the model of care
TRANSCRIPT
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?