Western Area Diabetes Multi-disciplinary group - membership

Transcription

1 ICP West Diabetes

2 Diabetes Group Established June 2013 Chaired by Dr Neil Black, Consultant Diabetologist and Diabetes Clinical Lead in Western Trust. To look at the Diabetes service in the context of Transforming Your Care ( TYC) and to make it more community facing, streamlined and cost effective, maximising the involvement of the Community and Voluntary sector in supporting patients and carers at home.

3 Western Area Diabetes Multi-disciplinary group - membership Dr Neil Black Dr Ahmed Helmy Dr Nicola Duffy Dr John O Donnell Dr Paul Bradley Dr Geraldine McGovern Liz Williams Lisa King Patrick McGill Deirdre McCay Lesley Hamilton Martrese Curran Brendan Heaney Barry Keenan Liam Bradley Consultant Physician, Diabetes and Endocrine. Clinical Lead for Diabetes Consultant Physician, Diabetes and Endocrine, SWAH. GP - Oakleaf Medical Practice, Derry GP - Park Medical, Derry GP - Three Spires Surgery, Omagh GP - Lakeside Medical Practice, Enniskillen Community Diabetes Specialist Nurse Diabetes Specialist Nurse Diabetes Specialist Podiatrist Team Lead Diabetes Dieticians Diabetes Network Manager Practice Nurse Diabetes UK Hospital Pharmacist Community Pharmacist Northern Ireland Ambulance Service Liz Gallagher Deborah Clifford Dearbhlea Lynch Admin Support TYC and ICP Patient Representative

4 The Diabetes group made proposals in relation to four key areas: 1. Practice Support 2. Avoidance of Duplication of service 3. Specialist Diabetes Team 4. Education programmes

5 1. Practice Support Practice Visits Virtual Clinic Website Maintenance of pathways Central referral point development (with NIAS, incorporate NIECR /CCG)

6 2. Avoidance of Duplication of service Diabetes Care Types Review of registers in Hospitals and Practices. Assignment of Patients to; 1. GP Care 2. Diabetes Support Team & GP care 3. Hospital based Care

7 3. Specialist Diabetes Team Establishment of Multi-disciplinary Specialist clinics Establishment of Community based Urgent Access Clinics on seven sites

8 4. Education programmes Patient Education Type 1 - CHOICE Programme Type 2 DESMOND Programme At High Risk of Type 2 DESMOND module Walking away from Diabetes to be developed Staff Education GP, Practice nurse and Community Pharmacist education

9 Diabetes Pathway

10 Diabetes Care Pathway Integrated Care Partnership West GP Assessment Access to Diabetes Opinion for Advice Virtual Clinic Review on target WHSCT Diabetes Website Review out of target Newly diagnosed Diabetes Support Team +/ - other Specialists e.g. CVS, renal, vascular, palliative care, tissue viability Admission to Hospital Education / Self Management Family Support Smoking Cessation Nursing/Residential Homes Psychology Support Groups Dietitian Podiatry Exercise Programmes Hospital and Community Pharmacy Maintenance of stability includes community/ voluntary and other statutory sector organisations

11 General Practice

12 GP Assessment QOF - Diabetes ± Advice from Consultant WHSCT Diabetes Website Guidelines re pathways Medicines management

13 QOF - Diabetes Records DM001. The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed Ongoing management DM002NI. The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 mmhg or less DM003NI. The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 15months) is 140/80 mmhg or less DM004NI. The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 15 months) is 5 mmol/l or less DM005NI. The percentage of patients with diabetes, on the register, who have a record of an albumin: creatinine ratio test in the preceding 15 months

14 QOF Diabetes Ongoing management cont d DM006NI. The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs) DM007NI. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 15 months DM008NI. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 15 months DM009NI. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 15 months DM010NI. The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 September to 31 March DM011NI. The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 15 months

15 QOF Diabetes Ongoing management cont d DM012NI. The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months DM013NI. The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 15 months DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register DM015NI. The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 15 months DM016NI. The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 15 months

16 Maintenance of stability at home

17 Access to Diabetes Opinion for Advice / Virtual Clinic The establishment of option for Diabetes Opinion will facilitate shift left and allow for routine/non urgent queries to be addressed within 48 hours. A centralised referral point for queries and referrals would allow triage of referral and appropriate treatment as soon as possible. Clinic appointments, if required, can be arranged with appropriate members of the Multi disciplinary team. NB : Urgent referrals, as per pathways, are not suitable for query

18 Diabetes not controlled / problem cannot be resolved by primary healthcare professional For advice: WHSCT Diabetes website +/or [email protected] Need response within 24h No Yes Immediate advice for admission avoidance Call Diabetes Centre direct Monday-Friday h Please discuss all potential referral with DST first via CCG referral for advice to agree appropriate steps. Any inappropriate referrals will be redirected to the appropriate part of the service or returned with advice Only refer to the Diabetes Centre for the following specialist clinics: 1. Pregnancy and Preconception Care 2. Acute Type 1 diabetes 3, Structured education for Type 1 diabetes 4, Patients appropriate for or using insulin pump therapy. 5. Adolescent diabetes (northern sector >14y, southern sector >16y, ie not paediatric) 6. CKD 3b or lower (egfr <45ml/min Refer to Diabetes Foot MDT if: 1. Non-healing foot ulcer 2. Acute, hot swollen neuropathic foot 3. Sudden change to foot shape (see separate foot pathway) Diabetes Centres within Western Area Integrated Diabetes Service Londonderry Sevenoaks Centre - Altnagelvin Hospital Tyrone County Hospital Omagh Southwest Acute Hospital Eniiskillen h urgent / routine advice Phone: Diabetes Centre (DSN) - Monday-Friday h [email protected] - use practice only - Subject box: specify Consultant or DSN - state own name and contact details - patient HCN and initials only please - state nature of problem We will respond within 2 working days and provide appropriate advice Your consultant diabetologists are: Neil Black. Athinyaa Thiraviaraj, Ahmed Helmy Your GPwSI is... Diabetes Support Team (DST) Western Area Integrated Diabetes Service

19 Type 2 Diabetes Review- stable On Target- individualised targets if appropriate HbA1c BP Lipids Renal Function Screening: Feet Eyes Mood Diet Health promotion: Smoking Alcohol Activity Diet/ weight control Medications : Compliance issues Polypharmacy Ongoing support: Symptoms: Review plans: Local support Groups/ Diabetes Updates/ Information sessions Awareness of symptoms (NB : if on SU- hypo awareness) 6-12 month review Refer to Western Area Integrated Diabetes Website for information on health promotion topics, group updates and contact details.

20 Refer to Secondary Care Altnagelvin: SWAH: Admissions pathway Yes Reasons for referral to secondary care at diagnosis: 1. Unwell 2. Hyperglycaemia 20mmol/L +/or HbA1c 3. Ketonuria >2+ / Ketonaemia 2.0mmol/L 4. Involuntary weight loss 3.5kg over less than 3mth See Western Area Therapeutic guidance Refer to Digital Retinal Screening Programme New Diagnosis of Diabetes ARE THERE REASONS FOR URGENT REFERRAL TO SPECIALIST TEAM +/OR FOR ADMISSION? No Refer to Diabetes Support Team Inform patient of planned multidisciplinary assessment, Education programme & follow-up arrangements 4 monthly review of diabetes control, risk factors, guardian medication & screening Diagnostic Criteria: HbA1c 48mmol/mol Random plasma glucose 11.1mmol/L Fasting plasma glucose 7.0mmol/L OGTT 2h post 75g anhydrous glucose 11.1mmol/L Single value suffices if clear glycaemic symptoms Repeat same measure different day if asymptomatic Do not rely on glucose values if acute inflammatory event Do not rely on HbA1c if pregnant/postpartum/ suspect type 1 diabetes Glycaemic Symptoms: Urinary frequency, polyuria, nocturia Involuntary weight loss (>3.5kg with ketonuria suggest need for insulin) Baseline tests: HbA1c Lipids (non-fasting) EP, Liver profile (if abnormal also check iron profile) Urine ACR Podiatry Dietitian Exercise Programme DESMOND Smoking Cessation Yes Controlled? Diabetes Support Team 6-12 monthly review of diabetes control, risk factors, guardian medication & screening. See Pathway On Target. No See Western Area therapeutic guidance If not controlled then see pathway Diabetes not controlled /problem cannot be resolved by primary healthcare professional [email protected] Telephone - Diabetes Support Teams: Londonderry - Sevenoaks: Tyrone & Fermanagh - Oakhill:

21 WHSCT Diabetes Website Information on contact details and team members Medicines management Resources Diabetes pathways Hypo advice Admission criteria and urgent referrals SMBG Guidelines Details of hospital clinics- types of clinics Clinic locations Education programmes for patients Education programmes for staff

22 Diabetes Support Teams Multi Disciplinary Team- Diabetologists, Diabetes Specialist Nurses, Diabetes specialist Dietitians, Diabetes Specialist Podiatrists, Diabetes Psychologists, Exercise professionals, Diabetes Pharmacists and clerical support Specialist team approach- acute and community support Range of clinics and locations Centralised referral- triaged to appropriate support. Northern and southern support team- equity of service

23 Education/Self Management Establishment of practice visits by members of specialist Diabetes team to focus on appropriate diabetes care types for individual patients. Patients assigned to either GP care, Specialist team +GP, or Hospital based care Ongoing education for GPs and Practice Nurses. Ongoing education for people with diabetes and updates for Patients and carers. -DESMOND - Type 2 Education -CHOICE - Type 1 -Pre- Diabetes -Diabetes Update (annual review / stable)

24 Smoking cessation Strong existing team in WHSCT working with PHA QOF - Smoking (SMOK)

25 QOF - Smoking (SMOK) Records SMOK001NI. The percentage of patients aged 15 or over whose notes record smoking status in the preceding 27 months SMOK002NI. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 15 months. NICE 2011 menu ID: NM38 Ongoing management SMOK003. The contractor supports patients who smoke in stopping smoking by a strategy which includes providing literature and offering appropriate therapy SMOK004NI. The percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months. NICE 2011 menu ID: NM40 SMOK005NI. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 15months. NICE 2011 menu ID: NM39

26 Support Groups Diabetes UK Local DM UK support groups Peer Support options Long term conditions programmes Paediatric Diabetes Support Groups

27 Dietitian Diabetes dietitians- Diabetes Support Team, Altnagelvin Hospital and South West Acute Hospital Locality of clinics Referral criteria- regional work. Diabetes Education programmes Diabetes update sessions Dietary review questions Benefits of MDT review- joint reviews with DSN and /or Podiatry

28 Podiatry Diabetes podiatrists- Diabetes support Team Clinic locations High risk foot clinics local access Diabetic foot pathway Foot Risk status- resources Urgent referral criteria Routine podiatry availability Benefits of MDT review

29 Exercise Programmes Local programmes Diabetes Exercise Professional- Northern sector only Fermanagh Active Living Programme Creggan Healthy Living Centre

30 Psychology Contact details: Psychology department, Agnes Jones House, Altnagelvin Hospital and Camowen Bungalow, Tyrone County Hospital Location details for clinics/ sessions Group work Living with diabetes Self management programmes

31 Nursing / residential homes Availability of Diabetes Updates for staff Ongoing support for queries and insulin adjustments Planned training programme for nursing and healthcare staff

32 Hospital and Community Pharmacy Medicines Optimisation Programme for patients/ family carers-delivered by integrating Hospital and Community Pharmacy teams. Role in practice visits reviews Polypharmacy patients Community pharmacist awareness of service Referrals from DM team for inpatients as required.

33 Ref Description Current position Currently funded Funding Source DA1 QOF - Diabetes live 2013/14 Y QOF DA2 Advice from consultant virtual clinic Live & Planned P IPT 14/15 DA3 WHSCT Diabetes Website Live and Planned y Core DB1 Education sessions for GP / Practice Nurses / to include diabetes ketoacidosis awareness Live and Planned P Core / ICP IPT 14/15 DB2 Practice visits Planned Y ICP IPT 14/15 DB3 Pre diabetes education Planned Y ICP IPT 14/15 DB4 Insulin Pump Therapy proposals for service to be confirmed. P Core/regional project DB5 Smoking Cessation live 2014 Y Core DB6 Support Groups live 2013 Y Core

34 Ref Description Current position Currently funded Funding Source DB7 Podiatry / Diabetes Foot Pathway (Surgical project) Live & planned Y Core / ICP IPT 13/14 DB8 Psychology/ Exercise / Dietetics live y Current core Trust funding DC1 Diabetes Team / Shared Care live y Current core Trust funding DD1 Pharmacy Live & proposed P Current core Trust funding /ICP IPT 14/15

35 Activity Information Diabetes Hospital Information Diabetes QOF Information Total Outpatient Referrals (New) Diamond Practice Reports Unscheduled Diabetes Admissions Bed Capacity User survey GP Practices Total Outpatient Waiting List Number of MDT clinics % of referrals to high risk clinics % of patients assigned diabetes care type Attendances at education sessions (GP, Practice Nurses) Patient experience- questionnaire Attendance at Pre diabetes education Programmes and number of programmes delivered. % of patients managed by GP