improving foot health: “what does good look like” dmi board 13 march 2014 dr. jane doherty,...

Improving foot health: “What does good look like”

DMI Board13 March 2014

Dr. Jane Doherty, Carol Gayle, Laura Price & Monique Ferdinand

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Foot health – DMI programme board

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Contents

1. Background

2. “What does good look like”

3. Work to date to build improvements

4. Recommendations to reinforce improvements

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Background: Objectives of DMI foot health work

• Reduce variation in foot assessments across primary care and increase the number of foot assessments conducted accurately and consistently

• Increase patient & 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

• Understand the capacity of community podiatry service to manage cohorts of patients previously managed in hospital

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Background: Foot Health Group Membership

DMI Clinical Leads:• Dr. Carol Gayle • Dr. Jane Doherty

Members & Contributors:KCH Diabetes Foot Clinic

GSTT Hospital Foot Clinic

GSTT Community Podiatry

Lambeth & Southwark CCG

• Dr. Marcus Simmgen (Diabetes Consultant in Foot Medicine, KCH)•Dr. Prash Vas (Diabetes Consultant in Foot Medicine, KCH)•Maureen Bates (Manager, KCH Diabetes Foot Clinic)

•Tejal Patel (Deputy Head, GSTT Dept of Foot Health) •Liza Curtis (Head of GSTT Dept of Foot Health)•Steve Thomas (Diabetes Consultant , GSTT)

•Rupert Maher (Head, Lambeth & Southwark community podiatry) •Laura Gearing (Principal Podiatrist, Southwark)•Monica Fisk (Community Podiatrist, Southwark)•Christian Pankhurst (Senior Orthotist, GSTT)

•Leah Herridge (Redesign Manager for LTC, Southwark CCG)•Mahroof Kazi (PCC Commissioning Manager, Lambeth CCG)•Linda Drake (Practice Nurse, Southwark CCG)•Bob Skelly (Patient Rep, Southwark CCG)

• Transition meeting from DMI hosted by KCH: February 20, 2014 • Agreed terms of reference for Lambeth and Southwark Diabetes Foot Health Group

Regular Meetings for Development:• 6 meetings in 5 months• Several redesign activities, actions

and owners

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“What does good look like”: Foot assessments in primary care

For 2013/14, we would expect Lambeth and Southwark to be at or above the England average for DM29, a level Lambeth has already achieved

Variation reduced and more practices to be closer to the expected performance for the average achieved in Lambeth and Southwark

65%

70%

75%

80%

85%

90%

95%

100%

0 200 400 600 800 1,000 1,200

% o

f pati

ents

on

diab

etes

reg

iste

r re

ceiv

ing

foot

che

ck (

no e

xcep

tion

s)

Diabetes Register Size (QOF 2012/13)

QOF 2012/13; DM29 - Percentage of patients with foot checks, by practice register size

Southwark

Lambeth

Lambeth and Southwark Average

Lower control

Upper control

National Lower Quartile

National Median

National Upper Quartile10861

11229

11512

12764

10526

8741

9818

9762

11064

9967

0

2000

4000

6000

8000

10000

12000

14000

2009/10 2010/11 2011/12 2012/13 2013/14 Nov

QOF DM29 - patients receiving foot checkDM9 prior to 2011/12 - no risk stratification

Lambeth Southwark

England average was 83.7% in 2011/12 and 85.1% in 2012/13

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“What does good look like”: Foot Health risk classification

Total Patients on Register 13,109 * Prevalence estimates based on Williams & Airey 2000 / Leese et. Al (2006, 2011) **Estimates based on actual 2012/13 patient caseload in specialist services within GSTT and KCH hospital clinics, and GSTT community podiatry

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Patients with a moderate or high risk classification in primary care to be seen within the community podiatry service caseload, in order to meet best practice outlined by NICE and Diabetes UK

Foot intactNormal sensationPalpable pedal pulses

Foot intactNeuropathy or absent pulses

Foot intactNeuropathy or absent pulsesPLUSPrevious ulceration, skin changes or deformity

High

Moderate

Low

Lambeth & Southwark community podiatry (Foot Protection Team)

Southwark & Lambeth community podiatry (Foot Protection Team)

Primary Care

Risk level Service How to refer

Neuropathic foot + new onset blister / superficial ulceration (up to 48 hours)

KCH diabetic foot clinic or GSTT foot healthA&E if out of hours

Lambeth & Southwark community podiatry (Foot Protection Team)

What should happen

Advise patients of their risk level Advice and information for emergencies Discuss self management care plan & self management options. Refer as appropriate.

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

See self management pathwaySouthwark: 020 3049 8863 / 8840Lambeth: 020 8655 7842

Southwark Community PodiatryTel 020 3049 7900Fax 020 3049 7901Lambeth community podiatry Tel 0203 049 4040 Fax 0203 049 6361/6362

Southwark Emergency clinics Mon,Wed, Fri Tel: 020 3049 7900Fax: 020 3049 7901Community podiatry:020 3049 7900Lambeth Emergency clinics Mon – Fri:Tel: 0203 049 4001/2/3Community podiatry 0203 049 4040 Fax 0203 049 6361/6362

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

Diabetic foot patient pathway for Southwark and Lambeth March 2013

Tailored intervention by community podiatry (Foot Protection Team)Referral to specialist hospital team if requiredInform GP of intervention

Tailored intervention by specialist teamInform GP of intervention

King’s Diabetic Foot ClinicTel: 020 3299 3223 Fax 020 3 299 4536 Guy’s Foot Clinic Tel: 0207188 2449 Fax 020 7188 2450St Thomas’ Foot ClinicTel: 020 7188 1983Fax: 020 7188 1991St George’s Foot Clinic 0208 725 1429 / 0232

Within 24 hours

Priority referral

Routine referral

As required

Holistic careAre diabetes & other risk factors well controlled?

At every appointment discuss self management care plan & refer if suitable to self mgnt pathway for options

Active

Foot ulcerationFoot intact BUT infectionIschaemic foot + infectionNeuropathic foot + infectionUnexplained foot inflammation ?Charcot

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Patients with a moderate or high risk classification in primary care to be seen within the community podiatry service caseload, in order to meet best practice outlined by NICE and Diabetes UK

With better communication from specialists, coded classification and actual caseload to be closer in number and give better indication of where the capacity should be in the system

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“What does good look like”: Addressing capacity concerns in community podiatry

Lambeth & Southwark Community Podiatry Service - Capacity Deficit

0

50

100

150

200

250

APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

2014 2015

Ave

rage

Mon

thly

Cap

acit

y D

efici

t (N

o. o

f Att

enda

nces

)

ADDITIONALATTENDANCES(AcuteTransfers )

EXISTINGCAPACITYDEFICIT(Attendances)

Assumes that: i) 'Healed' patients are discharged at their next attendance beginning in April 2014 ii) first community attendance is 60 days later i i i) patients attend 5 times per year, evenly spaced

Healed patients for over 12 months which meet the agreed guidelines begin to be transferred by April 2014, estimated:

98 for KCH 75 for GSTT

Community podiatry is supported to address the current + projected service capacity deficit (shown here)

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Work to date: DMI Foot Health Group improvements

Engage & Analyse

• Ensured proper representation & assigned owners

Design & Develop

• Baseline foot metrics across settings

• Record patients with diabetes in foot settings (esp. GSTT)

• Perform audit of healed patients at KCH & GSTT

• Analysis of community podiatry activity & capacity

• Clinical letter for specialist settings created to improve communications

• Guidance for healed foot patients drafted & approved

• Self-referral and referral to community podiatry revised + clarified

• Transfer process agreed

Promote & Sustain

• Foot health & diabetes education resources compiled for practitioners and patients

• Foot case study + 1° performance presented at DMI Learning events

• Promoted pathway at several primary care PLT & Locality meetings

• Foot health promoted at Patient Forum Launch & again in June 2014

• Foot health improvements communicated to 1° via CCGs (email, EMIS, online)

• Stronger relationships built between foot services & CCGs – Foot group TOR agreed

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Recommendations to continue to reinforce and support DMI improvement work

1. Support the current business case to increase the capacity of community podiatry, and continue to monitor and evaluate the demands on the service

Next Steps: Monitor and report on transfer activity (high risk) Referrals from primary care and patients (moderate / high risk) Audit community caseload to identify if patients could be shifted to primary care

2. Continue to ensure adequate communication to primary care from specialist settings

Next Steps: Clinical letter reinforced to be used by podiatrists across settings Foot Health Group to report on usage in 6 months and revise if changes are

needed Promote further touch-points with primary care for support (i.e. learning events)

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3. Reinforce the foot health pathway and continue education opportunities for patients and primary care practices

Next Steps: Local diabetes foot health group to own pathway developed and review annually CCGs and community podiatry to continue promote foot health & pathway (at

least once a year) at primary care and patient events

4. Continue to foster relationships built between specialist settings in community and hospital (and across trusts), as well as with CCGs and primary care

Next Steps: Diabetes foot health group meets at least three times a year and continues to

reinforce DMI work in organisations (next date: June 5 2014) CCG and provider organisations support group and efforts to sustain

improvements

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RecommendationOwner (DMI Board Member / Foot Group Member)

1. Support the current business case to increase the capacity of community podiatry, and continue to monitor and evaluate the demands on the service

Lambeth CCG (Therese Fletcher / Mahroof Kazi)

Southwark CCG (Leah Herridge) GSTT Community Services (Amanda

Williams / Rupert Maher; Laura Price)

2. Continue to ensure adequate communication to primary care from specialist settings

KCH diabetes foot clinic (David Hopkins / Carol Gayle; Prash Vas)

GSTT hospital foot clinics (Steve Thomas / Tejal Patel)

GSTT Community Services (Amanda Williams / Rupert Maher; Laura Price)

3. Reinforce the foot health pathway and continue education opportunities for patients and primary care practices


Southwark CCG (Leah Herridge) GSTT Community Services (Amanda

Williams / Rupert Maher; Laura Price)

4. Continue to foster relationships built between specialist settings in community and hospital (and across trusts), as well as with CCGs and primary care

KCH diabetes foot clinic (David Hopkins / Carol Gayle; Prash Vas)

GSTT hospital foot clinics (Steve Thomas / Tejal Patel)

GSTT Community Services (Amanda Williams / Rupert Maher; Laura Price)


Southwark CCG (Leah Herridge)

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What we need from the board:

• NOTE the actions completed by the DMI Foot Health Working Group

• SUPPORT the further actions required to sustain and reinforce improvements

• SUPPORT the Lambeth and Southwark Diabetes Foot Group as a forum for CCGs, GSTT and KCH hospital foot clinics, and GSTT community podiatry services to continue to develop services and reinforce DMI work

improving foot health: “what does good look like” dmi board 13 march 2014 dr. jane doherty,...

Documents

foot medicine

number of foot assessments

dmi board

gstt community podiatry

hospital slide

southwark england average

good look like

kch hospital clinics