Best network care initiative
This award recognises the significant gains to quality of care and productivity that may be achieved through integration of diabetes care through networks, whether across the whole diabetes care pathway, or through specialist networks.
The Super Six model: integrating acute and community diabetes care across South East Hampshire
Southern Health NHS Foundation Trust and Portsmouth Hospitals NHS Trust
Starting in November 2011, the existing community diabetes team was joined by the local hospital diabetes specialist consultant team to provide regular in depth educational support to GP practices and locality nursing teams as well as providing day-to-day advice via email and telephone. This was influenced by the need to tackle three key issues: pathway inefficiencies involving secondary care follow-up; unacceptable variations in quality of care and knowledge of diabetes and management; and the disconnect between care services resulting in fragmentation and duplication. Specific objectives included MERIT training for 50 clinicians per year; DESMOND training for 520 patients per year; and bespoke training to meet identified local need. Since the initial service began it has delivered MERIT training for 227 clinicians; DESMOND training for 2263 people with diabetes and 35 of 53 GP practices have had education visits. Feedback is overwhelmingly positive from clinicians, people with diabetes and their carers and training courses are consistently over-subscribed.
"It supports primary care healthcare professionals and ensures 100% of patients with diabetes have a personal care plan. An adaptable, sustainable programme with demonstrable cost savings."
Diabetes Service Redesign: The Wakefield Approach
NHS Wakefield District PCT
NHS Wakefield PCT restructured its local diabetes care pathway in order to enable specialist care services to support primary care teams in delivering high quality diabetes care. It was decided this new model should involved the allocation of a specialist team, including a diabetologist and diabetes specialist nurse, to a GP practice along with dedicated administrative support. A new local enhanced service was then developed to incentivise integrated working in the treatment of people with diabetes. Changes included the establishment of specialist primary care clinics, involving either a GP and diabetologist or a diabetes nurse and practice nurse; a clinical case review to identify priority patients; and practice-based education for healthcare professionals. More practices are now initiating insulin, titrating and managing stable patients on insulin, while prescribing of new diabetes drugs shows has escalated, signifying a significant unmet need in treatment has been identified.
Integrated community diabetes service
Bedfordshire Clinical Commissioning Group
Bedfordshire Clinical Commissioning Group (BCCG) commissioned a new integrated model of care to enable two secondary care trusts to provide seamless and accessible care in the community across Bedfordshire. After collating views from all stakeholders, including patients, a common set of principles was agreed between providers and commissioners. This has led to staff employed specifically to address the inequalities in care across the county; tailored clinics for black and minority ethnic populations; and patient education groups are being delivered from community settings. Staff are reporting better communication between primary and secondary care, renewed enthusiasm within their role and enhanced working relationships between the two acute hospitals.
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