1. Camden Diabetes Integrated Practice Unit (IPU)
Dr Miranda Rosenthal,
Strategic Clinical Lead of Camden Diabetes IPU,
Diabetes Consultant, Royal Free

2. What’s new for diabetes in Camden ?
What we had…
Where we are going…
Who we are…
Value based commissioning…
Integrated care…..

3. 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.

4. Structure within RFL

5. Lesley Roberts, Programme Lead, Haverstock HL
Creation of the IPU
Lesley Roberts,
Programme Lead, Haverstock HL

6. “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.

7. Phase 2 – Pilot Lead Provider Model with a shadow value-based contract
13/14 Q3
Oct 13 – Dec 13
13/14 Q4
Jan 14 – Mar 14
14/15 Q1
Apr 14 – Jun 14
14/15 Q2
Jul 14 – Sept 14
14/15 Q3
Oct 14 – Dec 14
14/15 Q4
Jan 15 – Mar 15
15/16 Q1
Apr 15 – Jun 15
15/16 Q2
Jul 15 – Sept 15
15/16 Q3
Oct 15 – Dec 15
15/16 Q4
Jan 16 – Mar 16
16/17 Q1
Apr 16 – Jun 16 Q2
Jul-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
Phase 4 – Diabetes service with value-based contract
Clinical Model Development
Recruitment and service developments
Clinical Model monitoring and development as necessary
Patient education resources embedded
GP Practice Visits
GP Education Events
Notice to pilot contracts
Long term value-based contract signed
Development of value based contract
Full costing of service
Contractual monitoring
Sign off service model
Notice to current contracts
Contract sign off by all parties
Subcontracting arrangements in place
Procurement Starts
Outcomes Measured and Reviewed

8. Significant Milestones
April 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

9. 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

10. 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.

11. Camden Diabetes Integrated Practice Unit Implementation
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?
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
Gaps between actual and predicted prevalence of diabetes: Half of people are undiagnosed.
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.
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
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 treat
AIM: Value Based Commissioning will be implemented.
Diabetes services that are not always cost-effective.
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
Aims?

12. Group Structure GOVERNANCE GROUP Camden CCG Diabetes
Camden Diabetes IPU STRATEGIC BOARD
EXECUTIVE GROUP
Camden Diabetes IPU
OPERATIONAL BOARD
(LES / QOF /Practice Visits/ Prevalence / Annual reviews / referral process)
Tier 1 &2 Development Group
Finance & Data Group
(Staffing / Care planning/ referral process /admin )
Tier 3 Development Group
(Staffing / Risk / screening / referral processes)
Foot Group
(Type 1's, A&E, in-patient, discharge)
Tier 4 Development Group
(Staff: competencies, capabilities, education, mentoring)
(Patient: information, education, education)
Staff & Patient Education Group

13. Start Date 10th September 2013
2.5 year project plan…
Programme Plan Overview - Camden Diabetes IPU Implementation Project (August 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
Programme plan to be agreed and communicated to all stakeholders
Full 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

14. 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

15. Camden IPU aims….. Improved: “undiagnosed” uncontrolled diabetes
patient experience
unscheduled attendances and admissions
mortality and morbidity

16. Patients will innovate….

17. 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

18. What matters to patients?

21. Changing Organisations2
INNOVATION
IN PRACTICE
Product development
Harnessing ideas
Innovative organisations
Supporting policy
Creative swiping
Scenarios
Scanning the environment
Benchmarking
Futures 3
LOOKING
OUTWARDS
Terminology
Types of Innovation
A history of innovation theories
Recent Developments 1
INNOVATION
IN THEORY 4
ENVIRONMENTAL
FACTORS
The Commercial Environment
The Green Environment
The Ethical Environment
Changing
Organisations
The EFQM Excellence model
The Quality Movement
ISO 9001:2000
Six Sigma
Lean
Reengineering 8
DELIVERING
CAPABILITY
Entrepreneurs, inventors and innovators
Effective organisations
Leadership 5
FADS &
THE LIKE
Projects, departments and divisions
Alliances
Outsourcing
The supply chain 7
CLIMATE
& CULTURE 6
ORGANISATIONAL
FORMS
Empowerment
Self-Organisation
© THE OPEN UNIVERSITY

23. Variability - referrals to CICS

24. Variability in Prevalence
Camden has the second lowest prevalence of diabetes in England in 2011/12.

25. But, prevalence is increasing – 3.7%
Over 17 Population
On DM register
coded with Type 1
coded with Type 2
other DM codes
224695
8473
631
7797 45 7%
92%
0.5%
Prevalence
GAP STILL LARGE
- 7.6%
Total Practices 39
Report run on 18/06/2014

26. Have we not done this before?
Other models are not the same!

27. Emergency Admissions
Why?

28. Camden Diabetes Admissions
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.
Source: SUS
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

29. 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
Source: SUS

32. Focus in first year POPULATION CHANGE PREVALENCE
STAFF EDUCATION /COMPETENCIES
SKILL MIX
DIABETES FOOT
TIER 4
WEBSITE – GP website IT

33. Where patient data is… Labs EMIS Social Services Investigations
Eye Screening
EMIS
Purpose built IT
Investigations
Hospital
IT systems
AHP’s
Pharmacy
Social Services

34. CIDR : Right information to make the right clinical decision
Where we are aiming ……
CIDR : Right information to make the right clinical decision
EMIS
Hospital
Social Services
Pharmacy
Labs
Purpose Built
Investigations
Eye Screening
AHPs

35. Lead Provider Patient Outcomes:
Commissioning Framework (Camden CCG)
Funded per person
based on “Year
of Care” Commissioning
Lead Provider
Royal Free London FT
Funded through bundled package
Haverstock Health
UCLH
Self-Management – patient education
Foot Care/Podiatry
CNWL
Practice Education
Patient Outcomes:
Patient Experience
Clinical Outcomes
Patient safety
Cost efficiency
GP Practices
Risk stratification
Diabetes UK
Community Step-Up Service
London Borough of
Camden
(Social
Care)
In-reach to Primary Care - MDTs
Case Management
Retinopathy Screening
Analysis & use of data for evidence-based improvements
Camden Diabetes
Integrated Practice Unit

36. 20 Objectives…. The objectives of the project are as follows:
Identify gaps in staffing and agree additional clinical and admin staffing required and appoint staff by March 2014.
Develop outcomes by March 2014.
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)
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.
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.
Deliver accredited Foundation Course in Diabetes from July 2014.
Develop clinical governance arrangements across and between all providers by July 2014.
For very complex and vulnerable people with diabetes develop High risk MDTs in clinic settings, homes and/or practices by July 2014
Develop process to monitor outcomes by July 2014.
Review and streamline all pathways by end August 2014.
Standardise all patient-held and staff communication care plans by August 2014.
Implement Diabetes Foot work-stream that ensures all patients are risk stratified and seen in appropriate tier of podiatry by March 2016.
Improve diabetes care in hospital by March 2016
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.
Implement Mental Health work-stream by January 2015.
Year on year improve and standardise quality of diabetes care at all Tiers by March 2016.
Ensure each patient with diabetes is seen in appropriate Tier of Care (or at home if housebound) by March 2016.
Ensure all staff dealing with diabetes patients meet TREND competencies by March 2016.
Promote the use of QDiabetes to Improve prevalence to meet expected prevalence by March 2016.

37. 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

38. Clinical Model Diabetes 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

39. Camden Diabetes Integrated Practice Unit (ADULTS ONLY) - Tiers of Care Version 0.6
ESSENTIAL CARE
Delivered 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 2
ENHANCED ESSENTIAL CARE
Delivered by General Practices in primary care, community settings and the patient’s home.
As Tier 1, plus:
Injectable therapies
GLP-1 agonists
GP 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 3
INTERMEDIATE CARE
Delivered 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 4
HOSPITAL BASED CARE
Delivered 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 LFTs
Malignant Hypertension
Access to Clinical Psychologists
Genetic causes of diabetes
Young adult clinics (18 – 25)
Inpatient services
Retinal Screening

40. Population change Tier 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

41. 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

42. Population change Community 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

43. 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

44. diabetes nurse specialist vascular surgeon orthopaedic surgeon
Foot protection teams in community & MDT in secondary care…. Putting feet first: national minimum skills framework NHS Diabetes/Diabetes UK
SIGN
A multidisciplinary foot team should include:
podiatrist
diabetes physician
orthotist
diabetes nurse specialist
vascular surgeon
orthopaedic surgeon
radiologist

46. Detection, Diagnosis and Register maintenance Complications screening
Population change – increase competencies Training 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

47. 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:
Supporting people of insulin and starting GLP-1 receptor agonists.
Starting & supporting people during first 6 months of insulin therapy.
Reflect on progress and carbohydrate awareness for people on insulin.
Certification requires completion of Assessment, Patients Progress Log and Reflective Report.

48. 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

49. 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).

50. Summary Clinical 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