Brent Diabetes Launch Day - Presentation

57
Welcome to the Brent Intermediate Diabetes Care Services Launch 10th May 2006 Clay Oven , Wembley

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Transcript of Brent Diabetes Launch Day - Presentation

Page 1: Brent Diabetes Launch Day - Presentation

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 MRCPConsultant 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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Referral criteria to ECC

• Young adults with Type 1 diabetes (<35yrs)

• Poor glycaemic control despite on insulin (needing insulin pump)

• Hypoglycaemia unawareness

• eGFR < 30

• Foot ulcers requiring intensive management

• Women with diabetes who are pregnant

• Very obese who failed therapy

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Higher tariff set in Payment by Results system for diabetes treatment

New figures issued by the Department of Health show that the tariff set for the treatment of people with diabetes under the payment by Results system has been increased.  New tariffs for 2006/2007 are as follow                                             Tariff 2005/06          New tariff 2006/2007New adult (i.e. adult receiving their first treatment)      £152                                £241 Follow up appointment (adult)      £61                                 £88

Diabetes UK 2006

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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

0

10

20

30

40

50

60

70

80

Wembley Kingsbury Harlesden Kilburn Willesden

total referrals

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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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Photo Courtesy of Prof. G.Williams

Dean of Medicine, Univ. of Bristol

100 years of hormones

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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

• Kilburn Kilburn Square clinic

• Wembley WembleyWCHC

• Willesden Willesden CHC

• KingsburyChalkhill Health Centre

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

• 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

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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%• DiabeticsALSO 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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***P<0.001 vs Rosuvastatin 10mg; ^^^P<0.001 vs Rosuvastatin 20mg

LDL-C reduction & cost across statin dose ranges

0 -10 20 -30 -50 -60-5 -15 -25 -35 -45 -55

20mg

£22.64

40mg

£28.21

80mg

£24.07

-40

20mg

40mg

80mg

LDL-C: Mean change (%) from baseline at week 6

20mg

£2.34

40mg

£4.23

40mg‡ ‡

20mg

rosuvastatin

simvastatin

atorvastatin

10mg £18.03

10mg

10mg£ 18.03

10mg

pravastatin

p<0.002 vs. rosuvastatin 10mg ‡ p<0,002 vs, rosuvastatin 20mg p<0.002 vs. rosuvastatin 40mg

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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 Diabetes Education NetworkNetwork

Dr Camelia KirollosDr Camelia KirollosAssociate SpecialistAssociate Specialist

Central Middlesex HospitalCentral Middlesex Hospital

* Please refer to handout for details

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Brent Diabetes Education Brent Diabetes Education NetworkNetwork

DSNs

Commun.Nurses

Dietician

Podiatry

CMH

Int Care

GPsWI

GPs

Brent PCT

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Diabetes Education Diabetes Education NetworkNetwork

• Professionals’ EducationProfessionals’ 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 Diabetes Education NetworkNetwork

• Patients’ EducationPatients’ EducationShort 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 Attendants of diabetes patient education courses courses

between July 2004 and March 2006

Attendance of diabetes education courses between July 2004 and March 2006

Wembley30%

Kingsbury30%

Kilburn14%

Willesden20%

Harlesden6%

Total = 550

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Patients’ self-management Patients’ self-management coursescourses

• 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 lastsDAFNE Improvement lasts

6

7

8

9

0

5

10

15

20

25

30

HbA

1c (

%)

Severe hyp

oglycemia

per 100 pt y

0 1 2 3 6Years of follow-up

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Certificate in Diabetes Care: Certificate in Diabetes Care: Warwick CoursesWarwick 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 NeedsEducational 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 FRCSConsultant Surgeon, Northwick Park Hospital,

Harrow

Hon. Professor, Middlesex University, London

National Clinical Lead, Elective Care Team

(m): 07 958 450 544

(e): [email protected]

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

0%

50%

100%

P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11

Practitioner

Pa

tie

nts

(F

CE

)

2nd Opinion

No Mans LandIntermediate Tier Level Care

Home to: (PwSIs) GPwSIs, NwSIs, AHPwSIs

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What is Fundamentalfor

Acquisition of Competency & Skills

1. Knowledge & Skills2. Knowledge & Skills3. Knowledge & Skills4. Knowledge & Skills

Adequate Training & Accreditation

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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

Clinical activity * Local mentoring *

Directed learning *

SEM M1 M2 M3 SEMREGn + EX PGCert CPD

Clinical Case Studies *

Seminars #(lectures, practical skills)

OSCE #VIVAS #

Middlesex University, LondonRoyal College of General Practitioners (RCGP)

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PwSIswith

Special Interests

( competent & skilled )Potential effects

• NSFs• Demand• Capacity• Access• Integrate 1*/2*

• Retention/Recruitment• Clinical Pathways• Clinical Governance• Community Care• Cost-Effective Care

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Page 57: Brent Diabetes Launch Day - Presentation

Questions?

[email protected]

www.brentpct.nhs.uk