Page 37 of 47
Appendix 7: Diabetes Prevention and Management Process
Core Services
Screening of High Risk Individuals Identification of people with diabetes
and pre-diabetes
Diagnosis and initial management Continuing care following agreed
protocol
Annual Medical Review for all patients on the diabetes register, in line with QOF Quality Indicators Referral to lifestyle services through
LiveWell Richmond
Referral to self-management programme
Referral to dietetic services Referral to counselling/psychology
services
Enhanced Services
Achieving all parameters outlined at Level 1
Provision of all care for Type 2 patients
Oral Glucose Therapy Hypertension Management Lipid Management
Initiation of Insulin/Injectable treatments in Type 2*
Ongoing management with insulin/injectable
Referral to lifestyle services through LiveWell Richmond
Referral to self-management programme
Referral to dietetic services Referral to counselling/psychology
services
* Where the skills within the practice exist
Specialist Diabetes Management
Consultant & Nurse Led
General MDT management and advice and/or access to therapies
• Specialist input
• Dietetics
• DESMOND Group education
• Podiatry
• Retinal Screening
• Patients with poor glycaemia control
• Insulin Initiation (for those practices not commissioned to undertake this themselves)
• Accept referrals from Level 2 Practices
• Develop Individual care plan with patient
• Insulin initiation for Type 2 patients
• Insulin initiation for BD & basal bolus regimens
• Titration of insulin regimens for both Type 1 and 2
• Telephone liaison and support for Level 1
& 2 practices
• Ongoing management of Type 1 patients
• Referral to lifestyle services through LiveWell Richmond
• Referral to counselling/psychology services
Secondary Care
Urgent Referral direct to consultant of choice:
Newly diagnosed/ registered type 1 patients Self-management programme, BERTIE
(Kingston Hospital or QMH)
Existing/ newly registered females with Diabetes who are pregnant
Newly diagnosed/registered adolescents and young people
Psychological support
Management of severe and acute complications
Inpatient care and diabetic emergencies Urgent Specialist Referral for X-ray and
Renal Unit
Prevention & Self-care Services
All patients at risk of diabetes, with pre-diabetes, or diabetes offered referral to LiveWell Richmond services to support with lifestyle changes and self-care:
Health Advisor, healthy eating, physical activity, weight management, Expert Patient Programme, Walking Away from Diabetes, stop smoking, safe drinking All eligible patients to be offered an NHS Health Check and referred to LiveWell Richmond services as needed
a
Level 1 Level 2 Level 3 Level 4
Patients will move across levels as their condition dictates
Page 38 of 47
Appendix 8: Stop Smoking
It is NICE guidance that all patients diagnosed with Diabetes should be referred for smoking cessation advice. This referral should be re-offered at every opportunity by all health care professionals until smoking ceases.
There are two QOF indicators for smoking related to diabetes for 2013-2014.
Smoking 2: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months
Smoking 5:The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months
Smoking cessation services are available through community pharmacies, GPs, secondary care and the dedicated smoking cessation service ‘Smoke Free’. The Smokefree contact number is 0800 085 2903 and the latest information can be found at:
http://www.smokefreekingstonandrichmond.nhs.uk/
Page 39 of 47
Appendix 9: LiveWell Richmond Services and Eligibility Criteria
Taking Care of Yourself: Eligibility Telephone help and advice in finding
support to achieve a healthier lifestyle Web Page
Mobile phone application for android and iphone
Volunteer Health Champions
Everyone who lives in LBRuT or has a Richmond GP
Supporting Change: Eligibility
Health Trainer Service – 1-2-1 health coaching in line with NICE PH6 Including smoking cessation
Everyone who lives in LBRuT or has a Richmond GP. Suitability for the programme is assessed by a fitness instructor, and data from practice required. Those with mental health problems and CVD are not excluded.
Weigh2loose BMI >25
Telephone befriending Adults aged 50+ who live in LBRuT or have a Richmond GP.
Expert Patient Programme Adults who are living with a chronic long-term condition and lives in LBRuT or has a Richmond GP.
Walking away from diabetes Those with pre-diabetes who live in LBRuT or have a Richmond GP.
Fasting blood sugar between 6 and 6.9 mmol/L.
Health walks No exclusions for adults; children
would need to be accompanied Expert Patients Programme (EPP)
The EPP is a self-management programme for people who are living with a chronic long-term condition. It is supports people by improving their confidence and quality of life, helping them manage their condition more effectively. The course covers: dealing with pain and extreme tiredness; coping with feelings of depression; relaxation techniques and exercises; healthy eating;
communicating with family, friends and healthcare professionals; planning for the future. The course is free, with six weekly sessions, each lasting around 2.5 hours. It is particularly helpful for those living with diabetes.
http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/expert-patients-programme.aspx
Walking Away From Diabetes
Part of the DESMOND programme, this is a specific programme for those with pre-diabetes, who are at risk of developing Type 2 diabetes. It is 3 hours of structured self management education delivered in groups of up to 10 participants by trained Walking Away Educators. Partners are welcome. Contents covered include: Understanding more about diabetes and blood glucose, how being at risk can affect long term health and how to reduce risk by increasing physical activity and eating healthily.
http://www.desmond-project.org.uk/
Page 40 of 47
Referral criteria to Exercise on Referral Fast Track to Level 3 Qualified
instructors
Details
Obese BMI > 30 (South Asians > 27.5), or BMI > 25 and high waist circumference:
o Male: > 94 cm or > 90 cm for South Asians o Female: > 80 cm (all females)
Without co-morbidity or complex need High normal blood pressure Not medication controlled (130-139/85-89) Type 2 diabetes Diet controlled
Osteoarthritis mild to moderate Mild, where physical activity will provide symptomatic relief, or Clinical diagnosis- with no history of previous low trauma fractures Mild stress/anxiety/depression Mild
Intermittent claudication No symptoms of cardiac dysfunction Mild bone density
changes/Osteoporosis
No history of low trauma fractures Refer to Exercise Referral
Instructor Level 4
Details
Obese BMI >35kg/m2 or
BMI >30kg/m2 with co-morbidity or complex need Hypertension Stage 1 Medication controlled (140-159/90-90)
Type 2 diabetes Medication controlled
Type 1 diabetes With adequate instructions regarding modification of insulin dosage depending on timing of exercise, and warning signs
Severe osteoarthritis/
Rheumatoid arthritis (RA)
With intermittent /severe mobility problems
Stroke/TIA >1 year ago. Stable CV symptoms. Mobile, no assistance required.
COPD/ emphysema Without ventilatory limitation but would benefit from optimisation of respiratory system mechanics and correction of physical
deconditioning.
Neurological conditions E.g. Early onset Parkinsons disease (stable); multiple sclerosis
Depression Moderate
Psychiatric illness Mental health classes with specialist supervision only.
Refer to Exercise Referral Instructor Level 4 BACR qualified
Details
A GP or other designated Health Professional can refer to Phase IV but only if it is 6/12 since the cardiac event or 6/12 since
discharge from Phase III or CHD history but no recent acute event Post myocardial infarct
Clinically stable and without any of the contraindications to exercise as listed below
Post angioplasty
Claudication with cardiac dysfunction
Exclusion criteria and absolute contra-indications to exercise:
Patients under the age of 18
A recent significant change in a resting ECG A recent myocardial infarction (within 2 days) Any other acute cardiac event
Symptomatic severe aortic stenosis
Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis
Suspected or known dissecting aneurysm Resting systolic BP > 180 / DBP > 100 Uncontrolled/unstable angina
Acute uncontrolled psychiatric illness Unstable or acute heart failure
New or uncontrolled arrhythmias
Other rapidly progressing terminal illness Experiences significant drop in BP during
exercise
Uncontrolled resting tachycardia > 100bpm Febrile illness
Experiences pain, dizziness or excessive breathlessness during exertion
A blood pressure drop of > 20mmHg demonstrated during ETT
Unstable diabetes
Uncontrolled arterial or ventricular arrhythmias
Page 41 of 47
Appendix 10: Local pharmacies offering the NHS Health Check
C. Goode Pharmacy
22 London Road, Twickenham Tel: 020 8892 1614
Health On The Hill
62 High Street, Hampton Hill Tel: 020 8977 2539
Minal Pharmacy 9 High Street, Whitton Tel: 020 8894 7933 Pharmacare 12 Back Lane, Ham Tel: 020 8940 7918 Kanset Pharmacy
177 Ashburnham Road, Ham Tel: 020 8948 0601
Lloyds Pharmacy
Teddington Memorial Hospital, 60 Hampton Road, Teddington Tel: 020 8977 0630
Springfield Pharmacy 124 Sheen Road, Richmond Tel: 020 8940 2304
Richmond Pharmacy
82-86 Sheen Road, Richmond Tel: 020 8940 3930
Page 42 of 47
Appendix 11: NHS Richmond CCG Referral Pathway for Adult Patients with Type 2 Diabetes to Intermediate or Secondary Care
Access to Psychological Therapies by referral to Richmond Wellbeing Service
Page 43 of 47
Appendix 12: DESMOND Education Referral Form
Page 44 of 47
Appendix 13: Community Ward
Page 45 of 47
Appendix 14: Emergency Admissions for Ambulatory Care Sensitive Conditions in Richmond for Patients with Type 2 Diabetes (April 2013)
Primary diagnosis
Number of emergency
admission
Tariff cost
£
Lobar pneumonia, unspecified 25 95,901
Non-insulin-dependent diabetes mellitus 1 3,184
Non-insulin-dependent diabetes mellitus 4 14,985
Non-insulin-dependent diabetes mellitus 1 2,647
Other iron deficiency anaemias 1 3,145
Iron deficiency anaemia, unspecified 3 7,566
Essential (primary) hypertension 2 1,519
Congestive heart failure 17 53,496
Left ventricular failure 3 14,178
Unstable angina 10 11,029
Other forms of angina pectoris 2 1,604
Angina pectoris, unspecified 4 5,900
Other forms of acute ischaemic heart disease 1 3,658
Acute ischaemic heart disease, unspecified 1 1,067
Chronic obstructive pulmonary disease with acute lower respiratory
infection 15 39,629
Chronic obstructive pulmonary disease with acute exacerbation,
unspecified 6 15,128
Chronic obstructive pulmonary disease, unspecified 2 1,371
Bronchiectasis 1 3,557
Asthma, unspecified 3 3,735
Volume depletion 3 6,772
Noninfective gastroenteritis and colitis, unspecified 1 2,903
Epilepsy, unspecified 1 540
Other and unspecified convulsions 3 5,478
Acute pharyngitis, unspecified 3 2,335
Acute upper respiratory infection, unspecified 2 1,470
Duodenal ulcer 1 2,914
Tubulo-interstitial nephritis, not specified as acute or chronic 1 2,334
Pyonephrosis 1 2,706
Cellulitis of other parts of limb 22 56,704
Pyogenic granuloma 1 933
Total 141 368,388
Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013
Page 46 of 47
Appendix 15: Performance Indicators
Indicator Baseline Figure
Benchmarking diabetes prevalence between CCG, London, and National
PCT 3.4%, SHA 5.6% National 5.8%
(11/12)
Benchmarking diabetes prevalence in GP Practices against CCG average
PCT range: 6.9% to 1.7% (11/12) PCT average: 3.4%
(11/12) QOF Diabetes Indicators
DM32: The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed
3.4% (11/12)
DM 26: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 15 months
71.9% (11/12)
DM 27: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 15 months
80.9% (11/12)
DM 28: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 15 months
89.6% (11/12)
DM 21: The percentage of patients with diabetes who have a record of retinal screening in the preceding 15 months
93.4% (11/12)
DM 29: The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months
89.7% (11/12)
DM 30: The percentage of patients with diabetes in whom the last blood
pressure is ≤150/90 mmHg in the preceding 15 months 89.6% (11/12) DM 31: The percentage of patients with diabetes in whom the last blood
pressure is ≤140/80 mmHg in the preceding 15 months 65.9% (11/12) DM 13: The percentage of patients with diabetes who have a record of
micro-albuminuria testing in the preceding 15 months (exception reporting for patients with proteinuria)
88.9% (11/12)
DM 15: The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or ARBs)
91.4% (11/12)
DM 17: The percentage of patients with diabetes whose last measured total
cholesterol within the preceding 15 months is ≤5 mmol/l 78.5% (11/12) DM 18: The percentage of patients with diabetes who have had influenza
immunisation in the preceding 1 September to 31 March
91.2% (11/12)
NEW for 13/14: The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months
No baseline figure yet
NEW for 13/14: The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register
No baseline figure yet
Page 47 of 47
NEW for 13/14: The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months
No baseline figure yet
NEW for 13/14: The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months
No baseline figure yet
National Diabetes Audit
Percentage of people in the National Diabetes Audit (NDA) with Type 1 diabetes receiving all nine key care processes
27.7% (1 Jan 2009- 31 Mar)
Percentage of people in the NDA with Type 2 diabetes receiving all nine key care processes
54.3% (1 Jan 2009-Mar 2010)
Percentage of people in the NDA having major lower limb amputation five years prior to the end of the audit period
0.09% (1 Jan 2009-Mar 2010)
Excess length of stay (%) in hospital among people with diabetes when compared with people without diabetes
9.2% (09/10)
Insulin total net ingredient cost (£) per patient on GP diabetes registers £129.5 (10/11) Non-insulin anti-diabetic drugs total net ingredient cost (£) per patient on GP
diabetes registers
£66.8 (10/11)
Hospital admissions
Avoidable emergency admissions for patients with diabetes per 100,000 population (age and sex standardised)
377 (2012/13) Other QOF indicators relevant to diabetes
Smoking 3: The percentage of patients with one of or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder and other psychoses whose notes record smoking status in the previous 15 months.
94.5% (11/12)
Smoking 4: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder and other psychoses who smoke whose notes contain a record that
smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months.
94.1% (11/12)
Prevention and Self-care
Number and percentage of patients with IFG/IGT attending Walking Away from Diabetes Programme Number and percentage of patients with diabetes who are case managed
through the Community Ward
No current figure as in pilot phase