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Integrated Community Diabetes Service (ICDS) NHS Bedfordshire.

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Presentation on theme: "Integrated Community Diabetes Service (ICDS) NHS Bedfordshire."— Presentation transcript:

1 Integrated Community Diabetes Service (ICDS) NHS Bedfordshire

2 Diabetes in Bedfordshire Prevalence is increasing: more with diabetes Diagnosed younger: more years of diabetes Increased duration: more chance of complications More human and economic cost

3 Local Issues Inequity of services Variable communication between primary and secondary care and other support services No access to specialist care in localities Low expenditure/ poor outcomes Duplication of care

4 Diabetes Outcome vs Expenditure

5 Our Vision Core Primary Care & Self Care Integrated Community Care Specialist Care

6 Integrated Community Diabetes Team Specialist Nurses Specialist Dietitians Social Support Voluntary Sector Primary Care GP Practice Nurse Community Matron District Nurse Community based health professionals Specialist Care Diabetes Consultants Obstetricians Other specialist consultants Integrating care across boundaries

7 Key features of the ICDS Specialist, close support for diabetes management in general practice - building confidence and competence in the practice Multi-disciplinary assessment and treatment planning of newly referred GP patients offered at local clinics Hard to reach groups Specialist guidance, support and training for community healthcare professionals, including staff at residential homes / hospices

8 Integrated Community Diabetes Team: Day to day leadership by Nurse consultant / Senior Diabetes Specialist Nurse Locality based Diabetes Specialist Nurses – each GP practice will have an allocated DSN Diabetes Specialist Dietitians Clinical supervision by Consultant Diabetologist

9 The DSN Structure is key to integrated services Communication with hospital based team means concerns and progress can be passed on Discharge planning Access to Diabetologist Shared data base Avoiding duplication

10 Proposed initial distribution of ICDS workforce* DSN 4 Ivel Valley Arlsey Med Centre Larksfield Arlsey Ivel Med Centre Shefford Health Centre Kings St Sandy Sandy Health Centre Gamlingay Surgery Potton Surgery Biggleswade Hth Centre Lower Stondon Shortstown Total number of patients with diabetes = 3624 DSN 5 South Beds Wheatfield Dunstable West Street Dunstable Priory Gdns Dunstable East gate Dunstable Kingsbury Dunstable Kirkby Rd Dunstable Chiltern Hills Houghton Regis Caddington Surgery Toddington Med Centre Total number of patients with diabetes = 3757 Diabetes Specialist Dietitians Diabetes Nurse Consultant Clinical Lead Clinical supervision from Consultant Diabetologist Diabetes Specialist Dietitians Senior DSN Clinical Lead Clinical supervision from Consultant Diabetologist DSN 6 South Beds Leighton Buzzard Linslade Surgery Bassett Road Salisbury House Lake Street Barton-Le-Clay Total number of patients with diabetes = 2153 DSN 3 Bedford Putnoe Health Centre Goldington avenue 2 Goldington Road Rothsay Surgery Deparys Avenue Linden Road Pemberly Avenue Great Barford Surgery London Road Cranfield Total number of patients with diabetes = 3808 DSN 2 Kempston / Ampthill / Flitwick St Johns Kempston Kings Street Kempston Cater Street Kempston Great Denham Wootton Vale Templars Way Sharnbrook Medical Cen Harrold Highlands Flitwick Houghton Cl Ampthill Oliver St Ampthill Greensands Ampthill Woburn Sands Total number of patients with diabetes = 3994 DSN 1 Central Bedford Ashburnham Road Victoria Road Clapham Road Queens park Lansdowne Road Priory M C Clapham Shakespeare Road 12 Goldington Road Total number of patients with diabetes = 2471 *reflecting current local demand – this will need to shift in response to any local changes over time

11 Which diabetic patients will the ICDS help you manage? Poorly controlled diabetes in otherwise stable patients Chronic: Raised HbA1c not achieving personal target Deteriorating but not requiring urgent intervention Complex conditions/ situations e.g. housebound or living in residential care Complex care, requiring step down from acute setting Hard to engage groups/ patients Pre-conception

12 Example of service impact Early dissemination of evidence based practice Community Initiation / support – Injectable therapies Locally developed Patient education programmes Care home support Working with District Nursing Service (148) Work with the Retinal Screening service to target and support those with referable eye disease Work with emergency services and out of hours services Safer use of insulin awareness Blood Glucose monitoring – Standardisation / Training – Internal and external QA

13 Education and Training MDT Interest Forum Formal and informal training for Primary care staff – Mentorship for new staff Informal and formal training for care home staff Development of local education and support programme for patient with Type 2 diabetes

14 What the service wont do: Take over the management of GP patients with diabetes – clinical responsibility remains with the GP Carry a large ongoing caseload

15 Referral Process Choose and book Letter Central Booking Triage Appointment allocated in the usual time frame

16 Moving clinics into the community Enhanced Treatment Centre (Horizon) Houghton Close Ampthill (West Mid Beds) Wootton Vale Healthy Living Centre (Horizon) Biggleswade Hospital (Ivel Valley) Shefford Health Centre (Ivel Valley) Dunstable Leighton Buzzard Houghton Regis

17 Leadership and Governance Delivered by a dedicated and highly motivated team under robust leadership. Close collaboration with commissioners and GP consortia ensuring we meet the needs of primary care colleagues. Clear clinical governance arrangements to ensure the service adapts and evolves in response to an active audit programme. Actively seek feedback to respond to the needs of the patient and their carers. Our aim is not simply to deliver secondary care in the community setting but to redesign services innovatively and improve patient experiences and outcome.

18 How to contact ICDS North and Central Beds Service hours 8.30 to General Enquires (not yet active) Urgent Advice TBA Paper referral by fax TBA Paper referral by post ICDS, The Diabetes Centre, Bedford Hospital NHS Trust, Kempston Rd, Bedford. MK42 9DJ South Beds Service hours 8.30 to General Enquires TBA Urgent Advice TBA TBA Paper referral by fax TBA Paper referral by post ICDS, The Diabetes Centre, Luton and Dunstable Hospital, Lewsey Rd, Luton

19 Next Steps Pending contract signing: Multidisciplinary assessment clinics for new patients will move out to community locations in a phased way from January 2012 Recruitment process for new staff in process Locality based support will come on stream once new staff are in place - ? Early 2012 Referral process wont change until new staff in place – please continue your current arrangements for now!

20 For further information Central and North Bedfordshire – Nick Morrish, Consultant Diabetologist – Julia Pledger, Nurse Consultant South Bedfordshire – Dr. Shiu-Ching Soo, Consultant Endocrinologist For diabetes resources and guidelines, log on to

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22 Additional slides Pathway diagrams and initial workforce distribution

23 Type 1 Diabetes Care pathway – diagnosis and initial management Key to colour coding: Unwell If weight loss, ketones and symptoms, treat as Type 1 and admit If not unwell, no ketones and mild symptoms only If not unwell, has no ketonuria but is symptomatic If not unwell but has positive ketonuria Monday to Friday 9-5, refer to Acute Diabetes Specialist Care, otherwise admit Refer to Acute Diabetes Team next working day Acute Specialist Care: Baseline investigations Initial treatment plan Initial advice and introduction to education programme Telephone advice line Plan for ongoing care Acute Specialist Care: Baseline investigations Initial treatment plan Initial advice and introduction to education programme Telephone advice line Plan for ongoing care Go to T1 continuing care pathway Questions: Severity of symptoms Any weight loss Age Ethnicity Build Presence of ketones Acute presentation via A&E In patient Diagnosis from Specialist care Go to T2 Diagnosis and continuing care pathway Depending on diagnosis Acute hospital-based service Primary / community based service Not unwell Suspected newly diagnosed Type 1 in primary care setting Refer to Integrated Community Diabetes Service for clarification and diagnosis

24 Type 1 Diabetes Care pathway – continuing care Joint working between specialist ICDS staff and primary care staff* From Type 1 diagnosis pathway Acute Specialist Care Integrated Community Diabetes Service Clinical Review by GP In patient management Complication Eyes/feet/feet/vascular Insulin pumps Pregnancy management Specialist Dietetics Transition from paediatric to adult service Annual review for those under specialist care In patient management Complication Eyes/feet/feet/vascular Insulin pumps Pregnancy management Specialist Dietetics Transition from paediatric to adult service Annual review for those under specialist care Stabilise glycaemic control Intensify insulin regimes Care planning Support for self care Managing illness / alcohol Pre / post pregnancy counselling Support and re-engage with those lost to follow up Telephone advice line Stabilise glycaemic control Intensify insulin regimes Care planning Support for self care Managing illness / alcohol Pre / post pregnancy counselling Support and re-engage with those lost to follow up Telephone advice line DAFNE / LIFE Annual Retinal Screen Stable well controlled Glycaemic control Vascular risk Renal assessment Foot review Medication review Care planning Lifestyle modification, including weight management, smoking cessation, exercise Stable well controlled Glycaemic control Vascular risk Renal assessment Foot review Medication review Care planning Lifestyle modification, including weight management, smoking cessation, exercise Key to colour coding: Acute hospital-based service Primary / community based service ICDS enables ongoing management by primary care staff, who may over time take on more of the specialised tasks *overall clinical responsibility remains with GP *Direct referral when needed

25 Key to colour coding: Type 2 Diabetes care pathway – diagnosis and initial management Suspected Diabetes / from case finding pathway Add to At Risk Register Annual assessment Diabetes Prevention: Lifestyle advice Weight loss programme Add to At Risk Register Annual assessment Diabetes Prevention: Lifestyle advice Weight loss programme Appointment at GP practice for diagnostic test Discussion and lifestyle advice, consider annual screening Acute presentation via A&E In patient Diagnosis from specialist care Initial exam. + baseline investigations Initial management plan agreed with patient Initial exam. + baseline investigations Initial management plan agreed with patient Specialist Care for complex cases Initial management plan & advice Specialist Care for complex cases Initial management plan & advice Integrated Community Diabetes Service DESMOND Healthy Lifestyles, weight programmes etc. Dietetic assessment Healthy Lifestyles, weight programmes etc. Dietetic assessment Community Matrons Social services Community Matrons Social services Appointment at GP Practice for ongoing management OGTT / FBG / RBG Go to T2 Continuous care pathway Initial advice Dietary information Diabetes UK Personal Health plan Register for Retinal Screening Initial advice Dietary information Diabetes UK Personal Health plan Register for Retinal Screening Negative IGTT / IFG Diagnosis confirmed Acute hospital-based service Primary / community based service Abbreviations: IGTT – Impaired Glucose Tolerance Test IFG – Impaired Fasting Glucose OGTT – Oral Glucose Tolerance Test FBG – Fasting Blood Glucose RBG – Random Blood Glucose

26 Joint working between specialist ICDS staff and primary / community care* Type 2 Diabetes care pathway – continuing care Key to colour coding: From T2 Diagnosis pathway Clinical Review by GP (Minimum annually) Clinical Review by GP (Minimum annually) Integrated Community Diabetes Service Acute Specialist Care Interim review with Practice Nurse (if needed) Glycaemic control problem solving Intensify treatment regimes for high risk patients Initiation of injectable therapies Develop treatment plans Support for self care Pre / post pregnancy counselling Telephone advice line Glycaemic control problem solving Intensify treatment regimes for high risk patients Initiation of injectable therapies Develop treatment plans Support for self care Pre / post pregnancy counselling Telephone advice line Glycaemic control Vascular risk Renal assessment Foot review Medication review Care planning Lifestyle modification Including weight management, stop smoking, exercise Glycaemic control Vascular risk Renal assessment Foot review Medication review Care planning Lifestyle modification Including weight management, stop smoking, exercise Complex Glycaemic management Management of complex co – morbidities -Feet -Eyes -Vascular -Renal Pregnancy care In patient care Transition paediatric to adult service Telephone advice line Complex Glycaemic management Management of complex co – morbidities -Feet -Eyes -Vascular -Renal Pregnancy care In patient care Transition paediatric to adult service Telephone advice line Annual Retinal Screening Education - DESMOND Exercise / weight loss programmes Dietetic Review Education - DESMOND Exercise / weight loss programmes Dietetic Review Acute hospital-based service Primary / community based service Links with other services including: Social Care Residential Care Voluntary groups (e.g. hard-to-reach patients) Links with other services including: Social Care Residential Care Voluntary groups (e.g. hard-to-reach patients) Acute Podiatry Services Direct referral when needed *Overall clinical responsibility remains with GP ICDS enables ongoing management by primary care staff, who may over time, take on more of the specialised tasks Community Matron Services Community Podiatry Services

27 Thank you Please ask Questions


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