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Dr Neil Black , Consultant Physician
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Reforms: Diabetes West 2012-2016 Neil Black MD FRCP (Edin.) Consultant Physician Lead Clinician Diabetes Network Western Health & Social Care Trust
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Transcript of Dr Neil Black , Consultant Physician
Reforms: Diabetes West 2012-2016
Neil Black MD FRCP (Edin.) Consultant Physician
Lead Clinician Diabetes Network Western Health & Social Care Trust
Reforms• Identify a problem
• Those at the sharp end come up with the solutions
• Take it from the patient perspective
• Evaluate and adjust
Themes of reform
1. Stratification
2. Care integration & Communication
Care types/levelsHospital MDT: T1 n ~1300, T2 ~3,000
Modified Portsmouth Model (‘Super Six’)• Acute inpatient• Pregnancy / Pre-Pregnancy• Active Foot disease • Advancing CKD/RRT• Type 1 (including insulin pumps)• Complex T2
• Care delivered as close as possible to ‘one stop shop’
Care types/levelsHospital MDT: T1 n ~1300, T2 ~3,000 Modified Portsmouth Model (‘Super Six’)• Acute inpatient, Pregnancy/PrePregnancy, Active Foot, • Advancing CKD/RRT, Type 1 (incl. insulin pumps),
Complex T2• Care delivered as close as possible to ‘one stop shop’
Primary Care: n=6,500
• At risk of diabetes
• Controlled T2
• Uncontrolled T2 with guidelines and advice
Care types/levelsHospital MDT: T1 n ~1300, T2 ~3,000 Modified Portsmouth Model (‘Super Six’)• Acute inpatient, Pregnancy/PrePregnancy, Active Foot, • Advancing CKD/RRT, Type 1 (incl. insulin pumps),
Complex T2• Care delivered as close as possible to ‘one stop shop’
Primary Care & Diabetes Support Team:
n=3,000•‘Uncontrolled’ T2• T1 DNA: to be invited to #Type1West online community
Primary Care: n=6,500
• At risk of diabetes• Controlled T2• Uncontrolled T2 with guidelines and advice
Care types/levelsHospital MDT: T1 n ~1300, T2 ~2,000 (↓ from 3,000)Modified Portsmouth Model (‘Super Six’)• Acute inpatient, Pregnancy/PrePregnancy, Active Foot, • Advancing CKD/RRT, Type 1 (incl. insulin pumps),
Complex T2• Care delivered as close as possible to ‘one stop shop’
Primary Care & Diabetes Support Team:
n=4,000 (↑ from 3,000) •‘Uncontrolled’ T2• T1 DNA: to be invited to #Type1West online community
Primary Care: n=6,500 (↔)
• At risk of diabetes• Controlled T2• Uncontrolled T2 with guidelines and advice
DiabetesWest care integration Open / shared records
Education
Guidance
Accessibility for advice
DiabetesWest care integration Consultants with Primary Care
Systematic Practice visits: organisation, audit, education, support, case discussionsRegular Diabetes slot at Primary Care Practice Learning Days
Reorganisation of diabetes community teamEquity of access across WHSCT area, professionals in specialty hubsCoordinated working as active MDTs rather than independent professionals
Guidelines and pathways
NI Electronic Care Record Diabetes PathwayOpen, transparent, patient-centredWestern adoption June 2016
Diabetes Service single point of referralNIECR e-referral triage: referral from GP desktop system
Communication: futuresNIECR Patient Portal
Electronic Document Transfer
Podcast GP / Practice nurse education (Public Health Agency collaboration)
Project ECHO (PHA /e-health collaboration)
When the case doesn’t fit…..Self-Management Education:
• DESMOND• Diabetes Updates (Diabetes CHAT)
• CHOICE (Insulin flexible dose adjustment: BERTIE)• CHOICE refreshers
• Divert Diabetes (prevention)
Diabetes West: IHI Triple Aim1. Improving the patient experience of care
(including quality and satisfaction);
Diabetes West: IHI Triple Aim1. Improving the patient experience of care
(including quality and satisfaction);a) Continuityb) Common, simple messagesc) Empowered patient making decisions together with their
teamd) Reducing waits for reviewse) Reducing waits at clinic attendancef) Clearer pathways for specialty access and urgent referralg) Bring care closer to people: diabetes support hubs
Diabetes West: IHI Triple Aim1. Improving the patient experience of care (including
quality and satisfaction);
2. Improving the health of populations; a) Systematic practice visits targeting low A1c on SU, high
A1cb) Auditing achievement of essential points of carec) Quality improvement initiative with GP QI leader on 5 point
critical care component initiatived) Increase direct communication, support and education for:
GPs, Practice Nurses, Community Pharmacy
Diabetes West: IHI Triple Aim1. Improving the patient experience of care (including
quality and satisfaction);
2. Improving the health of populations;
3. Reducing the per capita cost of health care.a) Reducing duplication of effortb) Reducing repeat testing by open access to common recordsc) Decomissioning Diamond systemd) Reducing complications?
