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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

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
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
what do patients want
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
what do gp s want
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)
what does somerset pct want
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
what are the key elements of the new service
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
what are the key elements of the new service continued
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
proposed model of care
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.
slide9

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.
next steps
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.
diabetes uk information packs
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.
year of care project
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
yeovil area only
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.