Post on 18-Jan-2016
Camden Diabetes Integrated Practice Unit (IPU)
Dr Miranda Rosenthal, Strategic Clinical Lead of Camden Diabetes IPU,
Diabetes Consultant, Royal Free
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What’s new for diabetes in Camden ?
• What we had…• Where we are going…• Who we are…• Value based commissioning…• Integrated care…..
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Lead provider role…..
Royal Free (RFL) are:• Lead Providers • Accountable for delivery of high quality integrated
diabetes services across WHOLE pathway (Community-based where possible.)
• Accountable for VALUE across pathway• Responsible for project success.
RFL have subcontracted the achievement of this to Haverstock Healthcare Limited (HHL) who manage the implementation.
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Structure within RFL
“Providers must lead the way in making value the overarching goal”
- Michael E. Porter and Thomas H. Lee, Harvard Business School
• Integrated Practice Unit: One diabetes Team, many providers- (CNWL, UCHL, Whit, RF, primary care, SW, MH, Vol sec working with patient and family)
• Grow excellent services • Integrate care delivery – seamless care
• Measure outcomes • Bundled prices for care cycles• Enabling IT platform – data viewable by all / reduce duplication and aid
communication.
13/14 Q3Oct 13 – Dec 13
13/14 Q4Jan 14 – Mar 14
14/15 Q1Apr 14 – Jun 14
14/15 Q2 Jul 14 – Sept 14
14/15 Q3Oct 14 – Dec 14
14/15 Q4Jan 15 – Mar 15
15/16 Q1Apr 15 – Jun 15
15/16 Q2 Jul 15 – Sept 15
15/16 Q3Oct 15 – Dec 15
15/16 Q4Jan 16 – Mar 16
16/17Q1Apr 16 – Jun 16
16/17Q2Jul-16 – Sept 16
Phase 1– model development and
initial implementation
Phase 2 – Pilot Lead Provider Model with a shadow value-based contract
Phase 3 – Pilot Lead Provider model with Value-based contract
Clinical Model Development
Recruitment and service developments
Patient education resources embedded
GP Practice Visits
Full costing of service Notice
to current contract
s
Sign off service model
Development of value based contract
Contract sign off by all parties
GP Education Events
Subcontracting arrangements in
place
Clinical Model monitoring and development as necessary
Outcomes Measured and Reviewed
Contractual monitoring
Phase 4 – Diabetes service with value-
based contract
Procurement Starts
Notice to pilot
contracts
Long term value-based
contract signed
Significant MilestonesApril 2014 Royal Free London Lead Provider – shadow year
Notice to all providers
Nov 2014 All providers to sign off value-based contract (pilot)
April 2015 Value-based contract to start
June 2015 Notice to Pilot Contract
Procurement for Integrated Diabetes Service to commence
Jan 2016 Value-based contract signed
April 2016 Value-based model to commence
Why integrated care?
Integrated care should be seen as a complex strategy to INNOVATE and
implement LONG-LASTING CHANGE in the way services in the health and social-care sectors are delivered.
European Observatory on Health Systems and Policies
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Why diabetes in Camden?• Low prevalence • Poor glucose control• Inequality in care delivery and outcomes • Lack of integration• Duplication of tests and poor communication• Lack of data on the quality of specialist diabetes care • Difference in the QOF scores for diabetes across Camden • Inadequate incentives • Insufficient and / or inadequate pathways e.g. MH, transient populations,
BME etc.• Inconsistent practice amongst specialist services and inadequate
incentives for making their practice cost-effective.• Inadequate availability and use of information on what is happening in the
system to assess local need to tailor diabetes services appropriately.
Camden Diabetes Integrated Practice Unit Implementation
Aims?
Too many people with diabetes have poorly controlled and managed diabetes, leading to excess early complications and death
Inequality in care delivery and outcomes
Disjointed service have been commissioned : integrated clinical and social care services planned that addresses poor control of diabetes, to prevent complications
What is the need?
Provide High Quality Integrated diabetes care, sharing data to reduce duplication and improve communication across service.
Improve the Health and wellbeing of people living with diabetes in Camden.
Support the Prevention of type 2 diabetes, through raising awareness and education.
Equitable and patient-centred services that enable people to achieve good control, thereby reducing complications.
Well informed, engaged patients and healthcare professionals committed to working in partnership to achieve best outcomes possible.
What will the programme do?
What will the programme deliver?
Patient-Focused: • Structured Patient Education / Patient Involvement and Experience AIM: Integrate around the patient / outcomes that matter to patients / Easier for patients and carers to understand and navigate all services / Promote self-care / More structured patient education and involvement.
• A year on year improvement in number of undiagnosed patients with diabetes in Camden• Improved management of patients with uncontrolled diabetes.• Improved patient experience and quality of life• Reduced mortality and morbidity from diabetes-related causes• Reduction in the numbers of unscheduled attendances and admissions to hospitals
Diabetes services that are not always cost-effective.
Gaps between actual and predicted prevalence of diabetes: Half of people are undiagnosed.
Strong Clinical Services:• Review and amend : Skill mix and Staffing / Pathways / Tiers of Diabetes /
Clinical IT Templates / Referral Forms / Care planning / Diabetes Foot Health / Kidney disease/ Heart Disease / Eye disease.
AIM: Equitable and of consistent high quality, accessible, provided as close to home as possible
Commissioned across a population•Working together across organisational boundaries sharing best practice, delivering value, breaking down barriers and improving outcomes by considering a whole population – prevent and treatAIM: Value Based Commissioning will be implemented.
Highly competent staff at all Tiers of diabetes care• Providing timely access to appropriately skilled healthcare professionals
responsive to the individual, including those with special needs, e.g. housebound.
• Build capacity and capability in primary care
AIM: Increased competencies at all levels
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Group StructureCamden CCG Diabetes GOVERNANCE GROUP
Camden Diabetes IPUOPERATIONAL BOARD
Camden Diabetes IPUTier 1 &2 Development Group
(LES / QOF /Practice Visits/ Prevalence / Annual reviews / referral process)
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2.5 year project plan… Programme Plan Overview - Camden Diabetes IPU Implementation Project (August 2013 - March 2016)
Start Date 10th September 2013
MILESTONE LATEST UPDATE ( MAY 2O14) RAG
PROJECT MANAGEMENT
Develop Service Specification for Diabetes Integrated Care Service CCG completed this for 13-15
Hold Diabetes Workshop to inform programme plan Completed August 2013
Establish Camden Integrated Diabetes Programme Board (prev. Partnership Board) Now Camden Diabetes IPU Strategic Board - meets bi-monthly
Establish Programme Governance Governance paper to be completed
Recruitment of Programme Lead and agreement of funding for Lead and Administrator Start date 10th September
Review Diabetes Workshop objectives and other docs to inform programme plan Within Implemementation plan
Camden Strategic IPU Diabetes Group TOR developed and agreed Agreed October 2013
Receive assurances that the culture of each organisation is "bought into" integrated working. Agreed but still requires constant vigilance
Create implementation plan Implementation plan completed - now PID and Service Handbook required.
PID to be developed Draft complete
Service Handbook to be completed Draft complete
Programme plan to be agreed and communicated to all stakeholdersFull programme Plan is sent to Governance group, Executive Group, Strategic Board Members, Operational Board memebers and members of all subgroups.
Monthly milestone plans to be developed Gantt chart on this plan
Communication Plan developed (incl. process to update Clinical Commissioning Leads regularly) DRAFT developed
Camden IPU Vision
A service that:• Delivers outcomes that matter to patients• Works across organisational boundaries• Considers a whole population – prevent and treat• Patients leading their own care• Provides the best value for Camden taxpayers
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Camden IPU aims…..
Improved:• “undiagnosed” • uncontrolled diabetes• patient experience • unscheduled attendances and admissions• mortality and morbidity
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Patients will innovate….
Delivers outcomes that matter to patients…GP patient survey 2012/13
Camden worse than the England average in giving support to those with long term conditions.
Source: GP patient survey 2012/13
278
215
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32
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Diabetes admissions 2012/13 by provider
ROYAL FREE LONDON NHS FOUNDATION TRUST
UNIVERSITY COLLEGE LONDON HOSPITALS NHSFOUNDATION
Other
IMPERIAL COLLEGE HEALTHCARE NHS TRUST
THE WHITTINGTON HOSPITAL NHS TRUST
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What matters to patients?
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Terminology
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© THE OPEN UNIVERSITY
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7CLIMATE
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1INNOVATIONIN THEORY
2INNOVATIONIN PRACTICE
ChangingOrganisations
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Weighted referral rate to CICS (diabetes only) by practice April 2012 -December 2013
Variability - referrals to CICS
Variability in Prevalence
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Camden has the second lowest prevalence of diabetes in England in 2011/12.
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But, prevalence is increasing – 3.7%
Over 17 Population On DM registercoded with
Type 1 coded with Type
2 other DM codes
224695 8473 631 7797 45
7% 92% 0.5%
Prevalence 3.770889428
GAP STILL LARGE
- 7.6%
Total Practices 39
Report run on 18/06/2014
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Have we not done this before?
NO!
Other models are not the same!
Emergency Admissions
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Emergency diabetes admissions 2012/13Rate per 1000 weighted list size
Camden average
Why?
Camden Diabetes Admissions
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0-4 yrs 5-9 yrs 10-14yrs
15-19yrs
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25-29yrs
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45-49yrs
50-54yrs
55-59yrs
60-64yrs
65-69yrs
70-74yrs
75-79yrs
80-84yrs
85-89yrs
90-94yrs
95-99yrs
Diabetes admissions by age2012/13
Male Female
0%
10%
20%
30%
40%
50%
60%
70%
White Mixed/Multiple EthnicGroups
Asian or Asian British Black or Black British Other Ethnic Group Not stated/Unknown
Diabetes admissions 2012/13 by ethnicity
Diabetes admissions 12/13 2011 Census - Camden
Who is admitted for Diabetes?There are more female admissions than male for diabetes up to the age of 45.
After age 45 there is a big leap in the level of diabetes admissions, with slightly more men being admitted.
There are fewer admissions for diabetes of people who are white than the 2011 census population data would predict. This is most likely due to the known link between ethnicity and prevalence in non-white communities.NB – the 2011 census data does not have an ‘unknown’ section and so some caution should be exercised when interpreting this as people identified from SUS data as not stated/unknown could be in any group.
Source: SUS
Source: SUS
But emergencies and Out Patients already decreasing.…
Emergency diabetes admissions to acute hospitals have been falling since the Camden Integrated Care (CICS) Diabetes service was launched.
Outpatient attendances in Diabetic Medicine at the Royal Free and UCLH (activity aimed to be reduced by the CICS business case) are also showing a downward trend since the new CICS diabetes service was introduced.
Source: SUS
Source: SUS
30
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Diabetes admissions
Diabetes admission 6 per. Mov. Avg. (Diabetes admission)
Camden Integrated Care Diabetes service launched
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April May June July August September October November December January February March April May
2012/13 2013/14
Camden Integrated Care Diabetes service attendances
Attendances 3 per. Mov. Avg. (Attendances)
Source: SUS
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Diabetic Medicine outpatient attendnaces at Royal Free and UCLH
DIABETIC MEDICINE 6 per. Mov. Avg. (DIABETIC MEDICINE)
Camden Integrated Care Diabetic Service launched
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Focus in first year
• POPULATION CHANGE• PREVALENCE• STAFF EDUCATION /COMPETENCIES• SKILL MIX• DIABETES FOOT• TIER 4• WEBSITE – GP website
www.camdendiabetes.co.uk• IT
Purpose built ITHospital
IT systems
EMIS
AHP’s
Labs
PharmacySocial Services
Investigations
Eye Screening
Where patient data is…
EMISHospital
Social Services
Pharmacy
LabsPurpose
Built
Investigations Eye Screening
AHPs
Where we are aiming ……CIDR : Right information to make the right clinical decision
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Patient Outcomes:Patient ExperienceClinical Outcomes
Patient safetyCost efficiency
Foot Care/Podiatry
Self-Management – patient education
Practice Education
Community Step-Up Service In-reach to
Primary Care - MDTsCase
Management
Risk stratification
Analysis & use of data for evidence-based improvements
Commissioning Framework (Camden CCG)Funded per person based on “Year of Care” Commissioning
Lead ProviderRoyal Free London FT
Haverstock Health
CNWL
UCLH
GP Practices Diabetes
UK
Camden DiabetesIntegrated Practice Unit
London Borough
of Camden(Social Care) Retinopathy
Screening
Funded through bundled package
36
20 Objectives….1. The objectives of the project are as follows:2. Identify gaps in staffing and agree additional clinical and
admin staffing required and appoint staff by March 2014.3. Develop outcomes by March 2014.4. Agree minimum level of knowledge necessary for
competency at Tier 1 level. Develop competencies in all practices (by DSN led visits for case-note review and management plan creation / facilitation clinics and mentoring of staff)
5. Agree, assess and improve clinical competencies for district nursing staff dealing with diabetes patients thereby providing safer high quality care for some of the most vulnerable people with diabetes by December 2014.
6. Develop support for District nurses: A review of diabetes protocols/ Assessment sheets / DN care plans / Blood glucose records /creation of Aide memoir for staff /updated policy and implementation of Hypo boxes / MDT Home visits with GP and Diabetes Specialist staff and Consultant if appropriate.
7. Deliver accredited Foundation Course in Diabetes from July 2014.
8. Develop clinical governance arrangements across and between all providers by July 2014.
9. For very complex and vulnerable people with diabetes develop High risk MDTs in clinic settings, homes and/or practices by July 2014
10. Develop process to monitor outcomes by July 2014.
11. Review and streamline all pathways by end August 2014.
12. Standardise all patient-held and staff communication care plans by August 2014.
13. Implement Diabetes Foot work-stream that ensures all patients are risk stratified and seen in appropriate tier of podiatry by March 2016.
14. Improve diabetes care in hospital by March 2016 15. Develop PIT-stop training for Tier 2 practices who can
deliver a higher level of diabetes care including insulin and GLP-1 agonist management with 3-6 Tier 2 practices in place by March 2016.
16. Implement Mental Health work-stream by January 2015.
17. Year on year improve and standardise quality of diabetes care at all Tiers by March 2016.
18. Ensure each patient with diabetes is seen in appropriate Tier of Care (or at home if housebound) by March 2016.
19. Ensure all staff dealing with diabetes patients meet TREND competencies by March 2016.
20. Promote the use of QDiabetes to Improve prevalence to meet expected prevalence by March 2016.
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What is different? • Camden Diabetes IPU began on April 2014 • RFL responsible for a POPULATION CHANGE in
outcomes• Everyone working as ONE TEAM and being
patient not provider focused.• Agreed standards, pathways, outcomes• Clinical Model - Diabetes Guide for London
Clinical ModelDiabetes Guide for London
Aims Tier 4 – used more appropriately
Tier 3 – expanded to support primary care at Tiers 2 and 1.
Tier 2 – set up Hub practices (3)
Tier 1 – Better essential care in practices
Patients seen in correct tier
Move unobstructed through tiers
http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Diabetes-Guide.pdf
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TIER 1ESSENTIAL CAREDelivered by General Practices in primary care, community settings and the patient’s home - all Practices will deliver Tier 1 care•Annual review•Follow up of patients with Type 2 diabetes•Medications reviews•Complications Screening & Management e.g BP, HbA1c, weight, lifestyle factors•Patient education (excluding Structured Patient Education on diagnosis)•Telephone support for patients•Referring appropriately to other Tiers/specialist services•Care planning•Family planning advice and referral for pre-conception advice•Care for housebound patients (including maintenance of a register of housebound patients)•Maintenance of a register of patients with Diabetes, indicating place of care•Testing “at risk of diabetes” patients and maintaining register•Referral to IAPT
TIER 2ENHANCED ESSENTIAL CAREDelivered by General Practices in primary care, community settings and the patient’s home.As Tier 1, plus:•Injectable therapies •GLP-1 agonistsGP Practices may choose to deliver these services for their own patients only or as a ‘hub’ service for a number of Practices.
Note: There will be a process to identify the
Tier 2 practices in Camden.
TIER 3INTERMEDIATE CAREDelivered by Consultant-Led Multidisciplinary team(s) in community settings•Structured Patient Education for patients newly diagnosed with diabetes (Type 2)•Access to “At Risk” foot clinic•Access to specialist diabetes dieticians•Assessment, specialist advice and individual interventions for patients *, especially:•Hypo-unawareness•Recurrent Hypoglycaemia•Peripheral Neuropathy•Insulin & GLP-1 analogue initiation and management for Type 2•Pregnancy planning & pre-conception advice clinic – in development•Referral to Specialist Diabetes IAPT team•Joint clinics where competency is known e.g CKD and Diabetes Clinic at Mary Rankin •Same day diabetes clinic – self referral(to avoid A&E attendance) – TO BE DEVELOPED •Persistent BP>130/80 despite having 3 maximum tolerated antihypertensive agents•Persistent total cholesterol>4;LDL>2 despite maximum tolerated statins•Mentoring and coaching support for primary care
TIER 4HOSPITAL BASED CAREDelivered by Consultant-Led specialist teams in secondary care•Assessment of patients newly diagnosed with Type 1 diabetes•On-going management of Type 1•Type 1 Structured Education•Review of complex/atypical patients•Review of patients with suspected secondary diabetes•Management of active foot disease•Assessment of Autonomic Neuropathy•Joint clinics (e.g. Diabetes and CKD /CHD / CVD clinics)•Initiation of CSII/Pump therapy•Assessment and management of all pregnant women with diabetes•Review and management of patients with severe and/or unstable and/or new complications of diabetes*, especially:
Abnormal LFTsMalignant Hypertension
•Access to Clinical Psychologists•Genetic causes of diabetes•Young adult clinics (18 – 25)•Inpatient services
Retinal Screening
Camden Diabetes Integrated Practice Unit (ADULTS ONLY) - Tiers of Care Version 0.6
Population changeTier 1: Senior DSN Practice Support
• Visit practices in each locality team – 1/3 of practices been visited since Jan 14
• Diabetes QOF results of each practice • Virtual Clinics within the practice• Mentoring and Coaching clinics (nurses and doctors)• Deliver clinics for poorly controlled patients• Work with the practices to create an action plan for
improvement• MDT VISITS IN PRACTICES / HOMES• CONSULTANT VISITS PLANNED LATES SUMMER
What can you do? • Have a DSN practice visit• REFERRAL FORM• Act on lab results• Develop management Plans• Flu vac• Lifestyle changes• Nine Care Processes• Administration processes• Complete care plan
Encourage patient to attend structured patient education
• Blood Sugar• Blood Pressure• Blood Fats – cholesterol• Eyes• Feet• Kidneys• Weight • Smoking cessation• Care plan
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Population changeCommunity Nursing Support
• Caseload• 50 Joint visits ( DSN and District nurses) • Safety issues highlighted• Treatment changes• Collaborative working to transform diabetes
community nursing care• MDT visits• Ongoing support
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Population change Diabetes Foot Work-stream
• Review staffing – new Band 7 Podiatrist• Internal referral process between podiatrists; • Discharge back to GP (standardise Care Plan etc); • Foot Check Training; • Practice Nurse and District Nurse Support; • Implement Risk Stratification Tool; • Move appropriate patients to clinics dependent on foot risk;• Pathways; • Standardise Patient Leaflets;• Develop Foot Protection team in Community; • Develop MDT Diabetes Foot team in Community; • QOF Foot Data; Standardise data to deliver outcome Metrics;• Review DUK latest on foot post code lottery; • National Diabetic Foot audit 2014; CIDR - Camden Integrated Digital record – use
podiatry as example by March 2016
Foot protection teams in community & MDT in secondary care….
Putting feet first: national minimum skills framework NHS Diabetes/Diabetes UK
SIGN 116 - 11.5.1A multidisciplinary foot team should include:
• podiatrist• diabetes physician• orthotist• diabetes nurse
specialist• vascular surgeon• orthopaedic surgeon• radiologist
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Population change – increase competenciesTraining and Education – Camden Diabetes Foundation Course
• Detection, Diagnosis and Register maintenance• Complications screening• Personal Care Planning• Oral medications• Patient and Carer advice• Signposting to more support• Family planning and initial pregnancy planning
Local population change - Hub practices Advanced Level - PIT-stop
Programme for Injectable Therapy• Accredited with Greenwich University – 15 credits at level 5 (Diploma)• 2.5 day course trains primary care clinicians to support people with type 2 diabetes on
more advanced medication regimens, including injectables.• Meets NICE criteria
Three modules:1.Supporting people of insulin and starting GLP-1 receptor agonists.2.Starting & supporting people during first 6 months of insulin therapy.3.Reflect on progress and carbohydrate awareness for people on insulin.
Certification requires completion of Assessment, Patients Progress Log and Reflective Report.
UCLH / RFL Tier 4
• Emergency admissions• Elective admissions – pre / post• In-patient care - commitment to the principles
of “Think Glucose” • Elective procedures – diabetes a consideration• Discharged – diabetes reviewed to prevent
readmission
Impact on Tier 4….
• Emergency Admissions• Elective admissions• Cohort of patients will change
• Complex type 1 patients – see more often, focus on control
• Patients who are Type 2 and stable will be referred back to community services (Tier 3)or GP (Tier 1).
SummaryClinical Model
Aims Tier 4 – used more appropriately
Tier 3 – expanded to support primary care at Tiers 2 and 1.
Tier 2 – set up Hub practices (3)
Tier 1 – Better essential care in practices
Patients seen in correct tier
Move unobstructed through tiers
http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Diabetes-Guide.pdf