Diabetes in Care Homes Dr Nicky Williams Deputy Clinical Chair – East & North Hertfordshire Clinical Commissioning Group Hertfordshire Diabetes Conference
Jan 02, 2016
Diabetes in Care Homes
Dr Nicky Williams
Deputy Clinical Chair – East & North Hertfordshire Clinical Commissioning Group
Hertfordshire Diabetes Conference
Diabetes in Care HomesThe Current Picture
When Marie moved to her care home a year ago, she had type 2 diabetes as well as COPD. During her stay, developing cognitive impairment meant she was increasingly dependent on staff who were not always informed or confident in caring for her diabetes. Marie’s frustration at losing responsibility for her own care led to depression and, without a comprehensive care plan in place, there was little improvement in her weight and mobility. When Marie experienced a complication from her COPD, care home staff were unsure what to do and called an ambulance to take her to hospital which Marie found distressing and disorientating.
PATIENT STORY
Diabetes in Care HomesThe Current Picture
Care Home Diabetes Audit (2014)
• No comprehensive assessment, monitoring or provision of specialist care
• Limited skills & knowledge among care home staff
• Ineffective communication with GPs and other services
• Likelihood of hospital admission when a resident is unwell
Care Homes - Demographic Background
4
Diabetes in Care Homes
25%of residents have diabetes
ACCESS
Managed crisis
Enhanced Support
(ST)
Enhanced support
(LT)
Enabling Independence
Self-care
Functions:Short term care with
rapid assessment
and responsive
service.
Functions:Short term
care required
Functions:Long term care, case
management with pro
active care.
Functions:Episodic
short term care
Functions:Information, advice and signposting
Cohort:In crisis or at
risk of requiring
admission to a hospital set
Cohort:Following
deterioration of
health/increase in need
Cohort:Multiple
long term conditions
with complex
care needs.
Cohort:Single long
term condition or
low level support
required.
Cohort:People fully managing
their needs themselves within the
community.
User access Professional access
Care Navigation
Proactive Care Co-ordination
Diabetes in Care Homes
Diabetes in Care HomesVanguard – Enhanced Health in Care Homes’
Our Vision:“To deliver an enhanced model of health and
social care to support frail elderly patients, and those with multiple complex long term conditions
in the community in a planned, proactive and preventative way”
Diabetes in Care HomesVanguard – Projected Benefits
Reductions in: Increases in:
• 999 calls, Ambulance and A&E attendances
• Non Elective Admissions• LOS in the acute care setting• Out of Hours GP services • Delayed transfers of care• Staff Turnover
• Preferred Place of Death • 111 calls• LOS in care homes• Staff, resident and family satisfaction
Diabetes in Care HomesVanguard – ‘Enhanced Health in Care Homes’
• Developing skilled and confident staff within the care home to enable them to care for increasingly complex patients with more confidence. This will allow residents to receive better care in their care home, and help staff support residents to die in their preferred place of death
1. Confident Homecare Staff
• Delivering effective planned, proactive and preventative care for care home residents from primary, community and acute care
2. Effective multi-disciplinary teams
• Providing effective alternatives to 999 services when a resident’s condition changes suddenly, so that the right professional can support that patient as quickly as possible, and attendances and admissions to hospital are avoided wherever possible
3. Rapid response services
• To underpin the care model, crucially allowing clinicians to access records in the patient’s care home, and allowing homes to access expertise remotely through telemedicine
4. Effective technology
Diabetes in Care Homes
Complex Care Premium
Patient presents with Complex Characteristics
Referral Accredited Care Home
Top up Payment
Quality care for complex
patients
The Patient
1. Confident Homecare Staff
Diabetes in Care HomesVanguard – Complex Care Premium
Advanced Nutrition Champion Pathway – ensures:
1. Procedure in place on nutritional care
2. Catering arrangements that promote choice and special diets
3. Access to specialist equipment4. Regular auditing5. Staff knowledge of nutritional
problems6. Working together with GPs,
pharmacist and dietetic support
5 Champion Pathways:
Diabetes in Care Homes
• Investment in two Homefirst teams of social care, community health & mental health staffo Virtual wardso Rapid response
• Enhanced Primary Care Support – dedicated GP practice for each care home
• Medicines Management Team covering 60 care homes
• Interface Geriatricians – rapid access frailty clinics, telephone advice line and outreach to care homes
2. Multi-Disciplinary Teams2. Multi-Disciplinary Team
Diabetes in Care Homes3. Rapid Response
• Homefirst Rapid Response – assessment within 1 hour of referral, to include nursing, therapy, social work or domiciliary care
• Rapid Response Car for Elderly People – acute focussed care that is an alternative to 999
Diabetes in Care Homes4. Effective Technology
• GP access to clinical records
• MedeAnalytics – community health, mental health, acute and social care data to risk stratify and track patients’ use of services
• Telemedicine based on the Airedale Foundation Trust model for a rapid alternative to acute care
Diabetes in Care Homes
The resident
GPs
Skilled care home
staff
Clear care procedures
Community health, social care & mental
health
Supportive technolog
y
End of Life care
Emergency care & crisis
response
Bringing it all together:‘Coordinating diabetes care around the needs of the
individual’
Diabetes in Care Homes
Questions?