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Diabetes Prevention

Diabetes Prevention. Dr Neel Basudev Lambeth CCG Diabetes Lead Clinical Director Health Innovaton Network. Healthier Who?. Free, nine month community-based behaviour change programme to help people prevent the onset of Type 2 diabetes

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Diabetes Prevention

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  1. Diabetes Prevention Dr Neel Basudev Lambeth CCG Diabetes Lead Clinical Director Health Innovaton Network

  2. Healthier Who?

  3. Free, nine month community-based behaviour change programme to help people prevent the onset of Type 2 diabetes • Lambeth is one of the first wave sites and has “gone live”. Partnership across South London lead by HIN and Southwark CCG • 18 supportive, group-based sessions for up to 20 people delivered by trained, local staff. Provider is Reed Momenta • Programme designed by experts and underpinned by a decade of research into community-based diabetes prevention Overview

  4. Flow chart

  5. Three stage approach • Engagement • Individual Assessment • Behavioural Intervention Patient Journey

  6. Aged 18 years or older • Be registered to a Lambeth GP practice • Not have been diagnosed with Type 2 diabetes • Not be pregnant at the time of referral • Have a HbA1c of 42-47 mmol/ml (6.0-6.4%) or an FPG of 5.5-6.9 mmol/l tested in the last 12 months Referral Criteria

  7. A CASE OF CONFUSION You will gain nothing by doing both FPG and HbA1c other than confusion….

  8. Different tests 575 (6.6%) FPG 1685 (19.4%) HbA1c 1610 (18.5%) 1110 (12.8%) 1035 (11.9%) Phenotypically, these are different populations.

  9. Sensitivity • Reproducibility • Ease of use • Cost • Limitations This is going to get ugly

  10. Includes: • Blood glucose test (if referral reading is >3 months) • Height, weight and BMI calculation • Warwick-Edinburgh Mental Wellbeing Score (WEMWBS) • Delivered from: • LloydsPharmacy • Third-partner affiliate pharmacies e.g. Cooperative • Community locations What’s involvedInitial assessment

  11. Getting Started • Session one: 1.5 hours • Sessions two-six: weekly, one hour • Sessions seven-eight: fortnightly, one hour • Example Topics • Introducing prediabetes • Eatwell guide and a healthy balanced diet • Cardiovascular activity What’s involvedgetting started

  12. Embedding Change • Session 9-12: fortnightly, one hour • Example Topics • Enlisting social support • Healthier eating outside the home What’s involvedEmbedding change

  13. Moving Forwards • Session 13-18: monthly, one hour in length • Blood tests are repeated at session 13 (6 months) and 18 (9 months) • Example Topics • Relapse prevention • Unhelpful thinking patterns What’s involvedMoving forwards

  14. Healthier YouSession overview

  15. This is a learning process for everyone eg FPG vs HbA1c debate in Bromley • Sutton & Southwark mail campaign, Bromley opportunistic, Lewisham & Wandsworth practice led • Feedback and data being collected in real time to inform the programme development • NIHR bids and NDA pilots • Referrals trickling in • 20 referrals from 13 practices • STEPS waiting list exists and is growing • 722 referrals for Q1 2016 • 13% attended Progress so far The success of this programme depends on us…

  16. Diabetes and high risk of diabetes template

  17. Nda data QOF & NDA Indicator Definitions: DM003 – The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the apreceding 12 months) is 140/80 mmHg or less. DM004 – The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within athe preceding 12 months) is 5 mmol/l or less. DM007 – The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the apreceding 12 months. NDA – T2 Eight Care Processes – The percentage of people with Type 2 or other diabetes receiving the Eight Care Processes. NDA – T2 Attended SE – The percentage of newly diagnosed people with Type 2 or other diabetes recorded as ‘attended' a astructured education program.

  18. Nda data

  19. Improvement and assessment framework

  20. Two virtual clinics. At least one clinic will be held with a consultant diabetologist or GP with a Special Interest (GPSI) in Diabetes. The other clinic will be held with a community diabetes specialist nurse (DSN). • Identify patients to be discussed at the virtual clinic. Searches are available on EMIS enterprise within the Medicines optimisation folder • Complete the indicated information in the outcomes summary spread sheet Delivery scheme

  21. Thanks for listening Questions…..

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