Amir Hannan, Ed Jude, Jean Eades, Richard Fitton, Quesir Mahmood

 Identified our patient population and their management to date  Identified staff’s confidence with managing diabetes and potential interest  5 sessions  Each session to last an hour  Health passports to be produced  Folders for patients to help them look after their own health  ICP also happening that the practice is a part of

 Who are we going to target ?  Severe complex patients at high risk of an event  Patients with impaired glucose tolerance

 Create a patient-centred programme for….  Develop an internet resource to support the programme  Review some of the material we have collected  Care plans or…other more acceptable  Intranet for staff  Internet for patients and families  Health Passport for staff  Research paper to describe what we do

 When do we want / need to start  What help is there  From pharma company  From Ed Jude  From Amir  From jean Eades  (From Richard Fitton)  What are we going to do  Who is going to do it  Next steps?  Next meeting

 Each session lasts about 1 hour 30 mins  1 st session (Ed Jude)  Who are you  What is diabetes  How many people can check their BP, weight, BMs  What knowledge have they got already  Compliance and concordance  What are the targets we should achieve  Are we asking the right questions  Bring your own machine  2 nd session (Richard Fitton)  What is wellness and health, illness, fitness, disease and death  Prevention, managing diabetes, reduce risk of complications  Heart attacks, blindness, kidney disease, neuropathy, stroke, PVD  Describing where you want to be 10, 20 or 30 years from now and then plotting how to get there  3 rd Session (Jean Eades)  Lifestyle changes – what is it,  what is available and costs nothing,  PCT health improvement plans and help available,  walking buses, getting off bus 1 stop early, parking car further away  Local sports activities, clubs etc  dietary advice, smoking, alcohol, drugs,  getting the best from clinicians to help achieve these goals (doctors, nurses, pharmacists, podiatrists, others including extended family, friends, colleagues)  4 th session (Amir Hannan)  Information is power, records,  records access,  role of IT to support lifestyle changes and monitor own health  What tools are needed to support lifestyle changes, improve concordance and get the best from your healthcare  ultimately help shape a healthier lifestyle,  5 th session (All of us)  What was good, what was bad, do you want to know more about anything that we talked about or go over things that you would like to be reminded  Presenting the data patients have measured and what they have achieved over the 5 months  What are the next steps now and how to encourage others to start the programme  Need to ask patients to do something alone and do something together, Assessments (key pad) give people tasks to do  Pre-confidence knowledge, skills and attitudes and then repeat post course

 Give the programme a “name”  Need a “Mission Statement”  Determine aims and objectives and results  Determine knowledge, skills, attitudes, practice and experience  Pre-consultation validated test and then post test  Each speaker to produce what they plan to do / raise, research to find out what they are going to do  Determine what patients should do before the session, during the session and afterwards  Produce a care plan with pictures for patients and showing what their targets should be  Consider differences between IGT group and Diabetes group  Patient passport needs to be developed  Intranet website with information for staff (consider for patients too)  Determine monthly appointments starting in 3 months time  Need to determine date of next meeting and one more prior to starting the session