Diabetes and Chronic Kidney Disease (CKD) commonly co-exist and management is complex, with frequent cardiovascular, retinal, foot and bone multi-morbidity and increased risks of hospitalisation. East and North Herts Clinical Commissioning Group (CCG) commissioned a pilot service to identify and provide a holistic virtual review of high-risk patients. The team worked with primary care to establish 15 pillars of care. A virtual specialist diabetes consultant review was carried out on each patient, followed by Skype case-based discussions with GP practices, to educate and upskill primary care colleagues to help manage vulnerable patients. The five core objectives were to: investigate the feasibility of extracting comprehensive ‘big data’ from primary care information systems; enable clinical data utilisation for individualised virtual diabetes specialist review; evaluate the practicality and acceptability of a Skype telehealth virtual case-based discussion for patient care and primary health care team training; record the extent of unmet clinical need and frequency of suggested therapy changes and to develop strategies to improve self-management of foot health and acute illness with metabolic-renal decompensation.
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