1. Fylde Coast Integrated Diabetes Care
Diabetes Care Pathway
Dr. Cruz Augustine

2. Where we are Now! Huge variations across NHS Services and outcomes
Socio-economic differences
High Mortality in diabetics
75, deaths with diabetes 1
1/3 can be prevented 1
Cost to society and NHS
2.9 million UK population has diabetes
Total expenditure on diabetes could be up to 10% of total NHS expenditure 2
2.9 million UK population has diabetes, 4.5%
>4 million UK population will have diabetes in 2025
Diabetes UK. Disease Prevalence, 2011
Commission for Healthcare Audit and Inspection, 2007

3. VISION : Bridging the secondary care and the Community

4. Fylde Coast Diabetes Care Pathway

5. THE VISION: The Strategic Priorities!
CCG and Providers vision for integrated, unified services balancing quality and cost-effectiveness
Current variations in service provision
NSF principles of patient empowerment and self management

6. THE VISION “INTEGRATED DIABETES CARE”
Patient centred not organisation centred
Care should be delivered
at the appropriate time,
in the appropriate place,
by the appropriately trained professional,
for that patient’s present needs

7. Objectives - Integrated Fylde Coast Diabetes Care
fully integrated service
avoid any gaps or duplication in service
smooth and quick referral from primary care for advice and management plan
increased specialist input into primary care settings
consistent high quality patient centred care

8. To improve the quality of diabetic care provided by GP practices
To improve capacity for diabetic services
Manage more complex patients in the community
To reduced unplanned diabetic admissions to secondary care

9. Pathway and Guidelines
To encourage care to be offered at the most appropriate site by the most appropriate method administered by the most appropriate clinical professional(s)
For care to be as near to the patient’s home and usual environment as possible
To encourage patient involvement in their own care
To foster professional development and training about diabetes
Enlarging knowledge basis
Acquiring appropriate skills
Increasing confidence about advising and / or treating diabetic patients

10. PHILOSOPHY OF CARE
All of the documents done by multidisciplinary input from community and secondary care
Seamless service where patients with diabetes will be at the forefront of planning
Service will ensure equity of care for everyone with diabetes, including the housebound, those in care homes, the mentally ill, and patients with learning disabilities

11. Hidden Health Care System3
Professional Care
20% 2 1
Self-Care
80%

12. Generalist Primary Care MAXIMUM ORAL TOLERATED THERAPY AS REQUIRED
Referral onto Tier 2 only when all primary care interventions exhausted
Referral of T1DM for expert assessment and intervention either enhance primary care service or specialist service if symptomatic
All of the above services to be provided via appropriately qualified staff
homes or housebound.
Maintenance of Diabetes register through coding as either T1DM or T2DM and ethnicity
Patient Education
Prevention/targeted Screening of at risk groups
Follow up IGTT patients
Diagnosis, assessment, treatment & monitoring
Patient education and provide Continual education for patients & practice staff
Provision of patient held care plan which includes the management of co-morbidities
Screening for complications – including foot, retinopathy, medication
Lifestyle management – including referral to exercise referral programmes, structured

13. Enhanced Primary Care Management and review of *stable Adult T1DM
Poorly controlled T2DM on insulin
Initiation of insulin or GLP 1’s
Ongoing Patient Education, and Enhanced Staff Education
Continued care planning and promotion of self management
Appropriate care, as applicable to the enhanced primary care service, of those patients in nursing and residential homes or housebound
Management of those with poor healing/recurrent infections and raised HbA1c
Provide research and audit as required
Structured Education

14. Specialist Care Pre conception clinic Consultant led Clinics
Inpatient care or specialist clinics not available in enhanced specialist services
Acute site-
• Acute admissions
Emergency insulin initiation
HSS and DKA
Immediate Post MI
Problematic management
Referral from retinopathy screening service
specialist service
Review of diabetic inpatients
Paediatrics
Consultant led Clinics
Pre conception clinic
Young Persons clinic
Foot clinic
Pregnancy
Difficulties in initiation for type 1&2
insulin Pump therapy
Telephone advice and support for professionals and patients
Complex patients
Management of complex Medical Problems:
Neuropathy
Vascular & Pain
Retinopathy
Cardiology
Nephropathy
Endocrine
Mental health
Structured education 14

15. Achieving Integrated Care
Integration vs integrated.
Normative = Values culture and vision.
Standardisation of care for common conditions through supported adherence to evidence-based guidelines
Electronic records, telephone/ advice, bench marking
Governance
Source: Rosen et al (2011) 15

16. Barriers Ownership Organisational & Professional boundaries
Changing environment
Lack of understanding each other’s perspective
IT & Clinical records
Governance

17. ACTION: What we Need to Do next !
SERVICE DECISIONS
Let Patients & GPs decide on services to choose
SMART NOT JUST HARD
We must work smarter as local demand speeds up.
PATIENT EDUCATION AND ACCOUNTABILITY
We need to assist people to manage their own illnesses
FOCUS ON PREDICT and PREVENT
We must move towards “predict and prevent”
   Keep in your Head that you have three CORE STRATEGIC messages for the presentation.
 We have a huge growing problem in diabetes
2.       NHS funding restricted and we need SERVICE changes
3.       As leaders we must Make decisions and ACT now
a.       Decisions on What are the Priorities/What Service Changes will increase innovation and reduce costs/ What quick wins can we have now (your diabetes example etc ) 17