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Welcome to the Brent Intermediate Diabetes Care Services Launch. 10th May 2006 Clay Oven , Wembley. Brent Diabetes Services. Dr. Senan Devendra MD MRCP Consultant in Endocrinology & Integrated Diabetes Care Brent tPCT & Central Middlesex Hospital. The Team. Claire Lawler

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Welcome to the Brent Intermediate Diabetes Care Services Launch

10th May 2006

Clay Oven , Wembley


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Brent Diabetes Services

Dr. Senan Devendra MD MRCP

Consultant in Endocrinology & Integrated Diabetes Care

Brent tPCT & Central Middlesex Hospital


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The Team

  • Claire Lawler

  • Nina Patel, Julia Anthony & Lucy Ogida (DSN’s)

  • Sala Salih & Camelia Kirollos (Diabetes Edu. Network)

  • Salma Butt, Helen Davies & Farhat Hamid (dietetics)

  • Rakhee, Gaytree & E. Shillingford (podiatry)

  • Leena Sevak & Maggie McClelland (pathway managers)

  • Rowland Hughes (DPAG chair)

  • Silvia Sedeghian & G.Vafidis(retinal screening)

  • Ricky Banarsee & Azeem Majid (Imperial - research)

  • Kirsten Darylmple (Imperial – education faculty)

  • JKC – too many to mention


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www.brentpct.nhs.uk


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Diabetes SPA total referrals per locality (according to GP post code)20.02.06 – 26.04.06 total = 207 x £241= £50,000


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Brent Diabetes Services

  • Clinical support: MDT approach

    - Intermediate care clinics

    - Email consultations

    - Liaising with District Nurses/out of hours

    - Up-skilling Primary Care colleagues

    - Telephone support clinics for patients


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Brent Diabetes Services

  • Education: MDT approach

    - patient education

    - health care professional education

  • Research & Audit


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100 years of hormones

Photo Courtesy of Prof. G.Williams

Dean of Medicine, Univ. of Bristol


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Expected Standard of Care& Microalbuminuria Pathway

Dr Encarna Fernandez

Diabetes GPWSI – Kilburn Locality


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Weight Management in Diabetes Intermediate Care

By Helen Davies & Salma Butt

Specialist Diabetes Dietitians


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The business case !

  • Type 2 DM – overweight at diagnosis

  • Av. BMI = 28-29

  • Relationship with macrovascular disease

  • Weight loss associated with survival

  • Does weight need to be managed “differently” in DM


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Current services

  • Diabetes education sessions

  • MDT intermediate care clinics

  • Fit for Life programme

  • Obesity clinic at Central Middx


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MDT intermediate care clinic

  • Initial assessment

  • Readiness to change

  • Brent options

  • Refer to pathway

    (enclosed in conference pack)


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Fit for Life

  • 12 week weight management programme

  • Nutrition education + exercise

  • Group support

  • Referral through Diabetes SPA


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Obesity clinic at CMH

  • Patients with complications/poor control + maximum oral therapy

  • Failed at Intermediate care clinic

  • Intensive weight management advice

  • Long term support if necessary

  • Bariatric surgery


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New package of care for improving Glycaemic control in primary care

Nina Patel

DSN Brent tPCT


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AIM

  • To provide focused intensive input to improve HbA1c with a clear supportive plan and exit strategy


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Referral criteria

  • Patient on maximum doses of oral hypoglycaemic

    (see protocol for the use of oral hypoglycaemic agents*)

  • HbA1c > 8 % (age < 75)

    *www.brentpct.nhs.uk


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Where will the patient be seen?

DSN clinic in own locality

  • KilburnKilburn Square clinic

  • WembleyWembleyWCHC

  • WillesdenWillesden CHC

  • KingsburyChalkhill Health Centre

  • HarlesdenMonks Park CHC


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First Review – Consultation 1

  • Patient considered for education session

  • Medication review – address compliance

  • Dietetic assessment – weight management pathway

  • Assessment of motivation, health beliefs, readiness to change

  • Set realistic goals

  • Obtain a contract with agreed roles of DSN and patient (minimum 1.5% HbA1c reduction by 3 months)

  • Start Blood glucose monitoring

  • Insulin discussed or started


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Consultation 2:(2 to 3 wks post visit 1)

  • Assess blood glucose results

  • If not started, start insulin e.g. once daily long-acting or twice daily mix. Insulin

    (this can be done with practice nurse/ district nurse)

  • Given algorithm to follow

  • Address weight gain issue with insulin

    Titration of insulin doses over telephone with daily or weekly contact.


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Weight check/ WC

Blood glucose control

BP

Injection sites

Management of pen device.

Hypo’s

Consider prandial insulin

Titration of insulin doses over telephone with daily or weekly contact.

Also consider

Orlistat/Sibutramine

Weight management clinic

Exercise classes

Patient support group

Expert patient course

Consultation 3: (4 to 6 weeks post visit 1)


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Consultation 4: 3 month review

  • Check HbA1c (1 week before appointment)

  • Further titration of insulin

  • Add pre-meal soluble insulin

  • Check weight gain/WC & dietitian review

  • Titration of insulin doses over telephone with daily or weekly contact.


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Exit strategy

  • Hba1c less than 7.5% (or desired goal achieved) return to the care of GP and Practice nurse.

  • Maintain regular contact (telephone of link DSN or Diabetes SPA given)

  • If HbA1c goal not achieved – consider other options (eg. restart package of care, JKC - insulin pump therapy, novel therapeutic agents)


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Joint British Societies Guidelines 2 on prevention of Cardiovascular Disease in Clinical Practice (JBS2):implications for Brent

Dr. Joan St John

Gpwsi Diabetes

Wembley Locality


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Introduction

  • How will the new guidelines affect the management of people with diabetes in Brent

  • What are the workforce and cost implications

  • What is the most effective way to implement the new guidelines ?


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JBS – 2 2005

High risk patients

  • Established athero-sclerotic disease

  • 1ry prevention CVD risk >20%

  • Diabetics

    ALSO elevated risk due to a single risk factor

    BP >160/ >100 (or less if target organ damage)

    Elevated TC: HDL >6 or FH of hyperlipidaemia


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JBS-2 targets for high risk patients

Total cholesterol <4

(25% reduction)

LDL-cholesterol <2

(30% reduction)


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Next Steps

  • What is the most effective way to implement the new guidelines ? In Primary care or Intermediary care

  • Guidelines for Titration of Simvastatin or

  • Trying to treat to target with one drug one visit


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“Highest” Risk Group ( Diabetes + one of the following)

  • Previous CV event

  • Peripheral Vascular disease

  • Family history of Premature (<60yrs) death from IHD

  • Renal Impairment (eGFR < 60)

  • Micro-albuminuric patients


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Treatment Pathway for High Risk Group

CHOLESTEROL < 5.5 OR LDL < 3.8 CHOLESTEROL > 5.5 OR LDL >3.8

Start Simvastatin 20mg Start Atorvastatin 20mg (titrate to 80mg)

to 40mg if needed to achieve target or Rosuvastatin 10mg od

Target:

T. Cholesterol = 4

LDL = 2

Law, BMJ 2003


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Education


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Diabetes Education

Network

Dr Camelia Kirollos

Associate Specialist

Central Middlesex Hospital

* Please refer to handout for details


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Brent Diabetes Education Network


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Diabetes Education Network

  • Professionals’ Education

  • Nurses: Practice nurses, District nurses, Twilight nurses, Residential homes, Nursing Homes

  • Doctors: GPs, GPwSI, Hospital Doctors

  • Health care Assistants


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Diabetes Education Network

  • Patients’ Education

    Short courses - 2 days

    Long courses 6 weeks

    Tailored Ethnic or Cultural courses

    Eg. For Pakistani, Gujarati Communities


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Attendants of diabetes patient education courses between July 2004 and March 2006

Total = 550


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Patients’ self-management courses

  • DAFNE: For Type 1 Diabetes (since 2002)

    Alternate Months at JKDC (CMH)

    Available soon in intermediate care

  • DESMOND: For newly diagnosed Type 2 Diabetes (NSF requirement)


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DAFNE Improvement lasts

30

9

25

HbA1c (%)

20

8

Severe hypoglycemia

per 100 pt y

15

10

7

5

6

0

0

1

2

3

6

Years of follow-up


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Certificate in Diabetes Care: Warwick Courses

  • Warwick Diabetes care

    • Run twice a year: February and September

  • Includes 4 units (Each is a whole day)

    • Understanding Diabetes

    • Therapeutic Options

    • Preventing & Managing Complications

    • Life Times


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Consultant led seminars

  • Insulin for life programme (Insulin initiation)

  • MERIT (Insulin initiation)

  • Consultant notes review service

    (eg. HbA1c >7.5%)


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Educational Needs

  • The network needs to extend and invite the front line workers:

    • Eg: Health care assistants

    • Twilight nurses

    • Pharmacist in the community and hospitals

    • Local initiatives for day release education.

    • Courses for Hospital staff.

    • Junior Doctors programmed trained.


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Competency & Skills“A Mandatory Requirement ”

Ram Dhillon FRCS

Consultant Surgeon, Northwick Park Hospital, Harrow

Hon. Professor, Middlesex University, London

National Clinical Lead, Elective Care Team

(m): 07 958 450 544

(e): ram.dhillon@talk21.com


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2nd Opinion

No Mans Land(Locus of Demand & Need for Capacity, Competency & Skills)

No Mans Land

Intermediate Tier Level Care

Home to: (PwSIs) GPwSIs, NwSIs, AHPwSIs


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What is Fundamentalfor Acquisition of Competency & Skills

  • Knowledge & Skills

  • Knowledge & Skills

  • Knowledge & Skills

  • Knowledge & Skills

    Adequate Training & Accreditation


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Clinical activity *

Local mentoring *

Directed learning *

SEM

M1

M2

M3

SEM

EX

Middlesex University, London

Royal College of General Practitioners (RCGP)

Clinical Case Studies *

Seminars #

(lectures, practical skills)

OSCE #

VIVAS #

A Model for Competency/Skills Training & Accreditation in Respiratory Medicine for Primary Care ( Dr Vincent Mak & Prof. Ram Dhillon)

  • NB. Further details on Postgraduate Training for Special Interests : www.pgdip.com

PGCert

REGn

+

CPD


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NSFs

Demand

Capacity

Access

Integrate 1*/2*

Retention/Recruitment

Clinical Pathways

Clinical Governance

Community Care

Cost-Effective Care

PwSIswithSpecial Interests ( competent & skilled)Potential effects


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Questions?

gm.e.diabetes.bre-pct@nhs.net

www.brentpct.nhs.uk


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