Transcript South Tees Diabetes Programme South Tees Diabetes Programme Commissioners: Middlesbrough PCT, Redcar and Cleveland PCT Programme Aims Development of an agreed and costed model of.

South Tees Diabetes Programme
South Tees Diabetes Programme
Commissioners: Middlesbrough PCT, Redcar and
Cleveland PCT
Programme Aims
Development of an agreed and costed model of care which describes
how the ‘must have’ components of the diabetes service are to be
delivered locally and how national specifications for diabetes services
are to be met.
Providers: South Tees Hospitals NHS Trust,
Middlesbrough PCT, Redcar and Cleveland PCT
Population: 280,000
Outcomes – Network Wide
16 LHC Demonstrator Stories on www.networks.nhs.uk
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Defined levels of care within primary care and plans to develop this further
Integrated primary and secondary care diabetes service
Patient education and self-care skills training in place
Defined roles for specialist teams
Defined skills and workforce training plans in place
Reduction in hospital outpatient appointments as care can be effectively
managed in a primary care setting
• Reduced unscheduled admissions and length of stay for diabetes patients
through effective case management and efficient discharge co-ordination
Benefits
• People with diabetes are supported, where appropriate, to manage their
condition as best they can themselves. Quality of life is improved and
people are empowered to manage their condition
• Improved patient experience as patients experience a seamless, coordinated journey through the healthcare system
• Proactive case management systems are in place across the care delivery
system
Measures
• Reduction of the gap between numbers of people diagnosed with diabetes
and projected diabetes prevalence
• Number and type of new referrals to specialist services for newly
diagnosed diabetes patients
• Numbers of unscheduled admissions where diabetes is a primary cause of
admission
• Numbers of occupied bed days for patients with diabetes
• Numbers of patients being actively managed in primary care
• Capacity and uptake of patient education on self-care skills training
South Tees Diabetes Programme
August 07 Progress to date
• Needs Assessment exercise carried out in line with NDST commissioning toolkit and supplemented by local data
sources
• Stakeholder events held to develop high level vision of future model of care and review that model in light of needs
assessment
• Diabetes Retinal Screening Service review undertaken and recommendations presented to commissioning
organisations
• Diabetes dietetic service review underway
• Costing of existing and future models of care in progress
April 07 Milestones
• Diabetes retinal
screening service
review completed and
recommendations
presented to PCTs for
implementation
• Dietetics
service/structured
education review
commences
June 07 Milestones
• PCT restructures in place
• Development of action
plans and briefings to
ensure transition of
responsibility and
governance for the project
shifts from current Network
structure to new
commissioning structures
is as smooth as possible
• Costing workshop –
bottom-up costing of
primary and community
based interventions
September 07
Milestones
• Costed current and
future models of care
are completed
• Prioritised and costed
implementation
recommendations are
in place for each
commissioning
organisation
Local Contacts
Anne Greenley, Senior Service Reform Manager,
Middlesbrough PCT/Redcar and Cleveland PCT
[email protected]