Liverpool Diabetes Partnership - Redesigning Diabetes with the Patient as the Centre in Liverpool

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1 Liverpool Diabetes Partnership - Redesigning Diabetes with the Patient as the Centre in Liverpool Juliette Palmer Liverpool Diabetes Partnership Diabetes Specialist Nurse Jan Fennell Rutherford Liverpool Diabetes Partnership Service Manager

2 Diabetes is one of the big health challenges faced by Liverpool Health Economy BACKGROUND The service is designed around the clinical need of our patients. As part of the Healthy Liverpool vision, healthcare teams across the city are working together to ensure that the care of patients with diabetes is proactive, tailored and provided locally in the community. Technology from EMIS Health is helping to turn the service redesign into reality Dr Janet Bliss, Liverpool CCG Healthy Liverpool Community Lead

3 Through Insight At Listening Events Through Diabetes UK Patient Groups Patients told us All participants felt they self manage mix of approaches & different levels of confidence Lower confidence need more support Self management is short term & reactive Lifestyle changes are not regarded as self management Low resonance of complications Diabetes education courses highly valued but poorly attended - Peer support excellent Lack of info regarding prevention (e.g. compared with cancer) & b) self care (diet & exercise) Lack of consistency of care & information Lack of signposting to non- medical services e.g. cookery classes Use of technology Lack of consistency in information explained to patients (also reflected at listening events) More/varied education programmes required Better support networks for younger people & more use of social media Presume we can be in control Diabetic exercise for health

4 Diabetes UK Integrated IT / Shared Clinical Records Voluntary & Independent Sector Telehealth / Telemedicine Enablers 4. Hospital Based Specialist Care 3. Community Based Specialist Service 2. Primary Care 1. Patient Self Care & Self management Diabetes & You (Patient Education) Introduction Pack Patient Held Record (electronic/paper) Peer Support Future Developments In-reach service NWAS Community Pathfinder Improving links between Adult s & Children s services

5 Integrated Service LDP is a Lead Provider Model 3 rd SECTOR NWAS Commissioner LCCG PUBLIC HEALTH Aintree University Hospital Lead Provider Liverpool Community Health Royal Broadgreen Liverpool University Hospital Diabetes Service Aintree UH Diabetes Service EMIS Health

6 Improving Self Care in LDP Patient Activation Measure Shared Decision Making Patient Education Social Model of Health and Wellbeing

7 WHAT WE DO Consultant led Community Clinics Nursing and Dietetic Intensive Management Clinics Diabetes Specialist Nurses working in Primary Care Podiatry Home Visits Education Clinicians People with Diabetes, their families and carers Nursing Homes And the list of WE DO THAT grows as the service develops.

8 How we do it 4 DSNs based in Primary Care covering 96 practices 7 Diabetologist Dietitcian s Podiatrist Primary Care staff

9 Where we do it Community Clinics General Practice Health Events Patients Home Nursing Homes Community Groups Anywhere we need to

10 PRIMARY CARE DSNs Impact of the Role: Link between Primary Care and Consultants Managing closer to home Monthly session delivered around what the practice needs and wants Innovative Radical Challenging Empowering Patients

11 Helping with shared decision making Empowering patients Working with hard to reach including the non engaged Youth/ gang culture BME Open Days Community Events specific to communities Pharmacists

12 Patient feedback Use of EMIS as the single patient health record meets their expectation that clinicians know what has happened before Patient engagement in best environment Patient centred care through practice and community settings, seen when needed quickly and closer to home Education more accessible to patients families and carers and tailoring education to meet the needs of the local community

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14 Innovative EDUCATION LED Patients and Clinicians Everyone has access to the information and can see interventions which influence and enhances discussions CHALLENGING MAKING A DIFFERENCE Communication single point of information EMIS

15 Usual suspects always done it this way the need a letter mentality SUBDIVIDED STAFF GROUPS How we are working through it Pushing the benefits of single point of information supporting decision making for the individual and the clinician FEAR OF CHANGE RESISTANCE

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17 Questions Thank You

18 CASE STUDIES Female aged 54 years Diagnosed Parkinson s, Type1 Diabetes Referred to service She cancelled a number of appointments Reviewed EMIS clinical information Contact made and visited MDT decision recorded and available for all clinicians involved to follow

19 CASE STUDIES Elderly gentleman mild learning disabilities Lives at home with his wife, with extensive care package Recurrent admissions to hospital due to ketones. LDP MDT Community MDT Individualise care plan developed and documented on EMIS No Diabetes related admissions since.