Integrated Care
Click example title to view full description
Words appearing in bold highlight other relevant themes or groups the example applies to.
Summary:
Following the merger of five PCTs in Leeds, a service model was designed which expanded services in an innovative way. Multidisciplinary teams work across the city in individual practices and local settings in the community according to need.
Submitted: 04/02/11
Summary:
In response to a greater number of people with Type 2 diabetes treated in primary care, an integrated pathway of care was implemented to ensure patients’ individual needs were met locally and supported by appropriately trained and skilled healthcare professionals.
A Community Assessment Clinic was set up to provide advice and support to healthcare professionals and run a four week structured education programme for patients who require insulin treatment.
Submitted: 14/10/09
Summary:
NHS Somerset established a model of care which emcompasses the whole patient pathway. The service specification covers all services contributing to the care of patients with diabetes and at risk of developing diabetes.
Submitted: 13/10/09
Summary:
The active management of diabetes in the community led to a reduction in referrals to secondary care services and acute services have become focused on the more complex management problems. Education sessions for district nurses, practices nurses are held on a bi-monthly basis. All people with diabetes have access to a hand held record and are aware of their treatment plan.
Submitted: 18/11/08
Summary:
The cost effective and efficient integrated service provided by specialist diabetes team offers care and support to people with diabetes as well as advising healthcare professionals involved in treating the conditions. People with Type 2 diabetes are seen by the practice nurse and a diabetes specialist nurse in a joint clinic in primary care as part of a shared approach. For this reason, people with diabetes are able to receive specialist care in the community and do not need to travel to secondary care to receive specialist care. In addition, increasing the diabetes knowledge and skills of colleagues in primary care improves the care of all people with diabetes in our health community.
Submitted: 10/10/08
Summary:
People with diabetes can see a named specialist nurse when they are referred by GP and no appointment is needed for these clinics in the intermediate specialist care. For each locality in Brent, there is also a DSN to provide diabetes care to the local community. Each DSNs in the 5 localities in Brent conduct email, telephone consultations for both healthcare professionals as well as people with diabetes, and visit people with diabetes who are housebound on request of district nurses. Moreover, there is variety of education courses throughout Brent catering for various ethnic communities and languages. This integrated service with a “team without walls” provides closer to home care, immediate access to a specialist and lastly provides flexibility and convenient follow up appointments for people with Diabetes. This service also underpins the future vision of the NHS London long term disease management aims.
Submitted: 05/09/08
Summary: The new service brings care closer to the homes of people with diabetes and offer more personalised one-to-one advice on understanding and managing diabetes within the community at the individual’s convenience. Another key element of the service is education for people with diabetes by providing them the knowledge and skills to make decisions and change their current habits and behaviour.
Submitted: 20/05/08
Summary: GP with a special interest in diabetes, dietician and Diabetes Nurse specialist working together to support and upskill diabetes care in the primary care setting.
Submitted: 20/06/06