Leeds Community Diabetes Team: Delivering enhanced multidisciplinary community diabetes care
05 February 2010
Intended Audience
GPs and primary health care teams, patients with diabetes, commissioners and diabetes specialists, community diabetes teams
Background
Following the merger of five PCTs in Leeds in March 2007 the delivery of diabetes services in Leeds has been reconfigured and enhanced. A service model was designed and approved in line with NSF Service Delivery Plan and subsequent White papers including ‘Your Health, Your Care, Your Say’ in 2006 with the aim of delivering services for the 25,000 people in Leeds currently known to have diabetes closer to their homes where appropriate. This consists of four levels of care, with level 3 being intermediate care.
Care Services in Leeds have been commissioned to contribute to Leeds Diabetes Services by delivering a level 3 community based intermediate service and supporting level 1 and 2 within practices.
As a consequence, we have been able to expand our services with considerable innovation. We have used previous work piloted in North-East Leeds as a framework to develop Multidisciplinary teams (MDT) across the entire city . These teams work in individual practice and locality settings in the community according to need. The core MDTs include Dietitians, DNS and GPSIs. with enhanced podiatry working alongside and mental health support workers available as necessary through a referral mechanism from the level 3 MDT team members.
How this service improves
Patients needs are met more effectively through the expansion of capacity. Providing choice and access to diabetes multidisciplinary teams Includes additional specialist services e.g. psychological support , specialist podiatry
Why this service is a good example of shared practice
This is a service that is well received by both patients and primary health care teams. It works effectively at the interface between primary and secondary care with a clear referral pathway.
The service provides an excellent example of integrated team work and collaboration in the face of on-going reconfiguration, in a large geographic and ethnically diverse area.
The level 3 service is integrated with regular secondary care input through mentorship and educational support for the GPSIs in the MDT.
The additional input from the dedicated Psychological Support Service for patients with Type 2 diabetes is an example of addressing the psychological needs of people with a significant long term condition.
Enhanced podiatry capacity for the 'at risk patient' is an excellent service expansion. There are strong links with the level 3 multidisciplinary team which allows a proactive approach to their diabetes care generally as well as more intensive podiatry input. There is a strong pathway between this service and hospital based podiatry services. It is an example of successful collaborative working, breaking down barriers between all stakeholders.
Unmet needs are being addressed. eg 'hard to reach patients' are accessing diabetes care. This service is a practical support and education resource for primary care, which encourages confidence within primary health care teams and appropriate referral behaviour for patients with diabetes.
The service aims to develop in line with national initiatives Including 'Year of Care' and Care planning.
This is a service committed to innovation and ongoing service development according to national and local agenda.
Objectives
- To deliver patient education
- To support the shift of care to primary care for appropriate patients with diabetes.
- Addressing patient needs by being flexible and responsive where possible.
- To provide short term intensive intervention to patients as required, encouraging self empowerment and developing management plans to be followed through in primary care.
- To up skill primary care through education and support to come up to the mark on delivering quality care addressing inequalities in the city.
Service Provided
The Leeds Community Diabetes Service was launched in June 2008. It is a provider service in its own right under the Leeds Community Health Care directorate of NHS Leeds. It is predominantly designed to cater for the needs of type 2 diabetes patients.
The core provider service includes GPs with special interest, diabetes specialist nurses and dietitians. There has been significant recruitment to the workforce in order to expand capacity. The team works within locality settings as well as continuing to encourage engagement within general practices, with regular bimonthly 'in practice' clinics in areas of high prevalence within the city.
Moreover, podiatry services have been enhanced and expanded in the community with a new specialist service for high risk people with diabetes that do not have active foot problems. There are two part time mental health workers to support people with diabetes within the community diabetes service. They have separate clinic times and also work with the whole team in locality clinics.
The service is run from a central administrative site where referrals are received. Referral access is via Choose and Book or Leeds Health Pathways. These are triaged weekly by experienced clinicians and distributed to four local teams. North East, East & South, West, North West.
The local teams provide the level 3 service and support level 1 and 2 work, which contributes to the good personal relationships with practices and patients.
Patients are booked in to each level 3 clinic according to specific referral criteria and there is the opportunity for each patient to be seen by GPSI, dietitian and DSN. Additional follow up clinics are arranged for patients to be reviewed by dietitian and DSN as necessary.
We have dramatically improved the DNA rate over the last year by working within GP practices and also introducing a partial booking system for the locality clinics.
The emphasis is on intensive short term support and intervention and not to develop a significant case load.
A dedicated administrative referral process has been developed with an emphasis on patient self management and empowerment, in line with 'The Year of Care' plan. The aim is to become less reliant on paper and make full use of new technology to enhance communication. We use System one for administration of the service and working towards using clinical templates in line with car planning and more shared working with primary care In the future Work is being done in collaboration with York and Humberside SHA ,LTHT and NHS Leeds to this aim.
(We are happy to share this documentation on request).
Accountability
This is a new service launched in June 2008 and patient satisfaction questionnaires and primary health care team feedback questionnaires have been completes. All of the activity is logged onto initially RIO and now System One and regular performance reports are produced.
The service is accountable to the commissioning arm of NHS Leeds and there are specific performance markers.
The service has been established according to the strict competencies required by the Service Specification.
There is almost 100% participation in the National Diabetes Audit from Leeds General Practices.
Project Aims
To work in partnership with patients.
To provide patient education through the Xpert patient program
To support primary care in delivering excellent diabetes care and to influence referral patterns so that appropriate referrals are made and seen by the most suitable service in the appropriate setting.
To provide specialist support where it is most needed in the Leeds community and combat any inequalities in care received by patients .
Evaluation
Working in partnership with patients:
The philosophy of the clinical service is to engage with patients and this is reflected in our paperwork. e,g a 'Your Diabetes' leaflet sent to patients with the appointment. This is an opportunity for the patients to reflect on their needs from the appointment in advance and also to consider the psychological impact their long term condition may be having on them. This is in line with the national 'Year of Care' initiative.
Each appointment is followed up with a formatted letter for the patient to reiterate the goals agreed together at the time of the appointment.
(Both available on request)
Providing patient education: Regular X pert program sessions are rolled out across the city. These are well attended and given positive feedback. Other less formal education packages have also been developed and rolled out e.g Jigsaw Education - a single group education session of 2 hours run by dietitians.
Supporting primary care:
The service is becoming recognised through direct clinical engagement activity with practices and various cross city meetings.
The referral pattern to secondary care has changed and the service is receiving approx 100-200 referrals per month overall and 60-100 per month for the community MDT clinics.
Performance management reports are regularly monitoring our clearly defined performance markers.
Podiatry and the Psychological Support Service have their own performance markers in place.
Combating inequalities:
The service is actively involved In a number of practices though this aspect of working practice needs further development.
Resources
An annual budget is set from the Leeds Community Health Care directorate of NHS Leeds
Learning
Referral patterns can be changed if a support structure is in place.
This is a cost neutral rather than cost saving service, but quality is the key.
Change is not easy!! A lot of passion and tenacity is required by the team.
Excellent communication within the team is paramount and without effective IT systems this can be cumbersome, hampered and very time consuming.
No service can be delivered in isolation. For the Leeds model to work the overall competencies of the whole health community needs now to be assessed and addressed. This is now being addresses through further collaboration with patients and colleagues in primary care, acute trust ,public health, and commissioning directorates with a view to Integrating services .
This is a service that does not stand still and it is not entirely clear what the end product will look like! Flexibility and an open mind is key to success by those involved in strategy. It is vital to be looking at medium to long term goals, not just short term.