Aiming For Excellence: Care
Home Diabetes & Dementia
• Tuesday 9th December 2014
• 10:00 – 16:00
www.england.nhs.uk
Dr Rob Moisey
Overview
 What is diabetes?
 Symptoms and signs
 Diagnosis
 Management
 Diabetes in care homes
What is Diabetes?
 Elevated blood glucose (sugar) level
 Normal glucose is 4-6 mmol/L
 High glucose is poisonous to the body (particularly
the very small blood vessels).
Insulin & the pancreas
The pancreas is normally very
good at keeping glucose levels
very stable by producing
insulin.
What goes wrong?
 Not enough insulin
 Resistance to insulin
Why get diabetes?
 Two main types
 Type 1 – insulin insufficiency
 Younger people
 Auto-immune
 Need insulin injections
 Type 2 – insulin resistance (and deficiency)
 Older people
 Overweight
 Diet, tablets, insulin
Type 1 DM
 Less common (8% of all
diabetes)
 Insulin producing cells killed off
 Need insulin for rest of life
Risk Factors for Type 2diabetes
 Age
 Lack of exercise
 Ethnicity
 Family history
 Weight
 6-7%
 25% in care homes
Symptoms of diabetes
 There may be no symptoms – often picked up on
routine screening or as part of blood tests
 Symptoms include:
 Tiredness
 Lethargy
 Weight loss
 Excess thirst
 Passing lots of urine
 Blurred vision
 Recurrent infections
Complications and harm from
Diabetes.
 Immediate:
 Symptoms ± harm when glucose high or low
 Long-term:
 Eye damage
 Kidney damage
 Nerve damage
 Cardiovascular disease
Eye damage
Neuropathy
Kidney damage
Cardiovascular disease.
Managing diabetes
 Regular checks (at least once a year)
 Blood tests
Target HbA1c <50
 Urinalysis
 Blood Pressure
 Weight + BMI
 Smoking status
 Foot check
 Eye screen
Treatment of Diabetes
 Tablets
 Injectables
 Statins
 Bp control
 aspirin
Managing diabetes
 Tablets:
Insulin
 Once a day long acting
insulin
 Humulin I
 Glargine
 Twice a day mixed insulin
 Humulin M3
 Novomix 30
 Humalog Mix 25
Managing diabetes in care homes
Are you aware of the ‘Guidelines of
Practice for Residents with Diabetes in
Care Homes’ available at the Diabetes
UK website?
Do you assess a resident’s knowledge of
hypoglycaemia (low blood sugar) using a
standard protocol?
Do you have a nominated member of staff
with a designated responsibility for diabetes
management?
Care Planning
 Designated responsible staff member
 Designated GP
 Named urgent contact
 Structured quality control process for CBG meters
 Annual screening
 Nutrition – dietary plan
 BM monitoring
 Individualized BM targets
 Recognising and managing hypoglycemia
Managing diabetes in dementia
and frailty
 Risks vs Benefits, highs vs lows
 “perfect” control glucose: 4-7mmol/l
 Older people and people with dementia may not have
typical symptoms of hypos- or high glucose level
 Increased risk of harmful hypoglycaemia
 Under nourished
 Unpredictable eating
 Renal function
 Greater dependency on health care staff to manage their
diabetes
Managing hypoglycaemia
Do you have a written policy for
managing hypoglycaemia (low blood
sugar)?
High BM
Low BM “hypo”
 Tiredness
 Confusion
 Lethargy
 Slurred speech
 Weight loss
 Pale, shaking
 Excess thirst
 Passing lots of urine
 Blurred vision
 Poor coordination
 Fall
Targets for diabetes
 Avoidance of symptoms of high BMs or low BMs
 Individualised targets for glucose control
 BMs 5-15mmol/l
 HbA1c 60-70
 Less importance of tight control to avoid long-term
complications
When to test the BM
 On tablets only – generally
no regular testing
required.
 Test 1-2 a day if poorly
 On insulin – generally 1-2
a day.
 Possible hypoglycaemia
Summary
 What is diabetes?
 Symptoms and signs
 Diagnosis
 Management
 Diabetes in care homes
Foot care for patients with diabetes
December 2015
Paul Cotton MSc
Podiatrist
Calderdale and Huddersfield NHS Foundation Trust
Diabetic foot Screening?
Who does it? Why do we do it:
Who?
GP practice or Podiatry Services
Why?
Annually:
• one in 20 people with diabetes develop a foot
ulcer
• One in 10 foot ulcers result in amputation of a
foot or leg
What is a foot screening?
The purpose of a diabetic foot screening is to
identify the risk to the patients foot.
What is the Patient Risk Category?
• Foot pulses (present / absent)
• 10g monofilament test (present/absent)
• Foot deformity (yes / no)
• Footwear
Diabetic Foot Risk Classification
• low risk (normal sensation, palpable
pulses)
• increased risk (neuropathy or absent
pulses)
• high risk (neuropathy or absent pulses
plus deformity or skin changes or
previous ulcer)
• ulcerated foot within the preceding 12
months
Risk Classification
So What?
Diabetic foot Integrated Care Pathway
Kirklees PCT (Effective from April, 2012)….derived from NICE, 2004
GP staff
New patient and low risk screening
Pulses Palpable
Sensation ok (10g
monofilament)
Sensory neuropathy
And / or Absent pulses
Low current Risk
(Do)
Increased Risk
(D1)
Screening
Managed by
primary care
staff
Refer to Podiatry
Service
Sensory neuropathy
and or absent pulses
and foot deformity
High Risk
(D2)
Refer to Podiatry
service
…………….Foot Protection Team…………….
Foot emergency
Acute foot
Ulceration
Acute Foot
(D3)
Refer to
Podiatry
Emergency
Foot team
Low risk with No podiatry need :
ie normal nail care only.
- Personal care therefore done by carers.
Daily care: Feet should be washed and
moisturised
Weekly care: areas of hard skin/dry skin and
nails should be carefully filed
When attending to the feet review for breaks in
skin, discolouration and areas of thickened hard
skin.
At Risk / High risk
These are patients that have been identified
through annual screening to be at an increased
risk of developing foot problems related to the
complications of diabetes affecting the feet.
Should be under care of podiatry team.
However, daily / weekly maintenance and
review by carers should continue as set out by
treatment plan set out by the podiatrist.
Complications of Diabetes affecting
the lower limb
• Peripheral Neuropathy
• Peripheral Arterial Disease
• Infection
Other factors including: smoking, foot deformity,
HbA1c, ill fitting footwear, trauma
….can all destroy the foot in diabetic patients
Diabetic foot ulcer (sensory neuropathy)
Photos Courtesy of: Louise Stuart, Consultant Podiatrist, NHS Manchester
To conclude…….
• Diabetic foot complications are common
• At risk / high risk feet should be referred to a
foot protection team (Podiatry)
• Acute / ulcerated feet should be referred to a
multidisciplinary foot care team (via Podiatry)
Podiatry contact No. 0800 0158222
Remember:
Daily footcare / review is down to a patients
carer.
Podiatry will provide care for those with a foot
health need as determined by the condition of
the feet and a patient’s Risk status.
Any questions?
A Local Focus on Good Practice
Quest for Quality
in Calderdale Care Homes
Rhona Radley
Senior Service Improvement Manager
(NHS Calderdale Clinical Commissioning Group)
Eileen King
Quest Matron
(Calderdale and Huddersfield NHS Foundation Trust)
Why Quest? - Background
Strategic Overview:
o Health and Social Care Strategic
Review
o GP Practice Leads identified as
key priority in 2012/13
o Reactive vs proactive approach
o Celebration of partnership
working
o Best in class
o Better Care Fund
National & local response to
failings in the care sector:
 Winterbourne View – Serious
Case Review
 Mid-Staffordshire Hospital –
DoH Review
 Serious Case Reviews
 The Care Bill 2013
3 domains of Quality:
Patient Safety, Effectiveness, Experience
Why Quest?
What do we know?
Statistics for hospital attendances and admissions from care
homes were very high.
The top 5 reasons up to November 2013 for emergency
admission from care homes were identified as:
1. Urinary Tract Infections (UTIs)
2. Respiratory Infection inc. Pneumonia
3. Fractured Neck of Femur
4. Senility
5. Syncope and Collapse
Why Quest? – Continued...
What do we know?
Variation in practice and inconsistency across care homes – a need to standardise
practice and up-skill staff
High rates of A&E attendances and hospital admissions from care homes
High rates of falls/ UTIs, Fractured Neck of Femurs etc
When moving to a care home, residents:
• Can loose contact with the NHS, such as access to specialised care, with little
contact with Geriatricians and Old-Age Psychiatrists (nationally 40% of residents
were identified as having dementia in a care home setting)
• Can receive reactive care from GP’s
• Can be at risk of malnutrition
• Could receive inappropriate prescribing
Aims of the project:




To improve quality of care
To maximise independence and dignity
To reduce unplanned demand on GPs
To reduce avoidable A&E attendances; and avoidable admissions
and readmissions to hospital
 To improve medicines optimisation through regular reviews,
modifications and clinical interventions both in and out of hours
 To improve end of life care
What is Quest?
3 key stages of the Quest for Quality in Care Homes project:
 Stage 1 –
Deployment of IT systems across the care
homes in order for clinicians (GPs and Quest
Matrons) to access real-time clinical records of
residents
 Stage 2 –
Deployment of Assistive Technology across the
care homes (Telecare; and Telehealth)
 Stage 3 -
Multi-disciplinary team supporting the care
homes
24 Care Homes included in the project
Lower Valley
· Elm Royd Nursing &
Intermediate Care
Home
North Halifax
· Bankfield Manor
Residential and
Intermediate Care
Home
· Ingwood Nursing Home
· Lands House Residential
& Nursing Home
· Cedar Grange
Residential Home
· Valley View Residential
Home
· Rastrick Grange &
Rastrick Hall Residential
& Nursing Homes (x 2
homes)
· The Manor House
Residential & Nursing
Homes (x 2 homes)
· Fernside Hall Residential
and Intermediate Care
Home
· Park View Nursing and
Intermediate Care Home
South Halifax
Upper Valley
· Saville House
Residential Home
· Asquith Hall Nursing
Home
· Summerfield House
Residential & Nursing
Home
· Trinity Fold Residential
Home
· Pellon Lane—Bracken
Bed Nursing &
Intermediate Care
Home
· High Lee Barn
Residential Home
· Mill Reed Lodge Nursing
Home
· Waterside Lodge
Residential & Nursing
Homes
· White Windows Nursing
Homes
· Bankfield Care Home
· Ferney Lee
· Woodfield Grange
Nursing Home
Stage 2 - Telecare
Currently over 750 telecare items across the care homes
Stage 2 - Telehealth
Myclinic2 and peripherals
50 myclinics across the Quest care homes
Stage 3 – MDT rollout
 Integrated social and clinical approach – person-centred
 A single point of contact for non emergencies
 Anticipatory care planning, prevention, early intervention and proactive management
 Support and advice for staff in care homes - provide training to care homes where
identified
 Responsive, timely interventions
 Specialist input for advice and support
 Consistency across the care homes
 Works alongside existing services to promote the health and well-being of residents
 To be the common platform to aid complex decision-making and communication
 Advance Care Plans; Self Management Plans; Complex medications review
The Quest team
Operational:
• 6 Quest Matrons
• Consultant Geriatrician
• Pharmacist
• Therapy team
• Psychology rep
• Palliative care rep
• Links to Speech and Language Therapy, Tissue Viability, Infection Control,
Safeguarding, Dietetics and GPs
• 2 managers
• Dedicated Performance and Quality Officer
• Dedicated admin post to support performance officer, and the MDT
Governance:
Monthly Contract meeting
Quest in action
 Matron cover 7 days a week, 365 days a year - 10am – 6.30pm
 Pharmacist support – 5 days a week
 Consultant Geriatrician - 2 afternoons per week
 Community location
 Full MDT meets once a week to discuss approx. 10 cases.
 Also Consultant Geriatrician & Matron/s meet once a week to visit complex patients.
 All information entered onto clinical systems and communicated to relevant partners, and
access to ICP Triage Manager (readings from telehealth)
 Working alongside:
 GP’s; Social services; Community Nurses; Support and Independence Team;
 Specialist Nurses – Palliative Care; Parkinson’s Disease; Respiratory; Heart Failure etc.
 Emphasis on integrated working with other members of the MDT
Performance Management
How will success be measured?
•
Questionnaires
•
Focus groups/ feedback
•
Monthly Contract Report including x2 case studies
•
Monthly Dashboard
Impact
Referrals:
•
1195 referrals to the MDT so far:
 52% non-urgent (response within 2 days)
 45% urgent (response within 4 hours)
 3% routine/ planned
Feedback from Primary Care:
•
Initial feedback from Primary Care that unplanned demand on GPs is significantly reducing
A&E Attendances:
•
Increased by approx. 10% compared to last year
Hospital Admissions:
•
25% reduction in hospital admissions compared to last year:
– April - October 2013 = 813
– April - October 2014 = 612
Length of Stay in Hospital:
•
April - October same as last year = 11 days
Cost of Stay in Hospital:
•
October 2014 was £235k compared to £255k in October 2013 = reduction of 8% = saving of £20k for
October.
•
Total cost April - October 2014 = £1.5m, compared to April – October 2013 which was £1.9m = 22% lower
= saving of £400k
Case studies
Case Study 1
• Resident with Dementia became less mobile and not eating. Care home staff requested
supplements.
• Quest Matron reviewed the individual, undertook a holistic assessment and established they
were constipated - suffering with faecal impaction.
• Quest Matron administered 2 enemas during the day and instructed care staff about fluid intake
and aperient administration.
• Within 24 hours, the individual was up and walking again, and was eating and drinking normally
within 4 days.
Outcome:
- Immediate action to resolve impaction
- GP visit avoided
- DN visits avoided
- Prescribing of supplements avoided.
Case Study 2
19 May
•
Quest Matron was asked to review an individual with a history of falls, agitation and unresponsive for up to 6 hours in the day.
Patient had previously been admitted to hospital twice, and attended A&E once due to falls
•
Comprehensive assessment carried out and emergency care plan put in place.
•
Telehealth monitoring initiated
•
Quest Matron checked care home staff familiar with nursing an unresponsive adult eg airway safety, positioning of patient etc.
•
To discuss at MDT meeting
21 May
•
Staff at care home concerned as to how they can manage the resident
•
Detailed discussions of events and past medical history along with review of tests done in the past
•
MDT concludes these daily episodes appear to be from recurrent seizures with no obvious trigger
•
MDT suggests to titrate the medication for seizure that was overdue; start an episode/ fit chart to monitor response; continue
telehealth; weekly review of progress at MDT; ensure DNAR in place; stop non essential medications.
•
Quest Matron liaise with G.P. to ensure medication changes were agreed
28 May
•
Staff at care home able to cope better as understand why the episodes happen, and maintaining the episode/ fit chart.
•
Still having daily episodes of the same pattern.
•
Increased titration of medications in a week and report to next MDT.
4 June
•
No further episodes - patient much improved and mobilising well
•
Good feedback from family and care home staff able to manage the situation better
•
Titrate medications as planned
•
Report to MDT in 2 weeks unless problems
Summary





15 months left of project
Already seeing significant benefits for patients and services
Impact in primary care
Practice becoming more robust and consistent across care homes
Support to care homes
Any questions?
The Role of Primary Care
Title to go here
Dr Judith Parker
Subtitle to go here
The Primary Care Team
GP
Nurse Practitioner
Practice Nurse
Practice Manager
Reception Team
Extended Primary Care and Community
Teams
Community Matron
District Nursing Team
Primary
Care Team
Mental Health
Heart Failure Nurse
Hospice
Tissue Viability Nurse
Diabetic Specialist Nurses
Podiatry
What you might expect from the GP
• Organising and agreeing care plans
• Where appropriate annual review or more likely interim
reviews
• Providing emergency care for the acutely ill patient with
Diabetes
• Secondary Care referrals as appropriate
• Liaising with Out of Hours providers
Expertise in Primary Care
• Variable within practices
• Plans locally to up skill all general practice clinical
staff in Diabetes Care.
• Plans to improve access to DSN’s and consultant
expertise within the community setting