integrated community diabetes service (icds) nhs bedfordshire

Integrated Community Diabetes Service (ICDS)

NHS Bedfordshire

http://www.ldh.nhs.uk/default.htm

http://www.bedfordhospital.nhs.uk/

Diabetes in Bedfordshire

• Prevalence is increasing: more with diabetes

• Diagnosed younger: more years of diabetes

• Increased duration: more chance of complications

• More human and economic cost

2010 2015 2020 2025 2030 -

10,000

20,000

30,000

40,000

50,000

60,000

APHO Diabetes Prevalence Predictions for NHS Bedfordshire

Lower limit Predicted Upper limit

Local Issues

• Inequity of services• Variable communication between primary and

secondary care and other support services• No access to specialist care in localities• Low expenditure/ poor outcomes • Duplication of care

Diabetes Outcome vs Expenditure

Our Vision

• Core Primary Care & Self Care

• Integrated Community Care

• Specialist Care

Integrated Community

Diabetes Team

• Specialist Nurses

•Specialist Dietitians

• Social Support•Voluntary Sector

Primary Care• GP• Practice Nurse• Community

Matron• District Nurse• Community based health professionals

Specialist Care

•Diabetes Consultants

•Obstetricians•Other specialist consultants

Integrating care across boundaries

Key features of the ICDS

• Specialist, close support for diabetes management in general practice - building confidence and competence in the practice

• Multi-disciplinary assessment and treatment planning of newly referred GP patients offered at local clinics

• Hard to reach groups• Specialist guidance, support and training for

community healthcare professionals, including staff at residential homes / hospices

Integrated Community Diabetes Team:

• Day to day leadership by Nurse consultant / Senior Diabetes Specialist Nurse

• Locality based Diabetes Specialist Nurses – each GP practice will have an allocated DSN

• Diabetes Specialist Dietitians • Clinical supervision by Consultant

Diabetologist

The DSN Structure is key to integrated services

• Communication with hospital based team means concerns and progress can be passed on

• Discharge planning• Access to Diabetologist• Shared data base• Avoiding duplication

Proposed initial distribution of ICDS workforce*DSN 4

Ivel Valley

Arlsey Med CentreLarksfield ArlseyIvel Med CentreShefford Health CentreKings St SandySandy Health CentreGamlingay SurgeryPotton SurgeryBiggleswade Hth CentreLower StondonShortstown

Total number of patients with diabetes = 3624

DSN 5

South Beds

Wheatfield DunstableWest Street DunstablePriory Gdns DunstableEast gate DunstableKingsbury DunstableKirkby Rd DunstableChiltern HillsHoughton RegisCaddington SurgeryToddington Med Centre


Diabetes Specialist Dietitians

Diabetes Nurse ConsultantClinical Lead

Clinical supervision from Consultant Diabetologist

Diabetes Specialist Dietitians

Senior DSN Clinical Lead

Clinical supervision from Consultant Diabetologist

DSN 6

South Beds

Leighton Buzzard• Linslade

Surgery• Bassett Road• Salisbury

House• Lake StreetBarton-Le-Clay


DSN 3Bedford

Putnoe Health CentreGoldington avenue2 Goldington RoadRothsay SurgeryDepary’s AvenueLinden RoadPemberly AvenueGreat Barford SurgeryLondon RoadCranfield


DSN 2Kempston / Ampthill / FlitwickSt Johns KempstonKings Street KempstonCater Street KempstonGreat DenhamWootton ValeTemplars Way SharnbrookMedical Cen HarroldHighlands FlitwickHoughton Cl AmpthillOliver St AmpthillGreensands AmpthillWoburn Sands


DSN 1

Central Bedford

Ashburnham Road Victoria RoadClapham RoadQueens park Lansdowne RoadPriory M C ClaphamShakespeare Road12 Goldington Road


*reflecting current local demand – this will need to shift in response to any local changes over time

Which diabetic patients will the ICDS help you manage?

• Poorly controlled diabetes in otherwise stable patients

• Chronic: Raised HbA1c not achieving personal target

• Deteriorating but not requiring urgent intervention

• Complex conditions/ situations e.g. housebound or living in residential care

• Complex care, requiring “step down” from acute setting

• Hard to engage groups/ patients

• Pre-conception

Example of service impact• Early dissemination of evidence based practice• Community Initiation / support – Injectable therapies• Locally developed Patient education programmes• Care home support• Working with District Nursing Service (148)• Work with the Retinal Screening service to target and support

those with referable eye disease• Work with emergency services and out of hours services• Safer use of insulin awareness• Blood Glucose monitoring

– Standardisation / Training – Internal and external QA

Education and Training

• MDT Interest Forum • Formal and informal training for Primary care

staff– Mentorship for new staff

• Informal and formal training for care home staff

• Development of local education and support programme for patient with Type 2 diabetes

What the service won’t do:

• “Take over” the management of GP patients with diabetes – clinical responsibility remains with the GP

• Carry a large ongoing caseload

Referral Process

• Choose and book• Letter• Central Booking• Triage • Appointment allocated in the usual time

frame

Moving clinics into the community

• Enhanced Treatment Centre (Horizon)• Houghton Close Ampthill (West Mid Beds)• Wootton Vale Healthy Living Centre (Horizon)• Biggleswade Hospital (Ivel Valley)• Shefford Health Centre (Ivel Valley)• Dunstable• Leighton Buzzard• Houghton Regis

Leadership and Governance• Delivered by a dedicated and highly motivated team under robust

leadership. Close collaboration with commissioners and GP consortia ensuring we meet the needs of primary care colleagues.

• Clear clinical governance arrangements to ensure the service adapts and evolves in response to an active audit programme.

• Actively seek feedback to respond to the needs of the patient and

their carers. • Our aim is not simply to deliver secondary care in the community

setting but to redesign services innovatively and improve patient experiences and outcome.

How to contact ICDSNorth and Central Beds

• Service hours 8.30 to 17.00• General Enquires 01234

792013 (not yet active)• Urgent Advice TBA• Email

[email protected]• Paper referral by fax TBA• Paper referral by post ICDS,

The Diabetes Centre, Bedford Hospital NHS Trust, Kempston Rd, Bedford. MK42 9DJ

South Beds• Service hours 8.30 to 17.00• General Enquires 01582 TBA

• Urgent Advice TBA• Email TBA• Paper referral by fax TBA• Paper referral by post ICDS,

The Diabetes Centre, Luton and Dunstable Hospital, Lewsey Rd, Luton

Next StepsPending contract signing:• Multidisciplinary assessment clinics for new

patients will move out to community locations in a phased way from January 2012

• Recruitment process for new staff in process• Locality based support will come on stream

once new staff are in place - ? Early 2012

Referral process won’t change until new staff in place – please continue your current arrangements for now!

For further information• Central and North Bedfordshire

– Nick Morrish, Consultant Diabetologist• [email protected]

– Julia Pledger, Nurse Consultant• [email protected]

• South Bedfordshire– Dr. Shiu-Ching Soo, Consultant Endocrinologist

• [email protected]

• For diabetes resources and guidelines, log on to www.bedfordshirediabetes.org.uk

mailto:[email protected]



http://www.bedfordshirediabetes.org.uk/

Additional slides

Pathway diagrams and initial workforce distribution

Type 1 Diabetes Care pathway – diagnosis and initial management

Key to colour coding:

Unwell Unwell

If weight loss, ketones and symptoms, treat as Type 1 and admit

If weight loss, ketones and symptoms, treat as Type 1 and admit

If not unwell, no ketones and mild symptoms only

If not unwell, no ketones and mild symptoms only

If not unwell, has no ketonuria but is symptomatic

If not unwell, has no ketonuria but is symptomatic

If not unwell but has positive ketonuria

If not unwell but has positive ketonuria

Monday to Friday 9-5, refer to Acute Diabetes Specialist Care, otherwise admit

Monday to Friday 9-5, refer to Acute Diabetes Specialist Care, otherwise admit

Refer to Acute Diabetes Team next working day

Refer to Acute Diabetes Team next working day

Acute Specialist Care:• Baseline

investigations• Initial treatment plan• Initial advice and

introduction to education programme

• Telephone advice line• Plan for ongoing care

Acute Specialist Care:• Baseline

investigations• Initial treatment plan• Initial advice and

introduction to education programme

• Telephone advice line• Plan for ongoing care

Go to T1 continuing care pathway

Go to T1 continuing care pathway

Questions:• Severity of

symptoms• Any weight

loss• Age • Ethnicity• Build• Presence of

ketones

Acute presentation via A&E


In patientIn patient

Diagnosis from Specialist care

Diagnosis from Specialist care

Go to T2 Diagnosis and continuing care pathway

Go to T2 Diagnosis and continuing care pathway

Depending on diagnosis

Acute hospital-based service


Primary / community based service


Not unwell Not unwell

Suspected newly diagnosed Type 1 in primary care setting

Suspected newly diagnosed Type 1 in primary care setting

Refer to Integrated Community Diabetes

Service for clarification and diagnosis

Refer to Integrated Community Diabetes

Service for clarification and diagnosis

Type 1 Diabetes Care pathway – continuing care

Joint working between specialist ICDS staff and primary care staff*Joint working between specialist ICDS staff and primary care staff*

From Type 1 diagnosis pathway

From Type 1 diagnosis pathway Acute Specialist CareAcute Specialist Care Integrated Community

Diabetes Service

Integrated Community Diabetes Service

Clinical Review by GP Clinical Review by GP

• In patient management• Complication• Eyes/feet/feet/vascular• Insulin pumps• Pregnancy

management• Specialist Dietetics• Transition from

paediatric to adult service

• Annual review for those under specialist care

• In patient management• Complication• Eyes/feet/feet/vascular• Insulin pumps• Pregnancy

management• Specialist Dietetics• Transition from


• Annual review for those under specialist care

• Stabilise glycaemic control• Intensify insulin regimes • Care planning• Support for self care• Managing illness / alcohol• Pre / post pregnancy

counselling• Support and re-engage

with those lost to follow up• Telephone advice line

• Stabilise glycaemic control• Intensify insulin regimes • Care planning• Support for self care• Managing illness / alcohol• Pre / post pregnancy

counselling• Support and re-engage

with those lost to follow up• Telephone advice line

DAFNE / LIFEDAFNE / LIFE Annual Retinal ScreenAnnual Retinal Screen

• Stable well controlled• Glycaemic control• Vascular risk• Renal assessment• Foot review• Medication review• Care planning• Lifestyle modification,

including weight management, smoking cessation, exercise

• Stable well controlled• Glycaemic control• Vascular risk• Renal assessment• Foot review• Medication review• Care planning• Lifestyle modification,

including weight management, smoking cessation, exercise






ICDS enables ongoing management by primary care staff, who may over time take on more of the specialised tasks

ICDS enables ongoing management by primary care staff, who may over time take on more of the specialised tasks

*overall clinical responsibility remains with GP

*Direct referral when needed


Type 2 Diabetes care pathway – diagnosis and initial management

Suspected Diabetes / from case finding pathway

Suspected Diabetes / from case finding pathway

• Add to At Risk Register

• Annual assessment• Diabetes Prevention:

Lifestyle advice Weight loss

programme

• Add to At Risk Register

• Annual assessment• Diabetes Prevention:

Lifestyle advice Weight loss

programme

Appointment at GP practice for diagnostic test

Appointment at GP practice for diagnostic test

Discussion and lifestyle advice, consider annual screening

Discussion and lifestyle advice, consider annual screening



In patientIn patientDiagnosis from specialist care

Diagnosis from specialist care

• Initial exam. + baseline investigations

• Initial management plan agreed with patient

• Initial exam. + baseline investigations

• Initial management plan agreed with patient

• Specialist Care for complex cases

• Initial management plan & advice

• Specialist Care for complex cases

• Initial management plan & advice



DESMONDDESMOND

Healthy Lifestyles, weight programmes etc.• Dietetic assessment

Healthy Lifestyles, weight programmes etc.• Dietetic assessment

• Community Matrons• Social services

• Community Matrons• Social services

Appointment at GP Practice for ongoing management

Appointment at GP Practice for ongoing management

OGTT / FBG / RBG

Go to T2 Continuous care pathway

Go to T2 Continuous care pathway

• Initial advice• Dietary

information• Diabetes UK• Personal Health

plan• Register for

Retinal Screening

• Initial advice• Dietary

information• Diabetes UK• Personal Health

plan• Register for

Retinal Screening

Negative

IGTT / IFG

Diagnosis confirmed


Acute hospital-based service Primary / community

based service


Abbreviations:IGTT – Impaired Glucose Tolerance TestIFG – Impaired Fasting GlucoseOGTT – Oral Glucose Tolerance TestFBG – Fasting Blood GlucoseRBG – Random Blood Glucose

Joint working between specialist ICDS staff and primary / community care*Joint working between specialist ICDS staff and primary / community care*

Type 2 Diabetes care pathway – continuing care


From T2 Diagnosis pathway

From T2 Diagnosis pathway

Clinical Review by GP

(Minimum annually)

Clinical Review by GP

(Minimum annually)



Acute Specialist Care

Acute Specialist Care

Interim review with Practice Nurse (if needed)

Interim review with Practice Nurse (if needed) • Glycaemic control

problem solving

· Intensify treatment

regimes for high risk

patients

· Initiation of injectable

therapies

· Develop treatment plans

· Support for self care

· Pre / post pregnancy

counselling

· Telephone advice line

• Glycaemic control

problem solving

· Intensify treatment

regimes for high risk

patients

· Initiation of injectable

therapies

· Develop treatment plans

· Support for self care

· Pre / post pregnancy

counselling


· Glycaemic control· Vascular risk· Renal assessment· Foot review· Medication review· Care planning· Lifestyle modification· Including weight

management, stop smoking, exercise

· Glycaemic control· Vascular risk· Renal assessment· Foot review· Medication review· Care planning· Lifestyle modification· Including weight

management, stop smoking, exercise

· Complex Glycaemic management

· Management of complex co –morbidities

- Feet- Eyes- Vascular- Renal· Pregnancy

care· In patient

care· Transition



· Complex Glycaemic management

· Management of complex co –morbidities

- Feet- Eyes- Vascular- Renal· Pregnancy

care· In patient

care· Transition



Annual Retinal ScreeningAnnual Retinal Screening

· Education - DESMOND· Exercise / weight loss

programmes· Dietetic Review

· Education - DESMOND· Exercise / weight loss

programmes· Dietetic Review





Links with other services including: · Social Care

Residential Care· Voluntary

groups (e.g. hard-to-reach patients)

Links with other services including: · Social Care

Residential Care· Voluntary

groups (e.g. hard-to-reach patients)

Acute Podiatry Services

Acute Podiatry Services

Direct referral when needed

*Overall clinical responsibility remains with GP

ICDS enables ongoing management by primary care staff, who may over time, take on more of the specialised tasks

Community Matron Services

Community Matron Services

Community Podiatry Services

Community Podiatry Services

Thank you

Please ask Questions

integrated community diabetes service (icds) nhs bedfordshire

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