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Integrated diabetes care underway in the West


Members of the Western Trust Diabetes Integrated Care team: Eilish McIvor, Diabetes Specialist Nurse; Lesley Hamilton, Western, Diabetes Network Co-ordinator and Dr Neil Black, Lead Clinician for Diabetes.

Diabetic patients in the Western area are now benefiting from new joined up arrangements between care providers.

Integrated Care Partnerships (ICPs) in the West are implementing service redesign for Diabetes patients with the support of, and funding from, the Western Local Commissioning Group.

Led by Dr Neil Black, Western Trust Consultant in Endocrinology and Diabetes, an ICP multidisciplinary group, involving a range of health professionals, was established to review diabetic assessment and care arrangements, and to consider how services could be improved and better coordinated. The group also heard views from service users and carers.

Arising from this work, the Trust is making steady progress with the implementation of integrated diabetes care, which is now a corporate initiative involving cooperation across many services and professional boundaries.

Dr Neil Black explains: “Diabetes is on the increase in Northern Ireland and learning to live with the condition can be challenging. At the heart of the ICPs’ success to date has been a focus on the patient’s pathway and outcomes. Adopting a fully collaborative approach allows us to further build upon the historically strong and growing partnership between secondary and primary clinicians, in addition to developing a strong core project team combining clinical expertise, technical and service knowledge with strategic response to population health outcomes and a philosophy of innovation and collaborative working.”

The same philosophy is being applied to several pathways to clarify diagnosis of diabetes, when people can be dealt with in the community, and the alternative pathway to specialist care to avoid emergency admission.

A number of initiatives are now underway to deliver integrated diabetes care across the West. An overview is outlined below.

Dr Neil Black pictured presenting the Western ICP area Diabetes pathway.

Dr Neil Black pictured presenting the Western ICP area Diabetes pathway.

Additional pathways guiding management of high and low blood sugars for Emergency Departments and acute medical and surgical units have been prepared after consultation with the respective professional groups and units.

In recognition of the need for integrated patient information pathways to support a patient’s journey the Western Trust is using the Electronic Care Record (ECR), single point of referral for Diabetes patients with electronic triaging. Other forms of virtual communication between clinicians to support patient care to make sure that the person with a diabetes foot problem sees the right person first time, in the right place and at the right time are also being utilised.

The Western Trust continues to build on the perinatal Diabetes services developed with the support of ‘Cooperation and Working Together’ (CAWT) under INTERREG IVA, and improve transitions and interfaces with other services to support patients of all ages.

Personalisation in Diabetes care will be a major theme of integrated working in the Western area throughout 2015. This will involve building on existing initiatives involving patient-led peer support networks and self-directed support for patients; and focus will continue on outpatient services and consolidating expertise for the treatment and management of complex foot problems as a response to the health needs of the border population.

A new integrated diabetic footcare pathway involves joint working between GPs, community nurses, Diabetes specialist teams, and Allied Health Professionals in primary and secondary care, for all diabetic patients at risk of developing foot conditions. Specific co-operation between medicine and surgery will also enhance services for patients with acute Diabetic foot problems.

The service redesign is being facilitated in partnership with GPs, enabled by the implementation of a GP Quality and Productivity Pathway for Diabetic Foot patients.

Dr Brendan O’Hare, ICP Clinical Lead for the Western region commented: “Improving diabetic podiatry care will assist the prevention of foot ulceration, reduce the number of minor and major amputations, and help patients to avoid unnecessary hospital admissions. As part of the new integrated pathway, diabetic patients will now be able to receive more specialist foot care in the community and a specific focus on increased patient education will promote better self-care by patients themselves. This will support earlier identification of potential foot problems and reduce avoidable complications.”