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PROGRESS ON COMMISSIONING A DIABETES SERVICE

PROGRESS ON COMMISSIONING A DIABETES SERVICE. Developing a Model of Care for Adult Patients with Diabetes January 2009. What do we know about current and future service demands? . Growth in obesity to continue Growth in new diabetics to continue Somerset: 19,200 in 2007 to 28,000 by 2017

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PROGRESS ON COMMISSIONING A DIABETES SERVICE

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  1. PROGRESS ON COMMISSIONING A DIABETES SERVICE Developing a Model of Care for Adult Patients with Diabetes January 2009

  2. What do we know about current and future service demands? • Growth in obesity to continue • Growth in new diabetics to continue • Somerset: 19,200 in 2007 to 28,000 by 2017 • Sizeable number of undiagnosed diabetics • Need to invest in services to meet demand • Need to increase emphasis on prevention • Need to ensure optimal use is made of specialist services

  3. What do patients want? • Better information at diagnosis • Improved access to information • More control over their condition • Better integration of care • More services closer to home • Better access to related services (dietetics, podiatry) • More focus on prevention

  4. What do GPs want? • To continue to provide best possible services from in-house skills • More training for members of primary healthcare team • Better access to Dietitians and Podiatrists • Better access to Diabetic Nurse Specialists • Access to timely advice • Optimise diabetes QOF scores • To have the option of providing services over and above ‘core’ diabetic care (e.g. insulin initiation)

  5. What does Somerset PCT want? • Ensure new service has the capacity to meet expected demand • Improved services for diabetics • Equitable access to services • Uptake from hard to reach groups • Measure improvements in meaningful terms (outcomes based specification) • Implement health care record (eventually electronic) • Affordable service

  6. What are the key elements of the new service? • Increased availability of structured education (Desmond/Dafne courses) • Expansion in capacity of Diabetic Specialist Nurses, Dieticians, Podiatrists • DSN run countywide community clinics • Clinics to co-locate Dietitians, Podiatrists (Psychologists) according to need

  7. What are the key elements of the new service? (Continued) • DSN service to focus on: glycaemic control insulin initiations complex patients pre-pregnancy advice 8-8 advice line • DSN service to deliver training to primary care teams • DSN service to be monitored through specialist supervision • Specialist care to focus on patients with complex care needs

  8. Proposed Model of Care • The proposed delivery model is based on levels of care: • Level 1 providing core basic care • Level 2 an intermediate level of care • Level 3 specialist level of care • It is proposed to deliver all of Level 1 and Level 2 and as much of Level 3 as possible in the community as close to the patient’s home or work as possible. • Level 1 care will normally be delivered at GP practices but with input from pharmacists, local councils, voluntary groups particularly in relation to opportunistic screening.

  9. Proposed Model of Care (Continued) • GP practices may also opt to provide some of intermediate care. • A new community based service will be introduced, managed by multidisciplinary teams. This will deliver specified intermediate services and related Level 3 services, as well as training and ongoing support for practices. • Hospital care will be focused on the most complex cases with an enhanced level of care for patients admitted with but not because of diabetes. • A key theme running through all levels of care will be supporting patients to self manage through structured education programmes and agreement of care management plans.

  10. Next Steps January 2009 • Clinicians finalise Care Pathways • Patient involvement – 21 January • Information Packs available Feb 2009 • PEC approval of final specification • Year of Care Project continues April 2009 • Commission Service – details of provision still to be confirmed.

  11. Diabetes UK information packs • 2000 packs have been purchased from Diabetes UK for issuing to patients when the diagnosis of Type 2 Diabetes has been confirmed in order to provide them with consistent, quality assured information about their condition.

  12. Year of Care Project • Creating integrated care planner • Delivering self-care training • Results sharing documentation • Identifying clinical champions • Further details from MaggieAyre@somerset.nhs.uk

  13. Yeovil area only Current Community Service • GP referrals directly to: • Su Down Diabetes Nurse Consultant su.down@somerset.nhs.uk Tel: 01935 848281 Clinics held in Crewkerne, Wincanton and Yeovil.

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