DR RAQUEL DELGADO DIABETES GP LEAD Diabetes CCWHE OOH Contracts.
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Transcript of DR RAQUEL DELGADO DIABETES GP LEAD Diabetes CCWHE OOH Contracts.
DR RAQUEL DELGADODIABETES GP LEAD
Diabetes CCWHE OOH Contracts
Aims and Objectives
Address variation of care across CCGs and practices
Early identification and preventionBetter management of the 9 care processesReward and promote specialist services in
the communityUp skill practices and clinicians
Tools to support the contracts
NWL Diabetes Education ProgrammeSystem1 OOH Diabetes TemplatesCCWHE Diabetes guidelines available from
Hounslow CCG websiteDiabetes Dashboards New Diabetes Community Service
Systm1 OOH Templates
CCG Dashboards
OOH Diabetes contracts
High risk diabetesDiabetes Level 1Diabetes Level 2 - injectables
Requirements for all the contracts
No exception reportingAll practices submitting data to the National
Diabetes Audit (NDA)Provide the data set requirement to secure
payments and monitor improvementsEngagement with local diabetes education
programme Named lead GP/ClinicianPeer review and clinical auditPayment based on KPIs achievement
High Risk Diabetes
Identify high risk patientsRegister of high risk patients XaZLG: gestational diabetes and abnormal glucose test Annual BP, HbA1c , lipids , smoking, BMI and lifestyle interventions/referral
Level 1 Diabetes Contract
Referral to structured education and provide patients with information at diagnoses
Annual 9 care processes including ACR and retinal screening
Annual review with ½ hour appointmentHypoglycaemia recording frequency and managementCCWHE Diabetes guidelines for BP, lipids, HBa1c, insulin
and glucometers + glucose stripsCare plans including housebound and care home patientsCopy of care plans given to patients with individualised
targets Patient satisfaction survey Discharge from secondary care suitable patients
Level 2 Diabetes Contract
Insulin and GLP-1 initiation and optimisation and insulin education
Two ccredited clinicians Only accredited clinicians can carry out the serviceAnnual accredited re-fresher courses Adhere to prescribing guidelines for insulinFace to face appointments , telephone, email, SkypeDietician and DSN support from the community
serviceReferral to insulin education programmesMinimum network population of 30,000
New Diabetes Service
Named diabetologist , dietician, DSN and podiatrist per locality
Clinical psychologistDiabetes podiatryFlexible service to meet the needs of localities and
patientsEmail and telephone access to all clinicians within the
serviceJoint clinics with diabetologist , DSN and dieticians Joint visits to housebound patients Larger choice of education programmes for Type 1 and
Type 2 (newly diagnosed, insulin and established diabetes)