Transcript Document

Improving foot
health proposal
DMI Programme
Board
19th July 2013
Dr Carol Gayle and
Monique Ferdinand
Contents
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•
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Our objectives
Work done to date
Conclusions from analysis
What we want to deliver and timescales
Measures of success
Risks and constraints
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Objectives of DMI foot health work
• Reduce variation in foot assessments across primary care
• Increase patient and 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
• Ensure capability and capacity of community podiatry
service to manage cohorts of patients previously managed in
secondary care
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Work done to date
1. L & S diabetes foot care pathway
• Created for 1° care clinicians to clarify when and where to
refer patients
2. Primary care education events
• Two events in Jan 2013
• Aimed to improve recognition of foot health problems,
launch pathway, provide practical support from podiatrists
3. Data collection and analysis
• Used to inform next steps for improving foot health
• Has been difficult to obtain, gaps in recording, unclear
coding
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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
Conclusions from analysis – foot assessments
in primary care
• Foot checks recorded in primary care have increased in the last year, although the
variation across GP practices is still wide
Lambeth
Southwark
2011/12
83.7%
(11,512)
81.5%
(9,762)
2012/13
85.6%
(12,761)
84.4%
(11,058)
England average
83.6%
QOF – DM29: percentage of patients receiving a foot check – values without exceptions
Practice level variation:
• 2011/12  21.7% to 94.2%
• 2012/13  44.4% to 96.8%
•
Although this variation has narrowed in
2012/13, there are still some practices with
low levels of foot checks being recorded
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Conclusions from analysis – community
podiatry
• Referrals from specialist podiatry teams in secondary care to community
podiatry are known to be low (none seen in audit performed)
• Source of referral most commonly from GP or Self
Lambeth
Source of referral
GP
Self
St Georges Rheumatology
Other
Unknown
Southwark
6
9
1
Total
% of total
16
8
22
19
1
1
9
1
9
44%
38%
2%
2%
18%
Audit of 50 patients in community podiatry in Jan 2012 (25 from each borough)
Reasons for referral
• Highest number of referrals were for nail
care (up to three reasons were allowed)
• Eight per cent were referred for a foot
check
70%
60%
50%
40%
30%
20%
10%
0%
il
Na
Foot health – DMI programme board
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% of reasons for referral in patients presenting at Community
podiatry in Jan 12
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Up to 3 reasons for appointment allowed D
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Conclusions from analysis – hospital podiatry
services
• There are potential cohorts of patients managed by KCH and GSTT podiatry
teams who could be transferred to community podiatry
•
KCH exploring if those who are high risk but stable needing ongoing surveillance
could be managed within community podiatry
• There would be a need to conduct a similar exercise within GSTT
Analysis of appointment type
Appointment type
Ulcer management
Follow-up - healed
Vascular management
Charcot foot
Orthopaedic management
Casts
Other
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•
•
19 July 2013
No. appts
% appts
1502
1025
474
116
73
61
72
KCH diabetic foot clinic: Patient level data for
2011/12 and being analysed for 2012/13
GSTT podiatry: The caseload includes
inpatients at GSTT, as well as outpatients at St.
Thomas. Difficulty in coding patients.
GSTT diabetic foot clinic: Patient level data
obtained for 2011/12, analysis not yet reviewed
by clinical
lead.
Foot health
– DMI programme board
45.2%
30.8%
14.3%
3.5%
2.2%
1.8%
2.2%
KCH to conduct
audit of f/up healed
patients
Reason for
appointment
Ulcer
Other
Diabetes foot check
Vascular
Amputation
Charcot
Nail care
Renal
BKA
Skin
Total patients
Total reasons given
%
47%
16%
10%
6%
5%
5%
5%
3%
2%
2%
42
62
GSTT: audit of 42 L&S
diabetic patients seen
by podiatry in January
2012
8
Conclusions from analysis – primary care risk
stratification compared to activity along pathway
•
Mismatch between perceived levels of demand determined by primary care risk
assessments and actual activity levels in specialist community and secondary podiatry
services in 2011/12 analysis
Risk level
GP assessed risk
Low
17,033 (81.48%)
Moderate
3,118 (14.92%)
High
616 (2.95%)
Active
136 (0.65%)
Total
20,903 (100%)
Patient count by service
5,432 community podiatry unique patients
577 KCH diabetic foot clinic + 1013 GSTT
(estimated)
Not clear why discrepancy exists. Possibilities include:
• Inaccurate / inappropriate risk stratification in 1°care
• Breakdown in communication re: patient information and activity across pathway
• Lack of confidence in managing low, moderate, high risk in community and 1°care settings
• Foot
Elements
of clinical podiatry service are not provided in 1°care, i.e. nail cutting
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Proposed deliverables and activities
1. Identify cohort of patients from secondary care who could be
managed in other appropriate settings, such as community podiatry
services
• Determine guidance / criteria for patients to be discharged
• Understand pathway required
• Seek appropriate approvals
• Understand capacity of community podiatry
2. Embed foot health improvements in primary care initiatives of the
DMI
• Use DMI primary care initiatives
• Target practices who are performing fewer
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Proposed deliverables and activities II
3. Improve communication for providers and for patients with diabetes
who require foot care through tools, guidance and decision aids
• Further development of existing templates
• Revisit methods to collect and share diabetes and foot health
patient information
4. Determine an appropriate “shared care” arrangements (secondary &
community care)
• Agreement about what care means in each setting
• Ensure clarity of pathway across providers
5. Promote and embed foot health pathway alongside development /
distribution of legacy phase outputs
• Promote / develop methods to improve patient experience
• Make available outputs from DMI work in accessible/known location
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Activities that are out-of-scope
1. Tertiary or super-specialist services
• Likely to be in scope of the Changing Diabetes @KHP
programme
• Work already underway at KHP to reconfigure integrated
vascular services
2. Improvement plans for Community Podiatry services
• Initiatives in place to reduce wait-times, improve processes
around home visits and reduce variation between service
provision in S & L
• Currently reviewing capacity, and will align with DMI work
3. Addressing nail care services in S & L
• Community podiatry to begin initiative to understand the
capability of services provided by AgeUK (i.e. training required)
• Will provide insight regarding the appropriate setting for those
haveboard
diabetes and cannot manage their nail care
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DMI programme
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Approach and Timescales
Stage
Engage
Task
J
A
S
O
N
D
J
F
Engage team
Engage stakeholders in foot health care
pathway
Baseline and analyse current foot care data
across pathway
Design +
Design, update and develop foot care
Develop
pathway outputs to support patients and
providers
Identify process adjustments ( esp. in
community and secondary care) required,
incl. measures to evaluate improvement
Develop strategy to disseminate and
promote deliverables
Implement Seek appropriate approvals of new outputs
+ Promote developed
Promote existing and new tools, guidance,
and criteria to providers and patients
Implement new protocol and shared care
agreements
Ensure deliverables are available in
accessible location for all providers
Evaluate
Develop plan to evaluate impact on services
once implemented
Implement processes to collect relevant
diabetes and foot health information
Begin collecting data regular basis to
Foot
health – DMI
programme
board
evaluate
impact
of improvements
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Measures of Success
Reduced variation in
foot assessments
across primary care
Greater number of risk
assessments recorded
accurately & appears
closer to activity
Improved patient
experience of specialist
podiatry services
Increased
understanding of
pathway and when to
refer to specialist
Patients seen in most
appropriate care setting
(i.e. shift of activity
experienced)
Community podiatry
manages cohorts of
patients previously
managed in secondary
How to Measure:
• Review QoF data
• EMIS reports from CCGs
• DMI improvement plans / reward scheme outcomes
• Activity data from secondary and community podiatry
• Assess primary care providers knowledge of pathway (i.e. survey at learning event)
• Audit of reason for referral from primary care to community podiatry and secondary
care
• Review patient experience survey results from specialist services
Foot health
– DMI programme
board learning touchpoints and meetings between community podiatry
• Number
of shared
and secondary care
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Constraints & Risks
1. Unable to fully understand patient activity and case mix within
GSTT podiatry services and GSTT diabetic foot clinic
2. Community podiatry does not have the capacity to manage
more patients from secondary care
3. Secondary care specialists hesitant to transfer patients or
unsure of capability of community services
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What we need from the board:
• NOTE the objectives, route to success, time
constraints and critical timescales
• SUPPORT the proposal, and;
• ACKNOWLEDGE & ADVISE on constraints and risks
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