Transcript Document

Improving foot
health: “What
does good look
like”
DMI Board
13 March 2014
Dr. Jane Doherty,
Carol Gayle, Laura
Price & Monique
Ferdinand
Contents
1. Background
2. “What does good look like”
3. Work to date to build improvements
4. Recommendations to reinforce improvements
Foot health – DMI programme board
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2
Background: Objectives of DMI foot health work
• Reduce variation in foot assessments across primary care
and increase the number of foot assessments conducted
accurately and consistently
• Increase patient & provider understanding and confidence
in the pathway, with clarity on when and how to refer to
specialist podiatry services
• Ensure patients are seen in the most appropriate care setting
• Understand the capacity of community podiatry service to
manage cohorts of patients previously managed in hospital
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Background: Foot Health Group Membership
DMI Clinical Leads:
• Dr. Carol Gayle
• Dr. Jane Doherty
Regular Meetings for Development:
• 6 meetings in 5 months
• Several redesign activities, actions
and owners
Members & Contributors:
KCH Diabetes Foot
Clinic
GSTT Hospital Foot
Clinic
GSTT Community
Podiatry
Lambeth & Southwark
CCG
• Dr. Marcus Simmgen
(Diabetes Consultant in
Foot Medicine, KCH)
•Dr. Prash Vas (Diabetes
Consultant in Foot
Medicine, KCH)
•Maureen Bates
(Manager, KCH Diabetes
Foot Clinic)
•Tejal Patel (Deputy
Head, GSTT Dept of Foot
Health)
•Liza Curtis (Head of
GSTT Dept of Foot
Health)
•Steve Thomas (Diabetes
Consultant , GSTT)
•Rupert Maher (Head,
Lambeth & Southwark
community podiatry)
•Laura Gearing (Principal
Podiatrist, Southwark)
•Monica Fisk (Community
Podiatrist, Southwark)
•Christian Pankhurst
(Senior Orthotist, GSTT)
•Leah Herridge
(Redesign Manager for
LTC, Southwark CCG)
•Mahroof Kazi (PCC
Commissioning Manager,
Lambeth CCG)
•Linda Drake (Practice
Nurse, Southwark CCG)
•Bob Skelly (Patient Rep,
Southwark CCG)
• Transition meeting from DMI hosted by KCH: February 20, 2014
Foot health – DMI programme board
• Agreed terms of reference for Lambeth and Southwark Diabetes Foot Health Group
March 2014
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“What does good look like”: Foot assessments in
primary care
QOF 2012/13; DM29 - Percentage of patients with foot checks, by practice register size
100%
QOF DM29 - patients receiving foot check
14000
Lambeth
12000
90%
Southwark
10000
85%
8000
0
National Upper Quartile
65%
400
600
800
1,000
9967
National Median
200
10526
2000
National Lower Quartile
0
11064
70%
12764
Upper control
9762
4000
Lower control
8741
Lambeth and Southwark Average
75%
9818
6000
Lambeth
11512
Southwark
11229
80%
10861
% of patients on diabetes register receiving foot check (no exceptions)
DM9 prior to 2011/12 - no risk stratification
95%
2009/10
1,200
2010/11
2011/12
2012/13
2013/14 Nov
Diabetes Register Size (QOF 2012/13)

For 2013/14, we would expect Lambeth and Southwark to
be at or above the England average for DM29, a level
Lambeth has already achieved

Variation reduced and more practices to be closer to the
expected performance for the average achieved in Lambeth
and Southwark
England average was 83.7% in 2011/12 and 85.1% in 2012/13
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“What does good look like”: Foot Health risk
classification
Total Patients on Register
13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within
GSTT and KCH hospital clinics, and GSTT community podiatry
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“What does good look like”: Foot Health risk
classification
Total Patients on Register

13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within
GSTT and KCH hospital clinics, and GSTT community podiatry
Patients with a moderate or high risk classification in primary care to be seen within the
community podiatry service caseload, in order to meet best practice outlined by NICE and
Diabetes UK
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Risk level
Active
Holistic care
Are diabetes &
other risk
factors well
controlled?
KCH diabetic foot clinic or
GSTT foot health
A&E if out of hours
Neuropathic foot + new onset blister /
superficial ulceration (up to 48 hours)
Lambeth & Southwark community
podiatry (Foot Protection Team)
Foot intact
Neuropathy or absent pulses
PLUS
Previous ulceration, skin changes or
deformity
Moderate
Foot intact
Neuropathy or absent pulses
At every
appointment
discuss self
management care
plan & refer if
suitable to self mgnt
pathway for options
Low
Foot intact
Normal sensation
Palpable pedal pulses
What should happen
Within 24 hours
Foot ulceration
Foot intact BUT infection
Ischaemic foot + infection
Neuropathic foot + infection
Unexplained foot inflammation ?Charcot
High
Annual foot check
• Test foot sensation
• Palpate foot pulse
• Inspect for
deformity / callus
• Check for ulcers
• Ask about history
of ulcers
• Inspect footwear
• Ask about pain
• Stratify risk and
inform patient
Service
Tailored intervention by specialist
team
Inform GP of intervention
Priority referral
Lambeth & Southwark community
podiatry (Foot Protection Team)
Routine referral
Southwark & Lambeth community
podiatry (Foot Protection Team)
Tailored intervention by
community podiatry (Foot
Protection Team)
Referral to specialist hospital
team if required
Inform GP of intervention
Advise patients of their risk level
Responsive to needs of patients
May include more specialised
vascular assessment
Specialist advice about footwear
and insoles
Arrange follow up care
Inform GP of intervention
How to refer
King’s Diabetic Foot Clinic
Tel: 020 3299 3223
Fax 020 3 299 4536
Guy’s Foot Clinic
Tel: 0207188 2449
Fax 020 7188 2450
St Thomas’ Foot Clinic
Tel: 020 7188 1983
Fax: 020 7188 1991
St George’s Foot Clinic 0208 725
1429 / 0232
Southwark
Emergency clinics Mon,Wed, Fri
Tel: 020 3049 7900
Fax: 020 3049 7901
Community podiatry:020 3049 7900
Lambeth
Emergency clinics Mon – Fri:
Tel: 0203 049 4001/2/3
Community podiatry 0203 049 4040
Fax 0203 049 6361/6362
Southwark Community Podiatry
Tel 020 3049 7900
Fax 020 3049 7901
Lambeth community podiatry
Tel 0203 049 4040
Fax 0203 049 6361/6362
As required
Primary Care
Advise patients of their risk level
Advice and information for
emergencies
Discuss self management care
plan & self management options.
Refer as appropriate.
Diabetic foot patient pathway for Southwark and Lambeth March 2013
See self management pathway
Southwark: 020 3049 8863 / 8840
Lambeth: 020 8655 7842
“What does good look like”: Foot Health risk
classification
Total Patients on Register
March 2014
13,109
* Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011)
**Estimates based on actual 2012/13 patient caseload in specialist services within
GSTT and KCH hospital clinics, and GSTT community podiatry

Patients with a moderate or high risk classification in primary care to be seen within the
community podiatry service caseload, in order to meet best practice outlined by NICE and
Diabetes UK

With better communication from specialists, coded classification and actual caseload to
Foot
health – DMI
be closer
in programme
numberboard
and give better indication of where the capacity should be in the
system
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“What does good look like”: Addressing capacity
concerns in community podiatry


Healed patients for over 12
months which meet the agreed
guidelines begin to be
transferred by April 2014,
estimated:
 98 for KCH
 75 for GSTT
Community podiatry is supported
to address the current +
projected service capacity
deficit (shown here)
Average Monthly Capacity Deficit (No. of Attendances)
Lambeth & Southwark Community Podiatry Service - Capacity Deficit
250
200
ADDITIONAL
ATTENDANCES
(Acute
Tra ns fers )
150
EXISTING
CAPACITY
DEFICIT
(Attenda nces )
100
50
0
APR
MAY
JUN
JUL
AUG
SEP
OCT
2014
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
2015
Assumes that: i) 'Healed' patients are discharged at their next attendance beginning in April 2014 ii) first community
attendance is 60 days later iii) patients attend 5 times per year, evenly spaced
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Work to date: DMI Foot Health Group improvements
Engage & Analyse
• Ensured proper
representation &
assigned owners
• Record patients
with diabetes in
foot settings (esp.
GSTT)
• Baseline foot
metrics across
settings
• Perform audit of
healed patients at
KCH & GSTT
• Clinical letter for
specialist settings
created to improve
communications
Design & Develop
• Foot health & diabetes
education resources
compiled for practitioners
and patients
• Self-referral and
referral to
community podiatry
revised + clarified
• Transfer process
agreed
• Analysis of
community
podiatry activity &
capacity
• Guidance for healed
foot patients drafted &
approved
Promote & Sustain
• Foot case study + 1°
• Promoted pathway at
performance
several primary care
presented at DMI
PLT & Locality Foot health – DMI programme
Learning
events
board
meetings
March 2014
• Stronger relationships built
between foot services & CCGs
– Foot group TOR agreed
• Foot health promoted at Patient
Forum Launch & again in June 2014
• Foot health
improvements
communicated to
1° via CCGs
(email, EMIS,
online)
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Recommendations to continue to reinforce and
support DMI improvement work
1.
Support the current business case to increase the capacity of community podiatry, and
continue to monitor and evaluate the demands on the service
 Next Steps:
 Monitor and report on transfer activity (high risk)
 Referrals from primary care and patients (moderate / high risk)
 Audit community caseload to identify if patients could be shifted to primary care
2.
Continue to ensure adequate communication to primary care from specialist settings
 Next Steps:
 Clinical letter reinforced to be used by podiatrists across settings
 Foot Health Group to report on usage in 6 months and revise if changes are
needed
 Promote further touch-points with primary care for support (i.e. learning events)
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Recommendations to continue to reinforce and
support DMI improvement work
3.
Reinforce the foot health pathway and continue education opportunities for patients and
primary care practices
 Next Steps:
 Local diabetes foot health group to own pathway developed and review annually
 CCGs and community podiatry to continue promote foot health & pathway (at
least once a year) at primary care and patient events
4.
Continue to foster relationships built between specialist settings in community and
hospital (and across trusts), as well as with CCGs and primary care
 Next Steps:
 Diabetes foot health group meets at least three times a year and continues to
reinforce DMI work in organisations (next date: June 5 2014)
 CCG and provider organisations support group and efforts to sustain
improvements
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Recommendations to continue to reinforce and
support DMI improvement work
Recommendation
1.
2.
3.
4.
Support the current business case to increase the capacity
of community podiatry, and continue to monitor and evaluate
the demands on the service
Continue to ensure adequate communication to primary care
from specialist settings
Owner (DMI Board Member / Foot
Group Member)



Lambeth CCG (Therese Fletcher / Mahroof
Kazi)
Southwark CCG (Leah Herridge)
GSTT Community Services (Amanda
Williams / Rupert Maher; Laura Price)
 KCH diabetes foot clinic (David Hopkins /
Carol Gayle; Prash Vas)
 GSTT hospital foot clinics (Steve Thomas /
Tejal Patel)
 GSTT Community Services (Amanda
Williams / Rupert Maher; Laura Price)
Reinforce the foot health pathway and continue education
opportunities for patients and primary care practices
 Lambeth CCG (Therese Fletcher / Mahroof
Kazi)
 Southwark CCG (Leah Herridge)
 GSTT Community Services (Amanda
Williams / Rupert Maher; Laura Price)
Continue to foster relationships built between specialist
settings in community and hospital (and across trusts), as well
as with CCGs and primary care
 KCH diabetes foot clinic (David Hopkins /
Carol Gayle; Prash Vas)
 GSTT hospital foot clinics (Steve Thomas /
Tejal Patel)
 GSTT Community Services (Amanda
Williams / Rupert Maher; Laura Price)
 Lambeth CCG (Therese Fletcher / Mahroof
Kazi)
 Southwark CCG (Leah Herridge)
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What we need from the board:
• NOTE the actions completed by the DMI Foot Health Working
Group
• SUPPORT the further actions required to sustain and reinforce
improvements
• SUPPORT the Lambeth and Southwark Diabetes Foot Group as
a forum for CCGs, GSTT and KCH hospital foot clinics, and
GSTT community podiatry services to continue to develop
services and reinforce DMI work
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