1. North Manchester CCG Diabetes in Care Homes Audit & Action Plan Practice Nurses Meetings – 21 st March & 28 th April 2014

2. Three Objectives To assess the current state of diabetes care delivered to care home residents in NMCCG and compare that with the general population; To identify the causes and impact of any deficiencies uncovered; To recommend a strategy to overcome them.

3. The Evidence - Base ‘Good Clinical Practice Guidelines for Care Home Residents with Diabetes’ (Diabetes UK 2010)

4. Methodology Invite all care home managers to participate; Structured interview averaging 45 minutes; Completion of a nationally accredited Institute of Diabetes for Older People (IDOP) questionnaire; Free text views of care home managers; Anonymised report to the CCG.

5. Sample 34 out of 38 care homes in North Manchester CCG 4 declined to participate – 2 were 3 bedded residential homes for patients with learning disability residents; – 1 was a 9 bedded residential mental health home; All stated they had no residents with diabetes. – 1 did not respond to request for interview, saying the manager had left; A fourth, 3 bedded residential mental health home with just 1 resident, who did not have diabetes, was included in the audit of the company’s larger home audit. 33 IDOP questionnaires were completed.

6. The Care Homes and Diabetes QuestionN Number of care homes34 Total beds available1113 Total beds occupied915 Bed occupancy82% DiabetesN Number of residents with diabetes142 Prevalence15% Residents on insulin34 Prevalence24%

7. Staff Training and Education QuestionN% Do your staff currently have access to any training and education courses in diabetes? 26% Have any of your staff had formal training and education in diabetes during the last 12 months? 26% Have your care home staff received training in recognising and dealing with hypoglycaemia? 1750% Have your care homes staff had training in the dietary need of residents with diabetes? 2161%

8. Policies and Procedures PolicyN% Are you aware of the Good Clinical Practice Guidelines for Care Home Residents with Diabetes? 720% Do you have a documented policy on diabetes management?1029% Do you have a policy on screening for diabetes?13% Do you have a written policy for managing hypoglycaemia?618% Do you have a nominated member of staff with a designated responsibility for diabetes management? 26%

9. Self Management Dietary Advice Do your residents have a routine nutrition assessment on admission to your care home? 2573% Do you ensure that dietary advice is available on request to residents with diabetes? 3294% Self Medication Do some of your residents self-medicate?720% Do you have a system to check that those who self-medicate take their medication? 7 100% Hypoglycaemia Do you access a resident's knowledge of hypoglycaemia using a standard protocol? 926% Do you ask your residents with diabetes if they know the symptoms / signs of hypoglycaemia? 1132% Are you aware of those residents who are at increased risk of hypoglycaemia? 34100%

10. Individualised Care Plans (ICPs) 100% of residents with diabetes had ICPs – But basic and focused on nutrition and exercise Many (most) residents not able to participate in developing / agreeing their plan – IDCP to include management advice for carers around individual’s personal needs All homes impressed with the IDOP template and have adapted a modified (shorter) one – To be implemented as Phase 2 and second audit

11. Diabetes Annual Review N% Do you ensure that all your residents have an annual review arranged with their GP? 2059% Do you receive an annual review report on each of your residents with diabetes? 00% Do you keep documented evidence of the latest HbA1C estimation carried out by the GP for each resident with diabetes? 00% Do you keep documented evidence of the latest test of kidney function (eGFR) carried out by the GP for each resident with diabetes? 00% Do your residents have an annual accredited retinopathy retinal screening?? Do your residents have a documented test of cognitive function within the past 12 months 2264% Do your residents have a documented test of mood in the previous 12 months 2264% Do you know what your GP’s latest assessment of each residents’ individual ‘foot risk’ is – Low Medium or High risk? 00% Are you aware of any of your residents with diabetes that have been exception reported by their GP? 00% Are residents with diabetes receive/are offered an annual flu vaccination?34100%

12. Information sharing with GPs Few had any idea of the outcomes of annual reviews or any patient specific information about diabetes 1 home only had requested such data from the practice which it received; All keen for more information None knew whether their residents had been exception reported

13. GP Support Care homes have between 1 and 8 practices supporting them; – Would prefer “one care home : one practice” RCGP / BGS recommendation But worries about CQC and patient choice 5 practice described as good or excellent – 1 GP visits every Monday – 2 practices hold monthly clinics for residents – 2 have practice nurse visits A few are ‘disrespectful’, ‘unhelpful’, ‘not very good’; Getting timely home visits is difficult Communication between GPs and DNs to change treatment can be slow.

14. Emerging Themes No care homes had a designated lead for diabetes Care homes do not have sufficient numbers of residents with diabetes to keep their skill set up; – How much impact this has on the status quo and QALYs or unplanned admissions is not known; – Can’t quantify emergency admissions for diabetes from NWAS data; Prevalence at 14% is probably too low – 20% is the average amongst hospital inpatients > 65yrs – Some studies report 17 -25% – Potentially around 40 - 80 residents with undiagnosed diabetes Most patients appear to get little or no annual monitoring of their disease Foot protection seems to be an issue

15. Key Conclusions DM care in care homes falls well below that of the general population, – Prevalence is too low – 40-80 undiagnosed cases based on national figures; – Most do not get the 9 care processes; – Using evidence from elsewhere this group may generate around 136 unplanned admissions p.a. half of which are preventable; Primary care support generally poor – needs to be improved; Much can be done by educating and supporting staff to do more; – With supporting guidelines and protocols Reliable external support and the leadership of a DSN would help and be welcomed.

16. Draft Recommendation Quantify the baseline – The second individual patient audit, being carried out whilst implementing Individual Diabetes Care Plans, as well as the demographics should include: a retrospective look at the number of diabetes related calls, attendances and admissions for residents with diabetes for years April 2012 – 2013 and April 2013 – current. ? And the total number for other reasons; An assessment of whether each was preventable; Coding patients on GP register, living in a care home;. Write up learning – as case studies.

17. Draft Recommendation # 1 Basic care and basic rights – Every resident should have a care plan which includes a 9 care process check list and clinical reason stated in notes as to why this was not done, if this is not possible or clinically inappropriate; – Care home staff should be informed by GP of special measures to prevent or minimise acute and chronic diabetes complications, via the IDCP; – Care home staff should have the responsibility and authority, as the residents’ carer, to ensure that these basic rights are delivered on time; – The level of exception reporting for care home residents should be monitored by the CCG. – Care Home residency to be coded on practice system

18. Draft Recommendations # 2 Education and training – Care home staff should receive a basic education package which is refreshed every two years; – Staff skills to be demonstrated through competencies. (Can this be linked to Gold Standard Framework somehow?); – Education should be backed by a standard set of accessible guidelines and protocols; – Specific management advice to be included in IDCPs; – Both could also be available to DNs.

19. Draft Recommendation # 3 Quantify undiagnosed diabetes – The CCG should consider whether it wants to screen residents for undiagnosed diabetes, either routinely as recommended in national guidelines (on admission and every two years there after) or continue with an as clinically indicated approach.

20. Draft Recommendation # 4 Provide external support for care home staff – Commissioners should consider external diabetes support for care homes, provided by DSN(s) – The DSN should have access to diabetes Consultant, for support in managing complex cases and without the need to refer to hospital.

21. My Diabetes Care Planning in Action: How my GP & PN can help me and my carers.

22. My Annual Diabetes Review & Goals

24. Appropriate Diabetes Care Planning: Quality of Care and Life Expectancy < 1 Year1 - 10 Years> 10 Years End Of Life care: GP decides targets & symptom relief; Foot care most important to avoid ulcers – tissue viability management. These guidelines Normal Care Target HbA1c 58mmol/mol

25. Diabetes Care (1 – 10 Years) HbA1c Annually Diet only +/- Oral Medication Target 64 mmol/mol No need for CBM. Call GP for advice if: Not eating / drinking Unwell or infection Injectables Target 75mmol/mol Daily Fasting CBM. + CBM test if symptoms suggest hypo and When unwell

26. Blood Pressure Control (1 – 10 Years) Blood Pressure Annually GP Discretion Treat to QOF Target At Risk of Postural Hypotension Yes No

27. Diabetes in Care Homes Project Over to you for your questions and thoughts please. Contact: peta.navein@nhs.netpeta.navein@nhs.net m: 07766814057