Integrated Diabetes Care
Diabetes in Community Care Extension (DiCE):
Sandwell & West Birmingham model
Dr Parijat De
Clinical Lead in Diabetes & Endocrinology
Nicola Taylor
Diabetes Nurse manager
City Hospital, SWBHT, Birmingham
The Challenges:
 Since 1996, the number of people living with diabetes has
more than doubled
 2.7 million people – or 6% of the adult population – have
been diagnosed with diabetes
 Prevalence of diabetes is double the national average in
Sandwell & West Birmingham area
 Eighty per cent of NHS spending on diabetes goes on
managing complications, most of which could be prevented
Integrated diabetes care (IDC)
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“approach seeking to improve QOC of the
individual with diabetes, service users
and carers by ensuring that services are
well co-ordinated around their needs”
Kings Fund & Nuffield Trust 2011
5 pillars of Integrated Diabetes Care
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1) Clinical engagement & partnership
2) Care planning – joined-up care & engaged
patients
3) Integrated IT systems
4) Aligned finances and responsibility
5) Shared clinical governance
The original Pathfinder project:
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The Pathfinder Diabetes Project (initiated 15 years
ago) started off with 2 practices in West Birmingham
initially (expanded to seven GP practices in 2010) to
address some of these unmet needs.
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In this model, GP practices would identify cohorts of
difficult diabetes patients with poor HbA1c control for
generally a one-off for advice and management plan
by the consultant/diabetes specialist nurse every 3-4
months. The primary care team then take this plan
forward and put it into action.
Diabetes in Community Extension (DiCE)
Team formation:
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Since April 2014, the DiCE model has been
accepted and agreed by the local CCG - all
SWBCCG GP and Primary care clinicians will have
access to clinical support from diabetes specialist
teams where necessary.
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Seamless care between primary and secondary
care teams working in unison to provide the desired
integrated care.
Objectives of DiCE model:
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Close working with every GP practice – integration
of specialist and generalist across boundaries
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Joint clinics and review – devolve care, provide care
close to home, reduce DNA rates
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Provide support & education to GP/PN – help build
capacity & capability in primary care
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Support patient education programmes and
empower patients to self manage – DAFNE, XPERT education courses
Objectives of DiCE model:
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Provide evidence based care according to NICE
and local pathways
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Develop protocols and pathways jointly - which
patients, seen where and by whom (including
specialist care in Hospital) - empower GP/PN to
manage locally & refer appropriately
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Dissipate and encourage wider use of Advice &
Guidance service
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To improve formulary compliance and value for
money prescribing
Integrated Care Model
Up-skilling
Primary care
& delivering
care closer
to home
Redesigned
& Integrated
Diabetes
service
Education &
Training
Programme
Mentorship
DiCE Teams
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10
Two teams – Sandwell and West Birmingham
Hospital and Birmingham Community Health Care
Trust
4 hours every 8 weeks with each practice
Assigned Diabetes specialist nurse and Consultant
Options to suit individual practice to support
diabetes patients
– Virtual clinics
– Joint consultations
Diabetes LIS (Local Improvement
Scheme)
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Increase Primary care expertise & management
90% type 2 and stable Type 1 diabetes care in
community
Aim to meet Diabetes UK 15 Care essentials
LIS Sign-up (total number of CCG practices 99)
– Level 1: 89 practices
– Level 2: GLP1- 72 practices, Insulin – 68 practices
Going forward the LIS will be part of the Primary Care
Commissioning Framework (PCCF)
Diabetes Education in Sandwell &
West Birmingham CCG
6 steps to excellence
Education! Education! Education!
Learning Needs
Assessment
• Learning needs assessment dashboard for ALL
Sandwell and West Birmingham CCG staff
delivering Diabetes Care.
Advanced Level
Diabetes
Education
• PIT stop (programme for injectable therapy)
train the trainer programme. Also previously
commissioned PREDICT to deal with demand.
Warwick course offered through BCHC Trust
Mentorship
programme
• To support practice based learning for PIT stop
and PREDICT courses.
• Complete level 2 competency sign off
Education! Education! Education!
Refresher
sessions
• Lunch and learn or half day sessions
supported heavily by BCHC trust and
CCG commissioned courses.
Business to
business tool
• Working in partnership with external
companies to identify practices requiring
support in diabetes care.
Clinical
Engagement
• Development and promotion of treatment
pathways according to NICE and local guidelines
in-conjunction with secondary care and local
CCGs.
• Area Prescribing Committee, Pan Birmingham
Medicines Management advisory group, Pan
Birmingham Diabetes Network.
Referral Pathways
The following Map of Medicine pathways have been
reviewed by the Diabetes Steering Group:
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15
Diabetes – complications
Diabetes – Foot Care
Diabetes - cardiovascular disease (CVD)
Diabetes - eye disease
Diabetes - renal disease
Diabetes - suspected in adults
Diabetes in pregnancy
Diabetes - suspected in adults
Type 2 Diabetes management
Type 1 Diabetes Mellitus in children and adolescents
4 key activities within DiCE:
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Case notes review
Joint consultation
Virtual clinic – advice & guidance/telephone
review, Telemedicine (FLORENCE), SKYPE
Education
Typical patients for joint consultation:
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multiple co-morbidity,
repeated admissions with hypo/DKA/HHS,
complex insulin regimes,
mixed/multiple complications,
difficult to control HbA1c
difficult to manage BP/lipids
social issues
repeat defaulters
Joint Consultation
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Baseline review of practice diabetes register/QOF
figures
Identify key needs of an individual practice
Work backwards
Prioritise difficult/complex patients – invite them for
joint consultation with GP/Consultant
Joint review benefits – familiarity with GP and
expertise of Consultant/DSN
Every 8 weeks, depending on need and f/u with DSN
and advice via email/phone as needed
Examples of joint consultations
Use of new insulin?
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58 year old, male, Type 2 diabetes, BMI 46
PMH failed gastric band, poor mobility
On Lantus 300 units once daily, metformin and pioglitazone.
HbA1C 62, few scattered hypos
Taking Lantus 150 units BD (4 injections/day) – he wanted to reduce
amount of insulin injections
We discussed the use of U300 Glargine (Toujeo) which would allow
him to reduce TDD of insulin by 20% initially and allow him to give as a
once daily and less volume of injection
SGLT2 inhibitor/GLP1 injection as the next step including support from
local weight management services.
Hypoglycemia in T1DM?
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42 year old female, Type 1 diabetes
PMH Stroke, CKD Stage 3A, severe retinopathy
DAFNE trained and HbA1c 79
On Levemir 18 units and Novo Rapid 1 unit to 10 g carbohydrate.
Severe hypoglycaemia on two occasions and hypoglycaemia
unawareness– basal insulin reduced by 50% by GP, fasted BG 15-18.
Practice nurse not confident in managing insulin adjustment.
We were able to discuss the guidelines for insulin adjustment for
severe hypo and target blood glucose to avoid risk of hypo-also to
ensure this lady had hypoglycaemia treatment on prescription
including Glucagon injection and glucose gel
We discussed re introducing a split basal insulin and referral for
pump assessment.
Substituting and adding in the
right agent?
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GM, male aged 64, T2DM for 5 years
Seen June 2015 – weight 83kg - BMI 31, HbA1c 78
On Metformin, Gliclazide and Levemir 16 units pm
fpg 8-10 mmol but not keen to increase insulin for fear of weight
gain
Gilclazide stopped and SGLT2 inhibitor Canagliflozin
300mg added
Explained less chance of hypos now and can uptitrate dose of
insulin without hypos (Glic stopped) and further weight gain (as
Canagliflozin added)
Next review in 2-3 months
When to think about insulin?
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MN, 56 year old male taxi driver
T2DM since 1988
On triple oral therapy – Glic/MF/Gliptin
HbA1c 78
BMI 25, losing weight
What next – insulin initiation vs job?
Discussed in clinic absolute need for insulin as clearly
insulinopenic – job implications discussed but importance of
avoiding DKA mentioned
Patient understood the importance and has started BD insulin
Virtual consultation examples
T2DM & diabetic nephropathy – high BP in
surgery ? Real ? White coat
FLORENCE simple telehealth
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Florence (Flo) is a mobile phone texting system for health care.
Flo texts advice and collects patient information. This
information can be accessed by clinicians a device connected
to the internet, e.g. a computer in their surgery, a tablet
smartphone.
It’s cheap for the NHS and works for patients with even a basic
mobile phone.
Flo uses a free text service for all patients in the UK. It doesn’t
cost patient anything to use, as texts are paid for by NHS
organisations.
FLO
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Patients don’t have to rush from work, or find a parking space,
so their blood pressure (BP) isn’t unduly raised – saves time yet
patient is monitored!
Clinician/PN can look at the readings sent in by a relaxed
patient from home or wherever they are, rather than the erratic
readings that can result from attending surgery, (it takes no
longer than a minute or two to do this).
And when you give advice to hypertensive patients to lose
weight, stop smoking, cut down on salt, do more exercise…
they don’t always listen. Flo is a great opportunity to send these
advice messages a couple of times a week, and patients may
be more able to understand the drip-feed of such lifestyle.
High BP confirmed through FLO at
home!
29/10/2015 13:40:07
152
65
Advice
This reading is too high
27/10/2015 09:30:16
165
66
Advice
This reading is too high
26/10/2015 12:12:37
161
65
Advice
This reading is too high
25/10/2015 09:25:14
145
64
Advice
This reading is too high
23/10/2015 15:45:28
160
77
Advice
This reading is too high
22/10/2015 15:08:55
162
70
Advice
This reading is too high
21/10/2015 10:13:35
157
77
Advice
This reading is too high
20/10/2015 12:34:14
160
72
Advice
This reading is too high
17/10/2015 11:45:33
160
71
Advice
This reading is too high
16/10/2015 11:41:01
160
80
Advice
This reading is too high
15/10/2015 11:09:45
160
72
Advice
This reading is too high
13/10/2015 17:13:30
160
75
Advice
This reading is too high
12/10/2015 08:42:13
160
80
Advice
This reading is too high
10/10/2015 10:20:31
154
75
Advice
This reading is too high
09/10/2015 10:25:38
155
60
Advice
This reading is too high
08/10/2015 15:38:56
174
68
Advice
This reading is too high
07/10/2015 15:31:03
172
75
Advice
Second reading is too high
Anti-hypertensive dose adjustments made via FLO
texting without clinic appointment
T1DM, renal transplant patient – high BP in
clinic ? White-coat
FLO home BP readings all good!
Date
Reading1
Reading2
24/10/2015 12:25:03
116
86
17/10/2015 07:35:09
114
84
10/10/2015 11:19:34
121
84
02/10/2015 10:40:10
122
86
26/09/2015 15:10:07
117
84
18/09/2015 08:15:26
131
90
12/09/2015 22:34:19
114
81
Level
Alert
Advice
Second reading is too high
Advice
Second reading is too high
Advice
Second reading is too high
FLO text advice given & discharged!
A complex house bound patient?
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TR - 68 year old male, T2DM few years
Recently joined practice
House bound due to obesity – weight 190kg, BMI 64
Back pain – inactive, only gets up to go to toilet, sleeps
downstairs
Erratic eating habits – eats late at night, snacks continually
Difficult to bleed, last hbA1c July 74, creatinine 190 – eGFR 30
Declined dietician, physiotherapy input, GLP1 due to s/e profile
On 270 units of Humalog mix 50 - 90 units tds (MF stopped)
What would you do?
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Discussed with very efficient PN who has regular
email contact with patient and who has also done
home visits
No easy solution!
Virtual consultation and advice!
Way forward:
 Try bleed patient to get latest HbA1c/renal function
 May need to revisit use of Liraglutide – now licensed up to
eGFR 30 ml/min
 Re-iterate need to reduce snacking and decrease portion size
 ? Get dietician in again/pshycologist
 Try using a basal bolus regime using new insulin Toujeo
(greater flexibility, less volume, true 24 hour profile)
 Regular communication with PN
DiCE Initial results (Apr 2014-May 2015):
Data from 53 practices :
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3060 patients have benefitted from DiCE service,
595 less outpatient appointments made,
25/53 practices (50%) have seen a decrease in their
outpatient activity,
31 practices reported positive engagement with their
respective DiCE teams,
22 practices have reported mixed feedback,
Both quantitative and qualitative data collection is
on-going
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Questions?