Dr Rustam Rea, Associate Clinical Director and Consultant in Diabetes, Derby Hospitals NHS Foundation Trust, talks about First Diabetes - an integrated diabetes service, delivering care in one place, closer to patients’ homes.
The health care professionals in the team are drawn from both the hospital and the community and include consultants, GPs, specialist nurses, health care assistants and dieticians. The team are able to communicate easily among themselves through a shared electronic patient record and work closely with the practices who are part of the First Diabetes service. As well as providing individual appointments for patients, team members also provide group education along the whole patient pathway, from prevention of diabetes to complex insulin regimes. They also go out to practices to see patients and provide professional training and advice.
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Rustam Rea: integrating diabetes care in Derbyshire
1. Integrating diabetes care in Derbyshire
Dr Rustam Rea
Consultant Diabetologist, Royal Derby Hospital
Co-Chair First Diabetes
www.firstdiabetes.co.uk
2. Person centered integration
BOB
AGE 60
Practice Nurse for
regular check-ups
GP for regular BP and
medication checks
Foot calluses
Podiatry Clinic at Village
St Health Centre
Referred by GP
for New patient
education
classes
DAY course at Coleman St
Health Centre delivered by
Nurse Consultant, Dietician and
Podiatrist
Referred by GP for
retinopathy screen
Retinopathy screening at
the London Road
Community Hospital
Referred by GP
for Podiatry
Bob has obesity
issues
Referred by GP to
dietician
Dietician
appointments at
the Walk-in
Centre
Bob confesses he
has erectile
dysfunction
Referred by GP to
Erectile Dysfunction
Clinic
Diabetic Specialist
Nurse at the erectile
dysfunction clinic at
RDH
Podiatrist at
Village St finds
foot neuropathy
Podiatrist refers to
Diabetic foot clinic
Diabetic Foot Clinic seen
by Diabetic Specialist
Nurse, Podiatrist, and
Consultant at RDH
Nurse Specialist at the
Osmaston Surgery has
recommended exenatide
Referred by GP to
RDH
Consultant Diabetologist
initiates exenatide
GP
eventually
thinks Bob
requires
insulin
Referred
by GP to
LES2
insulin
initiation
service
Nurse Specialist at the
Osmaston Surgery decides
exenatide is a better option
so refers patient back to GP
for referral to Consultant
Foot neuropathy
discovered
3.
4. Integration across a community
„Bringing together clinicians across the
system with legal and financial autonomy to
be responsible for the health outcomes of the
community‟
5.
6. Whole system integration
1 care 2 careIntermediate care
Specialist podiatrists
Diabetes service
Specialist dietitians
Specialist doctorsSpecialist DSNs
Practice nurses
GPs
7. First Diabetes – a very new model
Partnership
Shares held 50% by GPs
and 50% by acute trust
Single budget, not-for-profit
Comprehensive
Outcome focused, not
process driven
A network including primary
care, community and
hospital staff
No one directly employed –
staff either seconded or
sessional
Facilities rented
8. Pillars of integration in First Diabetes
IT
Financial
Patient participation
Clinical engagement
Clinical governance
9. SystmOne - the IT solution
Single real-time clinical record
Rapid access to decision making and referrals
Consent and confidentiality
Rolled out into tertiary hospital clinics
Patient access
10. Programme budgeting – the
financial solution
Single budget for diabetes, jointly owned by GPs and
hospital
Set by PCT based on previous years spend, scope of
specification and efficiency savings
Not-for-profit organisation
Re-invest surplus back into the service
11. Care planning – the patient
engagement solution
Care planning philosophy
Patients informed and educated before clinic appointment
Patient shadow clinical board
Diabetes prevention workshops
Education throughout the patient journey
12. Clinical engagement
Keeping colleagues engaged – primary care and hospital
New style of leadership – collaborative, shared
responsibility, acknowledging historical differences
MSc diabetes module for upskilling primary care
Practice visits, discussing difficult patients – 4 groups
Reporting outcomes and comparing practices
13. Clinical governance
Underpinned by a legal partnership
– Company limited by shares
– Equally owned by hospital and GPs
– Provides stability and confidence in long term future
Move from silo working to joint ownership
– Board of directors
– Clinical management board
– Wider team working – in hospital, in general practice
14. Cost of integration
50% lower DNA rate compared to non-integrated service
Cost per patient
Year First Diabetes
£
National tariff
£
2009/10 109 112
2010/11 124 118
2011/12 121 122
15. Reduction in prescribing costs
£0.00
£500.00
£1,000.00
£1,500.00
£2,000.00
£2,500.00
£3,000.00
CostperPU
Total diabetes costs
First Diabetes Act Cost Per
standard pu
Derbyshire Act Cost Per
standard pu
National Act Cost Per
standard pu
£200M savings if
figures were
extrapolated nationally
16. Biochemical outcomes
Sustained QoF improvements for diabetes
Reduction in HbA1c (1-2%) and weight (5-10kg) in
patients starting new diabetes drugs
75% reduction in insulin doses and 1.25kg weight loss in
patients on complex insulin regimes
17. Admission with primary code of diabetes
0
20
40
60
80
100
120
140
160
180
2009/10 2010/11 2011/12 2012/13
County Practices
First Diabetes
18. Admission with a secondary
code of diabetes
0
500
1000
1500
2000
2500
2009/10 2010/11 2011/12 2012/13
County Practices
First Diabetes
21% reduction in admissions in First Diabetes
9% reduction in surrounding county practices
19. Patient and professional satisfaction
“The FD service from Stoneleigh House is excellent. They
give excellent care and advise to any patients I have sent
there and have always improved the diabetic measures of
control as well as helping the patient with understanding
their condition. The patient satisfaction is very high.
They have also helped with my own understanding of
diabetes as well as being a considerable support to our
nursing team”
20. Recognition
Winner of Quality in Care Awards 2012 for Best Cross
Boundary Working and Best Primary and Community
Initiative
Finalist in HSJ Awards 2012 in Managing Long Term
Conditions category
Finalist in HSJ / Nursing Times Care Integration Awards 2012
in Diabetes Care
Finalist in Health Enterprise East Innovations Awards 2012
21. Challenges ahead
Providing diabetes care for Southern Derbyshire
Integrating with other long-term conditions
Integrating with social services and mental health
Ongoing clinical engagement
22. Acknowledgements
Dr Garry Tan
Dr Kyran Farrell
Staff and patients at First Diabetes
GPs, hospital management
PCT / CCG
The prevalence of type 2 diabetes mellitus (T2DM) and its rate of rise has been a source of concern in the UK.There is also much evidence of gaps and challenges in the care of people with diabetes. Areas that stand out in particular include the lack of access to and uptake of structured education, the high level of variability of care in both primary and secondary care and feedback from people with diabetes that the care they receive appears fragmented. For people with type 1 diabetes mellitus (T1DM), the present evidence suggests high levels of poor glycaemic control and a low rate of care process achievement increases the likelihood of future complications that can be avoided with good care.The need for integrated care is present at every stage of the patient journey. It is particularly important for those individual whose needs are becoming more complex. This group of people includes the elderly and infirm, those with longer duration of diabetes and those with multiple morbidities and a plethora of medications. Integrated care is pivotal for this group as their care is provided by multiple groups of professionals, who may have conflicting priorities. This can result in fragmentation of care, poorer outcomes and complications as well as hospital admissions that may have been avoidable with better integrated care.Best practice for commissioning diabetes services - An integrated care framework was developed in response to the needs of new commissioners and of health professionals involved in diabetes care. The overarching goal of this framework is to provide practical guidance and key principles for these professional groups to better commission and provide integrated care for people with diabetes. It aims to ensure that people with diabetes have access to a joined up service from the time of diagnosis, through more complex management, complications, inpatient care to end-of-life care.