The Super Six model: integrating acute and community diabetes care across South East Hampshire

Summary

Starting in November 2011, the existing community diabetes team at South East Hampshire 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 to provide 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 
  • 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 
  • Bespoke training to meet identified local need.

Challenge

Commissioners and providers across the health community jointly developed the initiative for people with diabetes. Some Secondary Care services have subsequently been decommissioned and resources reallocated to community-based services.  

There were three key issues to tackle:  

  • Inefficiencies in the traditional pathway as long-term follow ups for people with diabetes were conducted in Secondary Care clinics
  • Unacceptable variations in the quality of care provided in primary and community care. This was believed to be contributing to higher than expected rates of diabetic emergency admissions and complication rates in the local population
  • Disconnect between care services, which resulted in an absence of structured care plans or duplication of effort.  
Care quality issues centred on clinician and patient knowledge.  Among clinicians there was inequitable knowledge of diabetes and insulin management. In addition there was no access to prompt specialist advice regarding diabetes management. Patients were also expressing a preference for care management within the Primary Care setting. 

Drawing upon evidence from the NSF for Diabetes, care was shifted from Secondary Care, and education and empowerment of clinicians and patients put to the fore. Nationally recognised education and training programmes are used for patients (DESMOND) and clinicians (MERIT – which meets Local Enhanced Service requirements). 

A community diabetes team with two part-time specialist nurses and a GPwSI had been in place since 2006, providing support in diabetes care to Primary Care. This was principally to GP surgeries, but included training in insulin management and healthcare professional education. The team recognised that additional support from consultant diabetologists would bridge the gap between Primary and Secondary Care services and enable more integrated care.  

In particular, this would begin to address acute admissions via the local Medical Admissions Unit or A&E department, ambulance service calls, and give longer term potential to reduce amputation rates in the populations served in South East Hampshire by the Hampshire and Portsmouth PCTs. 

Starting in November 2011, the existing community 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.  

In addition to the consultant team support, the service now has two full-time and one part time specialist nurse, a GPwSI and full-time administrative support. The service is receives £152,100 each year in funding. It has capacity for income generation through training programmes for health professionals and health care assistants, including those working in care homes.

Objectives

Through integration the initiative aimed to improve knowledge and skills in management of diabetes among patients, carers and clinicians, and improve communication and relationships across the health community.  

Specifically it aimed to:

  • Deliver MERIT training for 50 clinicians each year
  • Deliver DESMOND training for 520 patients each year
  • Deliver bespoke training to meet identified local need, eg, care homes
  • Ensure regular engagement with GP practices, including planned visits from the team (including a consultant diabetologist) at least twice a year (can be training sessions if required) and joint caseload review of diabetic patients
  • Ensure the consultant diabeteologist is available daily, by phone, to GPs, practice nurses, and community nursing teams Daily mobile phone consultant diabeteologist availability to GPs, Practice Nurses and Community Nursing Teams and provide an email advice line
  • Improve patient reported ability to self-care – 100 per cent of patients seen should have a personalised care plan
  • Deliver seamless care for PWD through complementary working relationships between Primary, Secondary and community care – including rapid access to specialist support by telephone and email 
  • Instigate a long-term downward trend in hospital admissions, inappropriate referrals to secondary care and ambulance conveyance rates to secondary care.

Back to the top



QiC Diabetes Winner 2012
Best network care initiative
The Super Six model: integrating acute and community diabetes care across South East Hampshire
by Southern Health NHS Foundation Trust and Portsmouth Hospitals NHS Trust

Contacts

Dr Tim Goulder

Job title:
Place of work:
GPwsi, Southern Health NHS Foundation Trust
Email:
timgoulder@nhs.net

Resources

Model of care - 420.5 KB

QiC Diabetes is partnered by:
Supported by: