Fylde Coast Integrated Diabetes Care Diabetes Care Pathway Dr . Cruz Augustine

1. Fylde Coast Integrated Diabetes Care Diabetes Care Pathway Dr. Cruz Augustine

2. Where we are Now! • Huge variations across NHS • Services and outcomes • Socio-economic differences • High Mortality in diabetics • 75,000.00 deaths with diabetes 1 • 1/3 can be prevented 1 • Cost to society and NHS • 2.9 million UK population has diabetes • Total expenditure on diabetes could be up to 10% of total NHS expenditure 2 • Diabetes UK. Disease Prevalence, 2011 • Commission for Healthcare Audit and Inspection, 2007

3. VISION: Bridging the secondary care and the Community

4. Fylde Coast Diabetes Care Pathway

5. THE VISION: The Strategic Priorities! CCG and Providers vision for integrated, unified services balancing quality and cost-effectiveness Current variations in service provision NSF principles of patient empowerment and self management

6. THE VISION“INTEGRATED DIABETES CARE” Patient centred not organisation centred Care should be delivered • at the appropriate time, • in the appropriate place, • by the appropriately trained professional, • for that patient’s present needs

7. Objectives - Integrated Fylde Coast Diabetes Care fully integrated service avoid any gaps or duplication in service smooth and quick referral from primary care for advice and management plan increased specialist input into primary care settings consistent high quality patient centred care

8. To improve the quality of diabetic care provided by GP practices • To improve capacity for diabetic services • Manage more complex patients in the community • To reduced unplanned diabetic admissions to secondary care

9. Pathway and Guidelines • To encourage care to be offered at the most appropriate site by the most appropriate method administered by the most appropriate clinical professional(s) • For care to be as near to the patient’s home and usual environment as possible • To encourage patient involvement in their own care • To foster professional development and training about diabetes

10. PHILOSOPHY OF CARE • All of the documents done by multidisciplinary input from community and secondary care • Seamless service where patients with diabetes will be at the forefront of planning • Service will ensure equity of care for everyone with diabetes, including the housebound, those in care homes, the mentally ill, and patients with learning disabilities

11. Hidden Health Care System 3 2 Professional Care 20% 1 Self-Care 80%

12. Generalist Primary CareMAXIMUM ORAL TOLERATED THERAPY AS REQUIRED • Prevention/targeted Screening of at risk groups • Follow up IGTT patients • Diagnosis, assessment, treatment & monitoring • Patient education and provide Continual education for patients & practice staff • Provision of patient held care plan which includes the management of co-morbidities • Screening for complications – including foot, retinopathy, medication • Lifestyle management – including referral to exercise referral programmes, structured • Referral onto Tier 2 only when all primary care interventions exhausted • Referral of T1DM for expert assessment and intervention either enhance primary care service or specialist service if symptomatic • All of the above services to be provided via appropriately qualified staff • homes or housebound. • Maintenance of Diabetes register through coding as either T1DM or T2DM and ethnicity • Patient Education

13. Management and review of *stable Adult T1DM Poorly controlled T2DM on insulin Initiation of insulin or GLP 1’s Ongoing Patient Education, and Enhanced Staff Education Continued care planning and promotion of self management Appropriate care, as applicable to the enhanced primary care service, of those patients in nursing and residential homes or housebound Management of those with poor healing/recurrent infections and raised HbA1c Provide research and audit as required Structured Education Enhanced Primary Care

14. Acute site- • Acute admissions Emergency insulin initiation HSS and DKA Immediate Post MI Problematic management Referral from retinopathy screening service specialist service Review of diabetic inpatients Paediatrics Specialist Care Inpatient care or specialist clinics not available in enhanced specialist services • Consultant led Clinics • Pre conception clinic • Young Persons clinic • Foot clinic • Pregnancy • Difficulties in initiation for type 1&2 • insulin Pump therapy • Telephone advice and support for professionals and patients • Complex patients • Management of complex Medical Problems: • Neuropathy • Vascular & Pain • Retinopathy • Cardiology • Nephropathy • Endocrine • Mental health • Structured education 14

15. Achieving Integrated Care Source: Rosen et al (2011)

16. Barriers Ownership Organisational & Professional boundaries Changing environment Lack of understanding each other’s perspective IT & Clinical records Governance

17. ACTION: What we Need to Do next ! SERVICE DECISIONS Let Patients & GPs decide on services to choose SMART NOT JUST HARD We must work smarter as local demand speeds up. PATIENT EDUCATION AND ACCOUNTABILITY We need to assist people to manage their own illnesses FOCUS ON PREDICT and PREVENT We must move towards “predict and prevent”