3 dimensions of care for diabetes june 2015

3 Dimensions of care For Diabetes (3DFD)

Dr Carol Gayle, Consultant DiabetologistDr Anne M. Doherty Consultant Liaison Psychiatrist

18th June 2015

1

http://hww-kingsweb/news/display.asp?itemID=26054

http://www.guysandstthomas.nhs.uk/Home.aspx

Dissemination

The cost of diabetes to the NHS

Depression is associated with all stages of diabetes

odds ratio 1.37-1.60

Pre-diabetes: Mezuk Diabetes Care 2008; Kan Diabetes Care 2012 Diabetes: Anderson et al Diabetes Care 2001 Glycaemic control: Lustman et al Diabetes Care 2000Complications: de Groot et al Psychosom Med 2001 Mortality: Ismail et al Diabetes Care 2007; Winkley Diabetologia 2011

odds ratio 2.1

effect size 0.17

odds ratio 3.1

hazards ratio 2.0-5.0

pre-diabetes diabetes suboptimal glycaemic control

complications mortality

4

Depressive disorder and mortality in people with their first diabetic foot ulcer (n=253)

.65

.7.7

5.8

.85

.9.9

51

3 6 9 12 15 18

Observation time (months)

Major depressive disorder

Minor depressive disorder

No/minimal depression

Ismail et al Diabetes Care 2007

Adjusted hazard ratio 3.23 (1.39 to 7.5)

Adjusted hazard ratio 2.73 (1.38 to 5.40)

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Other psychiatric conditions

STEP 1: All known and suspected presentations of depression

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

STEP 4: Severe and complex1 depression; risk to life; severe self-neglect

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

Medication, high-intensity psychological interventions, combined treatments, collaborative care2, and referral for further assessment and interventions

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Focus of the intervention

Nature of the intervention

Assessment, support, psycho-education, active monitoring and referral for further assessment and interventions

NICE stepped-care model

2013 estimated prevalence of diabetes by local authority

•2030 estimate of diabetes, assuming obesity continues to rise at the current rate

Contains Ordnance Survey data © Crown copyright and database right 2013•Source: Diabetes Prevalence Model for local authorities in England

Social problems

Standards

Psychological care

Diabetes care

Social care

Parallel versus integrated services

Diabetes care

Psychological care

Social care

NHS London Regional Innovation Fund 2010

First round 117 applications = £30m

Final shortlist 17 applications = £5m

3DFD £125k =largest award

3DFD: PrinciplesA Blank Canvas

Inclusivity

Diabetes care

Psychological care

Social care

Integrated Care

3DFD- a few minor road blocks.....

3 Dimensions of Care For Diabetes- Innovation

Challenges and Opportunities 'Where ignorance is bliss, 'tis folly to be wise’

• debt management• housing support• occupational rehabilitation• literacy• advocacy

• medication support• biomedical monitoring• diabetes education• technology• complications

• increased self efficacy towards diabetes

• patient reported outcomes • patient led case meetings

• diagnostic assessment• risk management• psychotropic medications • brief psychological

treatments

The model

Integrated across the sectors

Diabetes care

Psychological care

Social care

Patient

3DFD- Current Service

Challenges and Opportunities - current service

3DFD characteristics Year 1

Oct 2012-2013

n=306

Year 2

Oct 2013-2014

n=255

Total

Oct 2012-2014

n=561

Age, mean (SD) 47 (14.8) 50 (15.1) 48 (14.9)

Gender n, (%) Male 121(39.4) 110 (43.3) 231 (41.2)

Female 181 (60.6) 144 (56.7) 325 (58.8)

Diagnosis n, (%) Type 1 89 (28.9) 60 (23.6) 149 (26.6)

Type 2 218 (71.1) 194 (76.4) 412 (73.4)

Ethnic group n, (%)

Caucasian 76 (24.7) 81 (31.9) 157 (28.0)

African/Caribbean 98 (31.9) 88 (34.6) 186 (33.2)

Other 133 (43.2) 88 (33.5) 218 (38.8)

HbA1cmean (SD)

% (DCCT) 10.7 (1.9) 11.6 (2.1) 11.1 (2.0)

mmol/mol (IFCC) 93 (10) 103 (11) 98 (10)

Quantitative outcomesPre 3DFD Post 3DFD Change score p-value

Mean HbA1c, mmol/mol (SD)** 102 (22) 84 (22) -18 (17) <0.001

Mean Patient Health Questionnaire-9 depression score (SD)** 8.8 (6.5) 6.4 (5.8) -2.4 (2.2) 0.021

Mean General Anxiety Scale-7 score (SD)** 8.9 (5.3) 4.9 (5.3) -4.0 (3.5) <0.001

Mean Diabetes Distress Scale (SD)** 47.3 (17.1) 36.0 (15.4) -11.3 (19.1) 0.01

Mean Outcomes Star score (SD)** 55.9 (11.5) 61.6 (14.9) +5.7 (9.1) 0.003

** Service for first 6-12 months (n=198)

Pre 3DFD Post 3DFD Change score p-value

Mean (SD) DCCT % (n=185) 11.3 (2.1) 10 .0 (2.0) 1.5 (1.6) <0.001

Mean (SD) IFCC HbA1c mmol/mol (n=185) 100 (23) 83 (22) 16 (17) <0.001

3DFD outcomes – HbA1c

98

87

82 82

70

75

80

85

90

95

100

Baseline 6 months 1 year 2 years

HbA1c, mmol/mol

Time

Maintenance of HbA1c

Psychiatric morbidity

Support worker assisting patient with type 2 diabetes with accommodation

Social Needs

Qualitative: Focus group (ThinkPublic)

“All of the patients we interviewed spoke extremely positively about their experiences of 3DFD and the difference the service had made to their lives. Patients identified a number of positive characteristics about the service:

– Optional and flexible nature of the service– Caring attitude of staff.– Self-directed nature of support– Reliability – Professionalism and communication

Patient testimonial

My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better.....Rochelle:(T1DM) HbA1c 15.2 to 8.7%

My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better.....Rochelle:(T1DM) HbA1c 15.2 to 8.7%

Cost benefit analysis

3DFD net saving £33K/borough/year/ 100 patients

Main 3DFD outcomes - economic

Pre 3DFD Post 3DFD Change score p-value

No of admissions to A&E/previous year (n=119) 141 77 -64 <0.001

No of bed days/previous year (n=119) 381 300 -81 0.08

No of recurrent admissions (days)/previous year (n=119) 10 (73) 4 (14) -6 (-59) 0.012

Dissemination

http://hww-kingsweb/news/display.asp?itemID=26054

Quality in Care Awards 2011

BMJ Awards 2014Diabetes Team of the Year

Mary McKinnon Lecture DUK 2015

NHS Innovation Challenge Prize 2015

Impact & Dissemination

Other Services Hillingdon

Oxford Hull

Service commissioned by Lambeth and Southwark CCGs from 2014

Would this work in other setting?

Regional Innovation Fund

Contact us

[email protected] 0203 299 1350

[email protected]@nhs.net

mailto:[email protected]




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Managing Demand and Capacity in Mental Health Settings

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3 dimensions of care for diabetes june 2015

Healthcare

kan diabetes care

mezuk diabetes care

estimate of diabetes

cost of diabetes

diabetes prevalence

care model

stages of diabetes odds

dimensions of care