St Pancras Community CKD Service - London …€¦ · Community CKD Service • CKD pathway agreed with 3 locality GP CKD leads • Established referral criteria • EMIS records

St Pancras Community CKD Service

Sheila Johnston

Lead Nurse CKD

Royal Free London NHS Foundation Trust

Case for Change

• Current model: Secondary

care and hospital centred

• Patients travel to us

• No strategy for prevention

• Treating disease reactively :

Expensive

Community CKD Service • CKD pathway agreed

with 3 locality GP CKD

leads

• Established referral

criteria

• EMIS records

( data sharing agreement)

• Service model agreed

• Embed community CKD

with local primary care

• Support GPs to manage

CKD

Virtual clinic

Secondary care

Community Nurse led

clinics

Community CKD Service • Primary Care

Partnership

• Virtual clinic

• Joint nurse led clinics

• Self management

• Shared decision

making

Referral Criteria

Urinary symptoms

Medical history

Medication

Examination e.g. BP,

oedema, palpable bladder

Urine dipstick for blood and

protein: ACR

Serum creatinine and eGFR, urea, sodium, potassium, albumin, calcium, phosphate, cholesterol, FBC, HbA1c

Historical creatinine results and eGFR

Result of renal ultrasound

Number of patients on CKD Practice Register

4400

4500

4600

4700

4800

4900

5000

5100

5200

5300

5400

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

4900

4920

4940

4960

4980

5000

5020

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

Number of patients with eGFR <60 (2 readings more than 7 days apart)

3400

3500

3600

3700

3800

3900

4000

4100

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

Number of patients with eGFR <60 (2 readings more than 7 days apart) on CKD register

0

200

400

600

800

1000

1200

1400

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

Number of patients with eGFR <60 (2 readings more than 7 days apart) not on CKD register

(uncoded)

0

5

10

15

20

25

30

35

40

45

50

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

Number of patients on CKD Register but no eGFR <60 (miscoding)

QOF outcomes

4000 4500 5000

As on12/09/2014

As on01/04/2014

As on01/04/2013

Those with BP in last 12 months

3000 3500 4000

As on12/09/2014

As on01/04/2014

As on01/04/2013

Those with BP < 140/85

0

500

1000

1500

2000

2500

3000

3500

4000

As on 12/09/2014 As on 01/04/2014 As on 01/04/2013

Those with ACR in last 12 months

QOF Outcomes

72% 73% 73% 73% 73% 73% 74% 74% 74% 74%

As on 12/09/2014

As on 01/04/2014

As on 01/04/2013

Proportion of patients with ACR > 30 on ACEi or ARB (287 patients out of 391)

Patient Outcomes

Measuring long term outcomes for patients seen in last 3 yrs

eGFR

Progression of CKD

BP management

CKD Activity 2014-15

Patient Experience

Patient Experience

Shared Decision Making

Knowledge of CKD

The Way Forward

Development of a whole CKD

service

Development of a capitated

contract for whole service

Link in with other LTCs

Teaching

Virtual MDT meetings