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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
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Lesley Roberts, Programme Lead, Haverstock HL
Creation of the IPU Lesley Roberts, Programme Lead, Haverstock HL
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“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.
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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
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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
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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.
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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?
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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
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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
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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….
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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
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What matters to patients?
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Changing Organisations
2 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
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Variability - referrals to CICS
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Variability in Prevalence
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 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
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Have we not done this before?
Other models are not the same!
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Emergency Admissions Why?
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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
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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
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Focus in first year POPULATION CHANGE PREVALENCE
STAFF EDUCATION /COMPETENCIES SKILL MIX DIABETES FOOT TIER 4 WEBSITE – GP website IT
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Where patient data is… Labs EMIS Social Services Investigations
Eye Screening EMIS Purpose built IT Investigations Hospital IT systems AHP’s Pharmacy Social Services
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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
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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
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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.
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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
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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
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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
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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
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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 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
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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
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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
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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
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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.
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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
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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).
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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
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