Fylde Coast Integrated Diabetes Care
Diabetes Care Pathway
Dr. Cruz Augustine
Where we are Now!
 Huge variations across NHS
 Services and outcomes
 Socio-economic differences
 High Mortality in diabetics
 75,000.00 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
1.
2.
Diabetes UK. Disease Prevalence, 2011
Commission for Healthcare Audit and Inspection, 2007
VISION : Bridging the secondary care and the
Community
Fylde Coast Diabetes Care Pathway
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
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
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
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
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
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
Hidden Health Care System
3 Professional Care
2
20%
1
Self-Care
80%
Generalist Primary Care
MAXIMUM ORAL TOLERATED THERAPY AS REQUIRED
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
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.
Screening for complications –
including foot, retinopathy,
medication
Maintenance of Diabetes register
through coding as either T1DM or
T2DM and ethnicity
Lifestyle management – including
referral to exercise referral
programmes, structured
Patient Education
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
Specialist Care
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
Consultant led Clinics
Complex patients
• Pre conception clinic
Management of
complex Medical
Problems:
• Young Persons clinic
• Foot clinic
• Pregnancy
• Difficulties in initiation for
type 1&2
• insulin Pump therapy
• Telephone advice and
support for professionals and
patients
•Neuropathy
•Vascular & Pain
•Retinopathy
•Cardiology
•Nephropathy
•Endocrine
•Mental health
• Structured education
Paediatrics
14
Achieving Integrated Care
Source: Rosen et al (2011)
Barriers
Ownership
Organisational & Professional boundaries
Changing environment
Lack of understanding each other’s perspective
IT & Clinical records
Governance
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”