Transcript Community diabetes project

Community diabetes project
Mandy Hunt
Lead Diabetes Nurse
West Suffolk Hospital Trust
AIMS
• Aims of the project.
• How the project was set up.
• Benefits of the project so far.
• Identified changes to diabetes
management so far.
• Further possible benefits / developments.
Aims of the project
• Where possible to see patients with
diabetes in their surgeries.
• To improve communication between the
surgeries and diabetes centre.
• To reduce hospital visits and admissions.
• To explore insulin and GLP-1initiation in
the 4 surgery's in the project.
The project
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Initiated by the West Suffolk CCG.
4 Identified practices.
Each practice supported by DSN.
22 mentored clinics each 4 hours (avg 8 patients
per clinic).
April 2013 – Aug 2013.
Progress meetings ccg, practice staff and DSNS.
Audit trail for each consultation, being reviewed
by ccg.
Observations
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We have all learnt from the mentored clinics.
Good recall at surgeries.
Good Annual reviews / aided by templates.
Patients seen on time by Practice Nurses who
treat them holistically.
Patients being given good lifestyle advice.
Good awareness of testing guidelines.
Developments
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More aggressive titration of OHA’s / sometimes reduced.
More timely follow-up, including telephone calls.
Improved treatment of hypoglycaemia.
Advice on pre conceptual care.
Shared care / education for previous non attendees to
diabetes centre eg; those with type 1 diabetes / during
end of life care.
• Attendance at meetings education eg Merit courses to
support initiation of insulin / GLP1’s.
• Insulin starts / insulin conversions/ GLP1 starts
(including group start of 3 patients).
Insulin starts
• 3 surgeries practice nurses are being
supported with insulin initiation.
• 11 patients new to insulin / 2 insulin
changes from once daily to bd regime.
• 3 insulin starts in surgery by DSN.
• Insulin advice and adjustment for patients
who no longer attend diabetes clinic.
GLP-1 STARTS
• 6 mentored starts, at least 6 more
planned. (one group start 3 patients).
• Attendees at Merit course from practices.
• Guidelines for GLP-1 Initiation.
• Clear criteria for continuation of therapy.
• No ongoing titration required.
Summary
• Better communication between primary and
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secondary care. (we are only a phone call away)
Agreed pathways for patients.
Increased confidence of practice teams.
Improved shared care / education for some
more complicated patients.
Audit results should confirm less referrals to
secondary care.
Initiation of injectable therapies in primary care.
Next steps
• Extending the project across the CCG.
• Continued support to surgeries in the
project.
• Results from the audit.
• Possible DSN links for each surgery.
• Continued further education / support for
general practice.