Community Diabetes Team

1. Community Diabetes Team Anna Potts Lead Diabetes Specialist Nurse Elaine MacAninch Community Diabetes Dietitian

2. Community Diabetes Team (CDT) Outline the structure and function of the team, including existing and new community diabetes services in the SLA Present some of the evidence base to support the service and outcome data from the pilot Indicate the criteria and methods for referring patients to the team. Was running in in Central and lately in East locality practices as a pilot project so some of you will be familiar with the team but this now extended across the city.Was running in in Central and lately in East locality practices as a pilot project so some of you will be familiar with the team but this now extended across the city.

3. Community Diabetes Team 0.8 Lead Diabetes Specialist Nurse 2 WTE Diabetes Specialist Nurses 1 WTE Specialist Diabetes Dietitian 1 WTE secretary/admin 3 hours a fortnight consultant time Employed by South Downs Health NHS Trust and based at Brighton General Hospital

4. Community Diabetes Team South Downs Health NHS Trust Clinics within community across city: Moulsecoomb Health Centre Stanford Medical Centre Portslade Health Centre Ship Street Surgery Conway Court Based at BGHBased at BGH

5. Service Level Agreement DESMOND group education Pre-Diabetes group education programme Insulin initiation in Type 2 diabetes Joint GP/Community Team management for individuals with T2 and suboptimal glycaemic control Educational programmes for primary care to support delivery of LES 73 and 73b and ongoing CPD

6. One of the key elements for providers of care (be it primary or secondary) is that they have to offer patient education. A main intervention outlined within the NSF and NICE is the provision of group education programmes. Historically, many centres have provided group education and the resource benefits are clear. However, until recently the impact on patient outcomes was not known. We will now explore 2 programmes, one of which is offered by within primary care and the other by secondary care. Although most individuals are offered group education there was a disparity in what they were offered - with variations in length, content and approach. Plus, most educators were not formally trained. Equally, there was insufficient evidence available to recommend a specific type of education or provide guidance on the setting or frequency of sessions. However, following the evaluation of some RCT�s observing specific programmes, NICE guidelines were published identifying key criteria which need to be satisfied for any group programme to be accredited (having a written curriculum, auditing, quality assurance programme and educators trained). Two such accredited programmes are DAFNE and DESMONDOne of the key elements for providers of care (be it primary or secondary) is that they have to offer patient education. A main intervention outlined within the NSF and NICE is the provision of group education programmes. Historically, many centres have provided group education and the resource benefits are clear. However, until recently the impact on patient outcomes was not known. We will now explore 2 programmes, one of which is offered by within primary care and the other by secondary care. Although most individuals are offered group education there was a disparity in what they were offered - with variations in length, content and approach. Plus, most educators were not formally trained. Equally, there was insufficient evidence available to recommend a specific type of education or provide guidance on the setting or frequency of sessions. However, following the evaluation of some RCT�s observing specific programmes, NICE guidelines were published identifying key criteria which need to be satisfied for any group programme to be accredited (having a written curriculum, auditing, quality assurance programme and educators trained). Two such accredited programmes are DAFNE and DESMOND

7. What is DESMOND? Recommendations for patient education RCT and QALY data Emphasis on self management Theoretical basis Quality assured Community Team accredited LES 73a DESMOND has a philosophy based on 4 core principles (people are ultimately responsible for their own self management, they wish to maximise their Q of L, barriers to self management are in the persons world and the consequences of DM are experience by the person with DM). � I won�t expand into too much detail but these have helped to develop the delivery, style and content of the programme. The programme has a theoretical basis which uses concepts form educational and health psychology Leventhal�s Theory behaviour shaped by patients beliefs about illness Social Learning Theory Behavioural theory and action planning Learning theories � dual processing theory Because of the philosophy there is a strong emphasis on the individual learning to take responsibility for making decisions about their self management The programme has an quality assurance programme, which is integral for local accreditation. This includes self, peer and external assessment. DESMOND has a philosophy based on 4 core principles (people are ultimately responsible for their own self management, they wish to maximise their Q of L, barriers to self management are in the persons world and the consequences of DM are experience by the person with DM). � I won�t expand into too much detail but these have helped to develop the delivery, style and content of the programme. The programme has a theoretical basis which uses concepts form educational and health psychology Leventhal�s Theory behaviour shaped by patients beliefs about illness Social Learning Theory Behavioural theory and action planning Learning theories � dual processing theory Because of the philosophy there is a strong emphasis on the individual learning to take responsibility for making decisions about their self management The programme has an quality assurance programme, which is integral for local accreditation. This includes self, peer and external assessment.

8. What is DESMOND 2, � day sessions or 1 whole day 10 patients, plus other Explore beliefs, causes/effects, food choices, monitoring, risk factors, physical activity and complications Complete individualised self management plan Process of care Total number of referrals 445Total number of referrals 445

9. Time from referral to session Highlight total numbers referredHighlight total numbers referred

10. DESMOND and satisfaction

11. DESMOND referral criteria Diagnosed with T2 in past year Suitable for group education Biomedical parameters required Referral template available PCT website 6/12 and appropriate for group education6/12 and appropriate for group education

12. Pre-Diabetes Education

13. Pre Diabetes NSF Associated risk of developing DM with IFG or IGT? Associated health risks with IFG, IGT Finish Prevention Study showed 58% reduction in risk of developing DM with intensive lifestyle intervention Role and efficacy of group education? Between 33% and 66% of people with pre-diabetes will go on to develop type 2 diabetes over a period of 3 to 6 years * Increased risk of medical conditions such as retinopathy and coronary heart disease ** The nurses health study demonstrated that those with pre diabetes had nearly 3 times the risk of CVDBetween 33% and 66% of people with pre-diabetes will go on to develop type 2 diabetes over a period of 3 to 6 years * Increased risk of medical conditions such as retinopathy and coronary heart disease ** The nurses health study demonstrated that those with pre diabetes had nearly 3 times the risk of CVD

14. PREPARE Study � 3/12 results

15. �Walking Away From Diabetes� Devised by DESMOND collaborative 3 hours of education, focus on diet and physical activity To be early implementer within BHC PCT practices Outcome data at one year Process of care Start of service January 2010

16. Pre DM referral criteria 6/12 and appropriate for group education6/12 and appropriate for group education

17. Insulin initiation in Type 2

18. Insulin initiation by CDT Process of care Patients assessed Insulin started individually Follow up individually, or group Telephone and subsequent ongoing contact as required

19. HbA1c on referral for insulin initiation 169 patients referred Seen within weeks of referral Range of HbA1c 6%-17.8% Mean HbA1c 10%

20. HbA1c on discharge following insulin initiation Range of HbA1c of patients on insulin at discharge 5.5% to 9% Mean HbA1c of patients on insulin at discharge 7.2% 14% of referrals did not require insulin

21. Patient behaviour changes

22. Satisfaction Very high satisfaction for: - process of care - involvement in decisions - ease of communication - information given Attending community clinics not perceived to be a problem

23. Insulin initiation referral criteria 6/12 and appropriate for group education6/12 and appropriate for group education

24. Joint Management of Type 2

25. Joint Management of T2 Individuals either on dual or triple oral hypoglycaemic agents or insulin with poor glycaemic control Joint management with GP/Practice Nurse Process of care??

26. Joint management referral criteria 6/12 and appropriate for group education6/12 and appropriate for group education

27. Education 2 day basic study day to support LES 73a for those without in-depth diabetes courses Those with in-depth course � refresher to support LES 73a 3 day course to support practices wishing to start insulin initiation � Warwick University Annual updates

28. Summary Community diabetes team are delivering DESMOND education sessions for newly diagnosed T2 now and will be earlier implementer for Pre-diabetes group education from Jan 2010 Service is now city-wide for insulin initiation in Type 2 and to review patients with poorly controlled Type 2 Range of edcuational opportunities will be available to support LES 73a and 73b.