Reforms: Diabetes West 2012-2016 Neil Black MD FRCP (Edin.) Consultant Physician Lead Clinician Diabetes Network Western Health & Social Care Trust Reforms: Diabetes West 2012-2016

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/levels Hospital 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/levels Primary Care: n=6,500 At risk of diabetes Hospital 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/levels Hospital 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/levels Hospital 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 Refer to the ‘shaft left’

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 discussions Regular Diabetes slot at Primary Care Practice Learning Days Reorganisation of diabetes community team Equity of access across WHSCT area, professionals in specialty hubs Coordinated working as active MDTs rather than independent professionals Guidelines and pathways NI Electronic Care Record Diabetes Pathway Open, transparent, patient-centred Western adoption June 2016 Diabetes Service single point of referral NIECR e-referral triage: referral from GP desktop system

Communication: futures NIECR 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 Aim Improving the patient experience of care (including quality and satisfaction);

Diabetes West: IHI Triple Aim Improving the patient experience of care (including quality and satisfaction); Continuity Common, simple messages Empowered patient making decisions together with their team Reducing waits for reviews Reducing waits at clinic attendance Clearer pathways for specialty access and urgent referral Bring care closer to people: diabetes support hubs

Diabetes West: IHI Triple Aim Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; Systematic practice visits targeting low A1c on SU, high A1c Auditing achievement of essential points of care Quality improvement initiative with GP QI leader on 5 point critical care component initiative Increase direct communication, support and education for: GPs, Practice Nurses, Community Pharmacy

Diabetes West: IHI Triple Aim Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; Reducing the per capita cost of health care. Reducing duplication of effort Reducing repeat testing by open access to common records Decomissioning Diamond system Reducing complications?

Neil Black Diabetes West 2016