Diabetes in Care Homes

Dr Nicky Williams

Deputy Clinical Chair – East & North Hertfordshire Clinical Commissioning Group

Hertfordshire Diabetes Conference

Diabetes in Care HomesThe Current Picture

When Marie moved to her care home a year ago, she had type 2 diabetes as well as COPD. During her stay, developing cognitive impairment meant she was increasingly dependent on staff who were not always informed or confident in caring for her diabetes. Marie’s frustration at losing responsibility for her own care led to depression and, without a comprehensive care plan in place, there was little improvement in her weight and mobility. When Marie experienced a complication from her COPD, care home staff were unsure what to do and called an ambulance to take her to hospital which Marie found distressing and disorientating.

PATIENT STORY

Diabetes in Care HomesThe Current Picture

Care Home Diabetes Audit (2014)

• No comprehensive assessment, monitoring or provision of specialist care

• Limited skills & knowledge among care home staff

• Ineffective communication with GPs and other services

• Likelihood of hospital admission when a resident is unwell

Care Homes - Demographic Background

4

Diabetes in Care Homes

25%of residents have diabetes

ACCESS

Managed crisis

Enhanced Support

(ST)

Enhanced support

(LT)

Enabling Independence

Self-care

Functions:Short term care with

rapid assessment

and responsive

service.

Functions:Short term

care required

Functions:Long term care, case

management with pro

active care.

Functions:Episodic

short term care

Functions:Information, advice and signposting

Cohort:In crisis or at

risk of requiring

admission to a hospital set

Cohort:Following

deterioration of

health/increase in need

Cohort:Multiple

long term conditions

with complex

care needs.

Cohort:Single long

term condition or

low level support

required.

Cohort:People fully managing

their needs themselves within the

community.

User access Professional access

Care Navigation

Proactive Care Co-ordination

Diabetes in Care Homes

Diabetes in Care HomesVanguard – Enhanced Health in Care Homes’

Our Vision:“To deliver an enhanced model of health and

social care to support frail elderly patients, and those with multiple complex long term conditions

in the community in a planned, proactive and preventative way”

Diabetes in Care HomesVanguard – Projected Benefits

Reductions in: Increases in:

• 999 calls, Ambulance and A&E attendances

• Non Elective Admissions• LOS in the acute care setting• Out of Hours GP services • Delayed transfers of care• Staff Turnover

• Preferred Place of Death • 111 calls• LOS in care homes• Staff, resident and family satisfaction

Diabetes in Care HomesVanguard – ‘Enhanced Health in Care Homes’

• Developing skilled and confident staff within the care home to enable them to care for increasingly complex patients with more confidence. This will allow residents to receive better care in their care home, and help staff support residents to die in their preferred place of death

1. Confident Homecare Staff

• Delivering effective planned, proactive and preventative care for care home residents from primary, community and acute care

2. Effective multi-disciplinary teams

• Providing effective alternatives to 999 services when a resident’s condition changes suddenly, so that the right professional can support that patient as quickly as possible, and attendances and admissions to hospital are avoided wherever possible

3. Rapid response services

• To underpin the care model, crucially allowing clinicians to access records in the patient’s care home, and allowing homes to access expertise remotely through telemedicine

4. Effective technology

Diabetes in Care Homes

Complex Care Premium

Patient presents with Complex Characteristics

Referral Accredited Care Home

Top up Payment

Quality care for complex

patients

The Patient

1. Confident Homecare Staff

Diabetes in Care HomesVanguard – Complex Care Premium

Advanced Nutrition Champion Pathway – ensures:

1. Procedure in place on nutritional care

2. Catering arrangements that promote choice and special diets

3. Access to specialist equipment4. Regular auditing5. Staff knowledge of nutritional

problems6. Working together with GPs,

pharmacist and dietetic support

5 Champion Pathways:

Diabetes in Care Homes

• Investment in two Homefirst teams of social care, community health & mental health staffo Virtual wardso Rapid response

• Enhanced Primary Care Support – dedicated GP practice for each care home

• Medicines Management Team covering 60 care homes

• Interface Geriatricians – rapid access frailty clinics, telephone advice line and outreach to care homes

2. Multi-Disciplinary Teams2. Multi-Disciplinary Team

Diabetes in Care Homes3. Rapid Response

• Homefirst Rapid Response – assessment within 1 hour of referral, to include nursing, therapy, social work or domiciliary care

• Rapid Response Car for Elderly People – acute focussed care that is an alternative to 999

Diabetes in Care Homes4. Effective Technology

• GP access to clinical records

• MedeAnalytics – community health, mental health, acute and social care data to risk stratify and track patients’ use of services

• Telemedicine based on the Airedale Foundation Trust model for a rapid alternative to acute care

Diabetes in Care Homes

The resident

GPs

Skilled care home

staff

Clear care procedures

Community health, social care & mental

health

Supportive technolog

y

End of Life care

Emergency care & crisis

response

Bringing it all together:‘Coordinating diabetes care around the needs of the

individual’

Diabetes in Care Homes

Questions?