Diabetes CCWHE OOH Contracts Dr Raquel Delgado Diabetes GP Lead

Aims and Objectives Address variation of care across CCGs and practices Early identification and prevention Better management of the 9 care processes Reward and promote specialist services in the community Up skill practices and clinicians

Tools to support the contracts NWL Diabetes Education Programme System1 OOH Diabetes Templates CCWHE Diabetes guidelines available from Hounslow CCG website Diabetes Dashboards New Diabetes Community Service

Systm1 OOH Templates

CCG Dashboards

OOH Diabetes contracts High risk diabetes Diabetes Level 1 Diabetes Level 2 - injectables

Requirements for all the contracts No exception reporting All practices submitting data to the National Diabetes Audit (NDA) Provide the data set requirement to secure payments and monitor improvements Engagement with local diabetes education programme Named lead GP/Clinician Peer review and clinical audit Payment based on KPIs achievement

High Risk Diabetes Identify high risk patients Register of high risk patients XaZLG: gestational diabetes and abnormal glucose test Annual BP, HbA1c , lipids , smoking, BMI and lifestyle interventions/referral

Level 1 Diabetes Contract Referral to structured education and provide patients with information at diagnoses Annual 9 care processes including ACR and retinal screening Annual review with ½ hour appointment Hypoglycaemia recording frequency and management CCWHE Diabetes guidelines for BP, lipids, HBa1c, insulin and glucometers + glucose strips Care plans including housebound and care home patients Copy of care plans given to patients with individualised targets Patient satisfaction survey Discharge from secondary care suitable patients

Level 2 Diabetes Contract Insulin and GLP-1 initiation and optimisation and insulin education Two ccredited clinicians Only accredited clinicians can carry out the service Annual accredited re-fresher courses Adhere to prescribing guidelines for insulin Face to face appointments , telephone, email, Skype Dietician and DSN support from the community service Referral to insulin education programmes Minimum network population of 30,000

New Diabetes Service Named diabetologist , dietician, DSN and podiatrist per locality Clinical psychologist Diabetes podiatry Flexible service to meet the needs of localities and patients Email and telephone access to all clinicians within the service Joint clinics with diabetologist , DSN and dieticians Joint visits to housebound patients Larger choice of education programmes for Type 1 and Type 2 (newly diagnosed, insulin and established diabetes)