1. Measuring Success
Demonstrating Impact

2. Working in collaboration with:
Pocket Medic which is a company that makes bespoke short health education films which can be prescribed to patients

3. Taking a STANCE on patient education
Patient Education and empowerment to self-care
Give back the responsibility of care to the patients
Increase patient confidence to self-care
Patients able to access support when they need it
Structured Group Education
1:1 Consultation
Directory of Services to facilitate referral to other services & 3rd Sector
Annual foot Assessment
Easy Access to help when needed
In the light of these drivers we established that we wanted to provide….
After our research and benchmarking we developed the idea of producing a….
Xpert/ DAFNE, Epp, Elderfit, NERS

4. Project Scope
To provide foot health education and healthier lifestyle support to all patients with diabetes who are referred to CAV UHB (Cardiff & Vale University Health Board). Developed in partnership with patients and healthcare professionals:
“My Healthy Feet” concentrates on diabetic foot health and foot pathology prevention
“Healthy Me” enables the patient to have the right knowledge and support to control their diabetes and other healthier lifestyle choices
So the scope of the project was defined as….
Healthy me pushes forward the idea of Making Every Contact Count using the Directory of Services to identify the first step support most appropriate for the patient.

5. What does success look like?
Numbers Attending No. of appointments saved
DNA Numbers No. of contact minutes
HbA1c No. of Wounds
Weight No. with Neuropathy/PAD
Height No. who F/U at wound clinic
BP Money saved
Cholesterol COMPARE to those not on STANCE
Foot Risk Other??????
Objective?

6. The Patients Perspective (Patient Focus Group)
I don’t need to worry about cutting/filling my nails
I know how diabetes affects my feet
I can look after my feet with confidence
I know when to get help
I know where to get help and how
I know what to do if I get and ulcer/wound?
I know the most important information to prevent me having an amputation?
I know I can be supported to make healthier life style choices
Subjective: NOT A SINGLE NUMBER TO WORK WITH!!!!

7. Patient Reported Outcome Measures (PROM’s)
Bristol Foot Score – Self administered, 15 pt Q/A – Perceptions of own foot health, used to measure efficacy of an intervention (nail surgery)
Manchester Foot Pain and Disability Index - Self administered, 19pt Q/A – measures foot pain and disability including functional limitations (Forefoot problems, HAV, etc)
EQ5D Index, EQ VAS – Self Administered, page Q/A with measuring mobility, looking after myself, doing usual activities, having pain or discomfort, feeling, worried, sad or unhappy
Aus Tom – Australian Therapy Outcome Measures - 3 sets, physiotherapy, occupational therapy and speech pathology, other? Clinician administered 4 scores – impairment, activity limitation, participation limitation and stress and wellbeing
PAM’s (Patient Activation Measures) – Self administered, 13pt Q/A, 4 levels – 1.Does not yet believe they have active important role, 2. Lack of confidence and knowledge to take action, 3. Beginning to take action, 4. Maintaining behaviour over time

8. Patient Reported Outcome Measures: STANCE
Patient Reported Outcome Measure Working together to help you look after your feet
Likert Scale: A scale used to represent people’s attitudes to a topic.
Question 1. Before your visit today, how confident were you to manage your own foot health?
Question 2. After your visit today, how confident do you feel to manage your own foot health?
Question 3. Before your visit today, how was your knowledge of how diabetes affects your feet?
Question 4. After your visit today, how is your knowledge of how diabetes affects your feet?
Question 5. Before your visit today, how confident were you to manage your healthy life style choice behaviours such as diet, exercise, smoking, alcohol intake or mental health?
Question 6. After your visit today, how confident were you to manage your healthy life style choices behaviours such as diet, exercise, smoking, alcohol intake or mental health?

9. Patient Reported Outcome Measures: STANCE
Question 7. How confident are you to spot a foot problem that needs professional help?
Question 8. How confident are you that you can get help when you need it?
Question 9. Do you feel your visit to podiatry has been beneficial to help you look after your foot health?
Question 10. Was the education given at the right level and easy to understand?
Was the Podiatrist:
Question 11a. Able to answer your questions?
Question 11b. Friendly and helpful?
Question11c. Able to engage you in your foot health and general health and well-being?
Question 12.
Is there anything you will do now to look after your feet that is different following your visit to podiatry today? Yes No   If yes, please state what:

10. Patient Reported Outcome Measures: STANCE
Question 13.
Do you know what your Foot Risk Classification is?
  Yes No I don’t know what this is If yes, please state what:
 And:
Do you know what this means for your feet?
   Yes, I understand what this means for my feet
  I think so but I need more information
  No, I don’t know what this means for my feet   
Question 14.
Do you know what your most recent HbA1c is?
Yes No I don’t know what this is
 If yes, please state what it is …………. mmols/mol
Any other comments:

11. PROM’s Questions 1,2,3,4,5,6

12. PROM’s Questions 7,8,9,10 & 11a,11b,11c

13. Question 12
Is there anything you will do now to look after your feet that is different following your visit to podiatry today?
 Yes No  
If yes, please state what:
Check my feet every day
Put cream on my feet every day
Wash and dry between the toes
Wear better shoes

14. PROM’s Questions 13 & 14
Of the 12 who said they new their HbA1c at education 2 stated what it was
Of the 6 who said they new their FRC at education, none stated what it was
Of the 32 who said they new their HbA1c at consultation 30 what it was
Of the 33 who said they new their FRC at consultation 18 stated what it was

15. Additional Data Consultation data Identified Foot Risk for each pt Low
Moderate
High/Active
Identified Average HbA1c for the 45 patients
Identified Average HbA1c for the moderate and above FRC pts
Identified Average HbA1c for the Low FRC pts
Any other comments:

16. Example Results
HbA1c (92 Patients): Average: 59 mmol/mol Range: 33 – 156 mmol/mol Number of patients who knew what HbA1c was: Before Education: 16.84% (16 of 95) After Consultation: 72.00% (28 of 39)
We looked at 58 patients HbA1c results, 54 had results recorded on Welsh Clinical Portal and the results were:

17. Example Results
Diabetes Education
Consultation
Invited
184
117
Attended 82
Pt Cancelled 35
DNA’d 32 9
PROM 95 39
Some patients did not require us to book a follow-up consultation, some were booked into other clinic types for patient convenience
64% Patients attended education (not including family and friends – 3 or 4 extra per session)
70% of those attending Diab. Edu. attended Consultation
Foot Risk Classification:
Low Risk: 50 Moderate Risk: High/Active: 1
One of the issues of the project is to get to grips with data. I have found it difficult to ensure that the data is collected and recorded properly, usually due to time constraints. There is little time to formulate and analyse the data and this is one area where we need to concentrate on as we go forward.
Initial data can give us a good idea of how the project is doing.
16 Lost to follow up consultation = reasons include 7 DNA’s, x 5 appts not issued or declined 2 cancelled and rebooked, 1 DNA rebooked, 2 cancelled not needed
Foot Risk Classification recorded at their Consultation.
Low risk: 49 (61%)
Moderate risk: 30
Of these 15 placed on Annual review with the ability to Self refer.
High/Active: 1
(80) (2 lost to F/U)
Only 3 of the moderate group were found to have a foot health need that required further appointments, 1 more needed nail surgery, 5 were given advice to self care, pocket medic video, Diabetes Uk literature, a contact number for help should they need it and have been placed on a recall register for their annual review

18. Opportunity Costing
CAV UHB Finance & Prof Nick Rich, Bevan’s Academy :
New Patients via STANCE
32 Moderate Risk identified
25 on open rapid access and annual review after support to self-care
4 ongoing care (4-6 contacts/year)
Pts seen within 2 weeks of referral for STANCE and 4 weeks for consultation
Creates clinic capacity for patients with greater need
Existing Podiatry Case Load
3700 Low and Moderate Risk foot
System to review existing patients roll out April 2018
Potential Case Load?
7800+
4 – 6 Appointments/year with annual foot assessment
STANCE education and 1 consultation
Annual Review including foot assessment
20 minute self referred appointment
1 Primary Care contact
£344
£143
£114
£57 £7
344 / 5 (sessions) = per session
25 x = 1720
25 x 344 = 8600
Net potential difference of £6880

19. Questions?