Intermediate Diabetes Care Services Southall

1
Intermediate Diabetes Care Services Southall

• Thord Theodorsson
• Sue Allan
• Ruth Barnes
• on behalf of
• the Intermediate Diabetes Care Group
• 16.02.2006

2
Intermediate Diabetes Care Group

• Ruth Barnes Director of Public Health
• Shabnam Sharma Neighbourhood Manager-S/Southall
• Antoinette Scott Service Development Manager
• Anita Gaida Diabetes Administrator
• Thord Theodorsson GPwSI
• Harpal Rai DSN
• Diljit Sidhu Dietician and PEC Member
• Bhajan Jassel Podiatrist
• Bindee Maroo Podiatrist
• Maria Carmon Health Care Assistant
• Harriet Livesey Operational Service Manager

3
Background

• ICS Pilot, Featherstone Road Clinic, Southall
• 5 Clinics were held between July and October and
  17 patients were seen
• Confined to UB1 UB2
• Referrals triaged at EHT Diabetes Clinic
• Patients met 5 different Health Professionals
• Health Care Assistant,DSN,Dietician,Podiatrist
  and GPwSI

4
Process Evaluation Workshop 10th November

• Patients views
• Appointment system and admin good
• Easy journey and access to clinic
• Attitude of staff helpful
• A good overall experience
• Health Professionals view
• Too resource intensive
• Referral process dysfunctional
• Patient flow dysfunctional

5
Referral Process Review

• A structured Referral Form
• Explicit referral criteria
• Baseline patient data provided by referring
  health professional
• Including Past Medical History and fresh Lab Data
• Outlining pathways of further Patient Care Plan

6
Patient Flow Review

• Patient to see following Health Professionals
  (HP)
• Health Care Assistant (HCA)
• Diabetes Specialist Nurse (DSN)
• GP with Special Interest (GPwSI)
• Patient to see as required
• Dietician
• Podiatrist
• Patient and HP agree on Care Plan

7
Patient Care Plan

• Referred back to GP Care along with a letter of
  recommendations
• Referred for further dietetic, podiatric or
  ophthalmic review
• Referred for further secondary care
• May need a short-term follow up at the IDCS
  Clinic
• Referred to DSN at Ealing Hospital for insulin
  initiation
• Referred to Group Diabetic Education
• Last and not the least Patient Self Management

8
Wider Issues

• Scope
• ICS as a Consultative Service
• Boundaries
• Context - relationship of ICS to overall Diabetes
  Community Services
• Training and network development - specialist
  training and support for community based staff,
  e.g. support for Warwick CIDC graduates
• Relationships with local commissioning groups

9
Recommendations

• For the purpose of optimal functioning of ICS
• An administrator is necessary
• Consideration is needed re. future location of
  ICS in Southall
• IT infrastructure is a must to ensure proper
  record keeping and communication to referring
  health professionals
• ICS Specification needs review
• For developing community based diabetes care
  across Ealing
• Review diabetes needs and explore potential
  models of care
• Address staff deployment issues (e.g. DSNs)

10
Next steps

• Presentation to the local commissioning group (1
  March)
• Letters inviting GPs to refer appropriate
  patients resident in UB1 and UB2 directly to the
  IDCS (early March)
• Clarification of the role of the Referral
  Management Centre (early March)
• First new IDCS clinic (13 April)
• Report back on progress to the PEC (September
  2006)