develop plan to evaluate impact on services once implemented

Implement processes to collect relevant diabetes and foot health information

Evaluate

Begin collecting data regular basis to evaluate impact of improvements

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Measures of Success

How to Measure:• Review QoF data • EMIS reports from CCGs • DMI improvement plans / reward scheme outcomes• Activity data from secondary and community podiatry• Assess primary care providers knowledge of pathway (i.e. survey at learning

event)• Audit of reason for referral from primary care to community podiatry and secondary

care• Review patient experience survey results from specialist services• Number of shared learning touchpoints and meetings between community podiatry

and secondary care

Reduced variation in foot assessments

across primary care

Greater number of risk assessments recorded accurately & appears

closer to activity

Increased understanding of

pathway and when to refer to specialist

Patients seen in most appropriate care setting

(i.e. shift of activity experienced)

Improved patient experience of specialist

podiatry services

Community podiatry manages cohorts of patients previously

managed in secondary

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Constraints & Risks

1. Unable to fully understand patient activity and case mix within GSTT podiatry services and GSTT diabetic foot clinic

2. Community podiatry does not have the capacity to manage more patients from secondary care

3. Secondary care specialists hesitant to transfer patients or unsure of capability of community services

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What we need from the board:

• NOTE the objectives, route to success, time constraints and critical timescales

• SUPPORT the proposal, and;

• ACKNOWLEDGE & ADVISE on constraints and risks

improving foot health proposal dmi programme board 19 th july 2013 dr carol gayle and monique...

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