Integrated Diabetes Care Diabetes in Community Care Extension
Integrated Diabetes Care Diabetes in Community Care Extension (Di. CE): Sandwell & West Birmingham model Dr Parijat De Clinical Lead in Diabetes & Endocrinology Nicola Taylor Diabetes Nurse manager City Hospital, SWBHT, Birmingham
The Challenges: l Since 1996, the number of people living with diabetes has more than doubled l 2. 7 million people – or 6% of the adult population – have been diagnosed with diabetes l Prevalence of diabetes is double the national average in Sandwell & West Birmingham area l Eighty per cent of NHS spending on diabetes goes on managing complications, most of which could be prevented
Integrated diabetes care (IDC) l “approach seeking to improve QOC of the individual with diabetes, service users and carers by ensuring that services are well co-ordinated around their needs” Kings Fund & Nuffield Trust 2011
5 pillars of Integrated Diabetes Care l l l 1) Clinical engagement & partnership 2) Care planning – joined-up care & engaged patients 3) Integrated IT systems 4) Aligned finances and responsibility 5) Shared clinical governance
The original Pathfinder project: l The Pathfinder Diabetes Project (initiated 15 years ago) started off with 2 practices in West Birmingham initially (expanded to seven GP practices in 2010) to address some of these unmet needs. l In this model, GP practices would identify cohorts of difficult diabetes patients with poor Hb. A 1 c control for generally a one-off for advice and management plan by the consultant/diabetes specialist nurse every 3 -4 months. The primary care team then take this plan forward and put it into action.
Diabetes in Community Extension (Di. CE) Team formation: l Since April 2014, the Di. CE model has been accepted and agreed by the local CCG - all SWBCCG GP and Primary care clinicians will have access to clinical support from diabetes specialist teams where necessary. l Seamless care between primary and secondary care teams working in unison to provide the desired integrated care.
Objectives of Di. CE model: l Close working with every GP practice – integration of specialist and generalist across boundaries l Joint clinics and review – devolve care, provide care close to home, reduce DNA rates l Provide support & education to GP/PN – help build capacity & capability in primary care l Support patient education programmes and empower patients to self manage – DAFNE, XPERT education courses
Objectives of Di. CE model: l Provide evidence based care according to NICE and local pathways l Develop protocols and pathways jointly - which patients, seen where and by whom (including specialist care in Hospital) - empower GP/PN to manage locally & refer appropriately l Dissipate and encourage wider use of Advice & Guidance service l To improve formulary compliance and value for money prescribing
Integrated Care Model Up-skilling Primary care & delivering care closer to home Redesigned & Integrated Diabetes service Education & Training Programme Mentorship
Di. CE Teams l l 10 Two teams – Sandwell and West Birmingham Hospital and Birmingham Community Health Care Trust 4 hours every 8 weeks with each practice Assigned Diabetes specialist nurse and Consultant Options to suit individual practice to support diabetes patients – Virtual clinics – Joint consultations
Diabetes LIS (Local Improvement Scheme) l l l Increase Primary care expertise & management 90% type 2 and stable Type 1 diabetes care in community Aim to meet Diabetes UK 15 Care essentials LIS Sign-up (total number of CCG practices 99) – Level 1: 89 practices – Level 2: GLP 1 - 72 practices, Insulin – 68 practices Going forward the LIS will be part of the Primary Care Commissioning Framework (PCCF)
Diabetes Education in Sandwell & West Birmingham CCG 6 steps to excellence
Education! Learning Needs Assessment • Learning needs assessment dashboard for ALL Sandwell and West Birmingham CCG staff delivering Diabetes Care. Advanced Level Diabetes Education • PIT stop (programme for injectable therapy) train the trainer programme. Also previously commissioned PREDICT to deal with demand. Warwick course offered through BCHC Trust Mentorship programme • To support practice based learning for PIT stop and PREDICT courses. • Complete level 2 competency sign off
Education! Refresher sessions • Lunch and learn or half day sessions supported heavily by BCHC trust and CCG commissioned courses. Business to business tool • Working in partnership with external companies to identify practices requiring support in diabetes care. Clinical Engagement • Development and promotion of treatment pathways according to NICE and local guidelines in-conjunction with secondary care and local CCGs. • Area Prescribing Committee, Pan Birmingham Medicines Management advisory group, Pan Birmingham Diabetes Network.
Referral Pathways The following Map of Medicine pathways have been reviewed by the Diabetes Steering Group: l l l l l 15 Diabetes – complications Diabetes – Foot Care Diabetes - cardiovascular disease (CVD) Diabetes - eye disease Diabetes - renal disease Diabetes - suspected in adults Diabetes in pregnancy Diabetes - suspected in adults Type 2 Diabetes management Type 1 Diabetes Mellitus in children and adolescents
4 key activities within Di. CE: l l Case notes review Joint consultation Virtual clinic – advice & guidance/telephone review, Telemedicine (FLORENCE), SKYPE Education
Typical patients for joint consultation: l l l l multiple co-morbidity, repeated admissions with hypo/DKA/HHS, complex insulin regimes, mixed/multiple complications, difficult to control Hb. A 1 c difficult to manage BP/lipids social issues repeat defaulters
Joint Consultation l l l Baseline review of practice diabetes register/QOF figures Identify key needs of an individual practice Work backwards Prioritise difficult/complex patients – invite them for joint consultation with GP/Consultant Joint review benefits – familiarity with GP and expertise of Consultant/DSN Every 8 weeks, depending on need and f/u with DSN and advice via email/phone as needed
Examples of joint consultations
Use of new insulin? l l l l 58 year old, male, Type 2 diabetes, BMI 46 PMH failed gastric band, poor mobility On Lantus 300 units once daily, metformin and pioglitazone. Hb. A 1 C 62, few scattered hypos Taking Lantus 150 units BD (4 injections/day) – he wanted to reduce amount of insulin injections We discussed the use of U 300 Glargine (Toujeo) which would allow him to reduce TDD of insulin by 20% initially and allow him to give as a once daily and less volume of injection SGLT 2 inhibitor/GLP 1 injection as the next step including support from local weight management services.
Hypoglycemia in T 1 DM? l l l l 42 year old female, Type 1 diabetes PMH Stroke, CKD Stage 3 A, severe retinopathy DAFNE trained and Hb. A 1 c 79 On Levemir 18 units and Novo Rapid 1 unit to 10 g carbohydrate. Severe hypoglycaemia on two occasions and hypoglycaemia unawareness– basal insulin reduced by 50% by GP, fasted BG 15 -18. Practice nurse not confident in managing insulin adjustment. We were able to discuss the guidelines for insulin adjustment for severe hypo and target blood glucose to avoid risk of hypo-also to ensure this lady had hypoglycaemia treatment on prescription including Glucagon injection and glucose gel We discussed re introducing a split basal insulin and referral for pump assessment.
Substituting and adding in the right agent? l l l l GM, male aged 64, T 2 DM for 5 years Seen June 2015 – weight 83 kg - BMI 31, Hb. A 1 c 78 On Metformin, Gliclazide and Levemir 16 units pm fpg 8 -10 mmol but not keen to increase insulin for fear of weight gain Gilclazide stopped and SGLT 2 inhibitor Canagliflozin 300 mg added Explained less chance of hypos now and can uptitrate dose of insulin without hypos (Glic stopped) and further weight gain (as Canagliflozin added) Next review in 2 -3 months
When to think about insulin? l l l l MN, 56 year old male taxi driver T 2 DM since 1988 On triple oral therapy – Glic/MF/Gliptin Hb. A 1 c 78 BMI 25, losing weight What next – insulin initiation vs job? Discussed in clinic absolute need for insulin as clearly insulinopenic – job implications discussed but importance of avoiding DKA mentioned Patient understood the importance and has started BD insulin
Virtual consultation examples
T 2 DM & diabetic nephropathy – high BP in surgery ? Real ? White coat
FLORENCE simple telehealth l l Florence (Flo) is a mobile phone texting system for health care. Flo texts advice and collects patient information. This information can be accessed by clinicians a device connected to the internet, e. g. a computer in their surgery, a tablet smartphone. It’s cheap for the NHS and works for patients with even a basic mobile phone. Flo uses a free text service for all patients in the UK. It doesn’t cost patient anything to use, as texts are paid for by NHS organisations.
FLO l l l Patients don’t have to rush from work, or find a parking space, so their blood pressure (BP) isn’t unduly raised – saves time yet patient is monitored! Clinician/PN can look at the readings sent in by a relaxed patient from home or wherever they are, rather than the erratic readings that can result from attending surgery, (it takes no longer than a minute or two to do this). And when you give advice to hypertensive patients to lose weight, stop smoking, cut down on salt, do more exercise… they don’t always listen. Flo is a great opportunity to send these advice messages a couple of times a week, and patients may be more able to understand the drip-feed of such lifestyle.
High BP confirmed through FLO at home! 29/10/2015 13: 40: 07 152 65 Advice This reading is too high 27/10/2015 09: 30: 16 165 66 Advice This reading is too high 26/10/2015 12: 37 161 65 Advice This reading is too high 25/10/2015 09: 25: 14 145 64 Advice This reading is too high 23/10/2015 15: 45: 28 160 77 Advice This reading is too high 22/10/2015 15: 08: 55 162 70 Advice This reading is too high 21/10/2015 10: 13: 35 157 77 Advice This reading is too high 20/10/2015 12: 34: 14 160 72 Advice This reading is too high 17/10/2015 11: 45: 33 160 71 Advice This reading is too high 16/10/2015 11: 41: 01 160 80 Advice This reading is too high 15/10/2015 11: 09: 45 160 72 Advice This reading is too high 13/10/2015 17: 13: 30 160 75 Advice This reading is too high 12/10/2015 08: 42: 13 160 80 Advice This reading is too high 10/10/2015 10: 20: 31 154 75 Advice This reading is too high 09/10/2015 10: 25: 38 155 60 Advice This reading is too high 08/10/2015 15: 38: 56 174 68 Advice This reading is too high 07/10/2015 15: 31: 03 172 75 Advice Second reading is too high
Anti-hypertensive dose adjustments made via FLO texting without clinic appointment
T 1 DM, renal transplant patient – high BP in clinic ? White-coat
FLO home BP readings all good! Date Reading 1 Reading 2 24/10/2015 12: 25: 03 116 86 17/10/2015 07: 35: 09 114 84 10/10/2015 11: 19: 34 121 84 02/10/2015 10: 40: 10 122 86 26/09/2015 15: 10: 07 117 84 18/09/2015 08: 15: 26 131 90 12/09/2015 22: 34: 19 114 81 Level Alert Advice Second reading is too high
FLO text advice given & discharged!
A complex house bound patient? l l l l TR - 68 year old male, T 2 DM few years Recently joined practice House bound due to obesity – weight 190 kg, BMI 64 Back pain – inactive, only gets up to go to toilet, sleeps downstairs Erratic eating habits – eats late at night, snacks continually Difficult to bleed, last hb. A 1 c July 74, creatinine 190 – e. GFR 30 Declined dietician, physiotherapy input, GLP 1 due to s/e profile On 270 units of Humalog mix 50 - 90 units tds (MF stopped)
What would you do? l l Discussed with very efficient PN who has regular email contact with patient and who has also done home visits No easy solution!
Virtual consultation and advice! Way forward: l Try bleed patient to get latest Hb. A 1 c/renal function l May need to revisit use of Liraglutide – now licensed up to e. GFR 30 ml/min l Re-iterate need to reduce snacking and decrease portion size l ? Get dietician in again/pshycologist l Try using a basal bolus regime using new insulin Toujeo (greater flexibility, less volume, true 24 hour profile) l Regular communication with PN
Di. CE Initial results (Apr 2014 -May 2015): Data from 53 practices : l l l 3060 patients have benefitted from Di. CE service, 595 less outpatient appointments made, 25/53 practices (50%) have seen a decrease in their outpatient activity, 31 practices reported positive engagement with their respective Di. CE teams, 22 practices have reported mixed feedback, Both quantitative and qualitative data collection is ongoing
l Questions?
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