service specification diabetes integrated service nhs ... fileservice specification diabetes...

Service Specification

Diabetes Integrated Service NHS Southern Derbyshire CCG

DRAFT: Version 8

27th May 2014

of 25

Contents 1. Population Needs ............................................................................................................... 2

1.1 National/local context and evidence base .................................................................. 2

2. Outcomes ........................................................................................................................... 4

2.1 NHS Outcomes Framework Domains & Indicators The Diabetes Integrated Service addresses the following domains within the NHS Outcomes Framework: ........................... 4

2.2 Local defined outcomes .............................................................................................. 5

3. Scope .................................................................................................................................. 5

3.1 Aims and objectives of service .................................................................................... 5

3.2 Service description/care pathway ............................................................................... 6

3.2i Potential Contracting and Sub-Contracting of Services (General condition 12) ....... 10

3.2ii Integrated IM&T ................................................................................................ 10

3.2iii Branding ............................................................................................................. 10

3.2iv Intellectual Property Rights ............................................................................... 10

3.2v Staffing ............................................................................................................... 10

3.3 Population covered ................................................................................................... 10

3.4 Any acceptance and exclusion criteria and thresholds ............................................. 11

3.5 Interdependencies with other services/providers .................................................... 11

3.6 Review and Audit ...................................................................................................... 12

4. Applicable Service Standards ........................................................................................... 14

4.1 Applicable national standards ................................................................................... 13

4.2 Applicable local standards......................................................................................... 13

5. Applicable quality requirements and CQUIN goals ......................................................... 14

5.1 Applicable CQUIN goals & Local Incentive Scheme (Schedule 4) ............................. 14

6. Location of Provider Premises ......................................................................................... 14

Appendix A: Footcare pathway ................................................................................................ 15

Appendix B: Health Outcomes ................................................................................................. 16

Appendix C: local Incentive Scheme …………………………………………………………………………………. 17

Appendix D: Local Quality Requirements ………………………………………………………………………….. 19

of 25

SCHEDULE 2 – THE SERVICES

A. Service Specification

Service Specification No. 001

Service Diabetes Integrated Service

Commissioner Lead NHS Southern Derbyshire CCG – Joint Commissioning

Provider Lead To be determined

Period Three years in the first instance with an annual review

November 2014 to November 2017

Date of Review November 2015

1. Population Needs

1.1 National/local context and evidence base

National context

Diabetes is one of the biggest health challenges facing the NHS and has been recognised as

becoming a significant priority both locally and nationally.

There is unwarranted variation across the country relating to the level of care patients receive and

disease outcomes.

There are several publications that recommend better integration and standards of care for people

with diabetes inclusive of:

NICE Quality Standards for Diabetes (2011)

Commissioning Diabetes without Walls (2009)

Best practice for Commissioning Integrated Diabetes Services (2013)

The National Service Framework for Diabetes

Local context

Locally there are currently in the region of 28,324 people diagnosed with either Type 1 or Type 2

diabetes (6.7% of the CCG population) based on 2012/13 QOF data. The national prevalence is 5.5%.

There are 57 GP practices in Southern Derbyshire CCG (SDCCG) all involved in the care of patients

with diabetes. There are also health professionals employed by Derbyshire Community Health

Services and local Acute Trusts who provide services in the community for people with diabetes

including specialist nurses, podiatrists, dieticians and consultants however these services are

geographically variable across the CCG.

There is variation in the number of patients with Type 1 and Type 2 diabetes who receive the nine

recommended care processes with 40.5% of patients with Type 1 diabetes receiving eight out of the

nine processes and 67.8% of patients with Type 2 diabetes receiving them (National Diabetes Audit

2011/12 – eight processes audited omitting retinopathy due to unreliable data).

of 25

There is a recognised need to move away from disease specific pathways, where specialists treat

only one disease, due to people often having multiple physical health conditions, along with mental

health and social care needs. Whilst such specialists are highly skilled this does not reduce

fragmentation of care.

Locally, there is an agreed model for an approach to all Long Term Conditions. The aim of all

provision in the community will be to ensure that as many people as possible maximise their ability

to self- manage their conditions as early as possible and develop / maintain support networks to

keep living the best life possible. This approach has been adopted across SDCCG and both Local

Authorities. It is the expectation that the diabetes integrated service does not seek to operate in a

vacuum but recognises it has a part to play in this wider health goal with partnerships and

relationships which may easily fall outside of this specification. The integrated diabetes service will

also be mindful of the implications of Personal Health Budgets for long term conditions

Each GP practice has a Community Support Team CST Care Coordinator in place for the highest risk

patients which may be required to be kept informed of progress for some of the people attended to

in this diabetes integrated pathway. The CST Care Coordinators are not part of this contract. A

representative may be required to participate in Multi-Disciplinary Meetings at the request of care

coordinators to help meet the needs of patients with multiple long term conditions. Holistic care is

at the heart of service delivery aiming to fully understand the root causes of patient’s issues. To

clarify, the model includes levels of care. Within each level it is anticipated that greater

communication / co-ordination is achieved throughout each level and better integration is achieved

across each level. The provider will need to remain a willing partner in this model. The integrated

diabetes provision is likely to span all five levels at the point of full implementation.

There will be a CCG wide approach to establishing a single point of access for all intermediate care

Functions. As this is finalised and developed, to avoid duplication of resources the Integrated

Diabetes service provider/s will be expected to participate in the function of this initiative.

Community Model - Definitions of Levels Level1: Can be described as Self-Help, centred on the person and their support networks, both formal and informal. – maintaining people in level 1 to have a “Good Life” is a primary aim. This level includes the use of assets, social capital, self-monitoring, prevention and education.

Level 2: Is centred around Primary Care, delivered close to the patient in the community. Community Support Teams, including social care and other associated practice based staff around the GP form the core offer for this level.

Level 3: Is community facing care delivered on a district wide basis. Groups of professionals delivering targeted and / or integrated interventions and rehabilitation, providing the correct amount of support alongside Level 2.

Level 4: Describes care delivered across the CCG which may deal with more specialised need. Typically fewer professionals will serve a greater area for needs which fall into this category.

Level 5: Refers to community-facing services delivered in, or from, a Hospital or a Care Home.

of 25

The Service will recognise that community focused delivery integrated with existing resources across levels 1-3 will be required for optimum results.

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

The Diabetes Integrated Service addresses the following domains within the NHS Outcomes Framework:

Domain one Preventing people from dying prematurely √

Domain two E nhancing the quality of life for people with long term

conditions

√

Domain three Helping people to recover from episodes of ill health or

following injury

√

Domain four Ensuring people have a positive experience of care √

Domain five Treating and caring for people in a safe environment and

protecting them from avoidable harm

√

of 25

3. Scope

3.1 Aims and objectives of service The overarching aim of the integrated service is to coordinate, promote, embed and provide, via the

usual integrated structures for access, a holistic care pathway that has self-care, preventative care

and medical care as the key components to improve the overall quality of life for patients and carers

affected by diabetes.

The integrated approach shall encompass the whole pathway across all levels of care from

prevention through to highly specialist care to streamline services. It shall empower individuals to

make informed choices about their health by changing from a traditional medical model to one that

is integrative and holistic that not only deals with symptom management but also addresses the root

causes of the condition and associated problems.

The objectives of the service are:

To implement a standardised, evidence based pathway that is responsive to local need and

represents good value.

To offer simplified and responsive access into diabetes pathway.

To implement coordinated, holistic assessments that ensures all patients have access to the

right care when they need it.

There is an on-going campaign to raise the awareness of diabetes.

To embed a harmonised care planning approach that encourages health professionals to

support patients to identify goals and empower them to self-care.

To support an appropriately skilled workforce.

To ensure that all patients are provided with timely foot care management.

To work with existing screening services.

To support the provision of joined up pre-conception care for women of child bearing age

with diabetes.

To provide support that meets the needs of vulnerable / hard to reach groups.

To create and allow peer support networks to flourish.

To optimise treatment through medicines management and regular treatment review.

To work in a collaboratively integrated fashion within acute model designed by SDCCG.

All elements of the service will be delivered in a fully supportive way and enhance

intervention.

2.2 Local defined outcomes It is expected that an integrated diabetes pathway will result in:

Better outcomes for patients and carers affected by diabetes.

Reduction in inequalities.

Reduction in secondary care activity.

Improved coordination of care.

Improved self-management of condition.

of 25

Develop and maintain excellent partnership working and relationships with acute providers

to help ensure timely discharge.

Regardless of place of residents in SDCCG area all people will have equitable opportunities

to access the different elements of this service.

Provision of services close to the patients home that meet patient’s needs with as few

medical hand offs or unnecessary re-referrals as possible.

There is direct liaison with appropriate partners and providers to ensure that patients gets

seen by the right person, at the right time and are referred and managed in accordance with

CCG approved guidelines and protocols.

3.2 Service description/care pathway The integrated diabetes service shall be delivered in community settings across SDCCG. Through the

provision of the service the Contractor shall ensure that it works within the levels of care model and

offers an integrated approach to the management of diabetes across SDCCG area with all health

professionals working in partnership to ensure that patients are seen by the right person, at the right

time according to their needs.

Personal Health Budgets (PHBs) for long-term conditions will mean that patients may choose to get

aspects of their needs met outside of this pathway should this be assessed as appropriate. The

Contractor will be responsible for working closely with commissioners in preparation for PHBs to

identify the average unit costs for each element of the pathway delivered of which related costs will

be adjusted in schedule 3a.

The Contractor shall ensure that the service is delivered utilising a range of flexible options including:

Locality based services that meet local patient’s needs and individual GP practice needs.

One stop shop appointments, where possible.

Combined specialist nurse and practice nurse clinics in general practice for teaching and

education.

A triage service for GP practices to enable potential secondary care referrals to be

appropriately managed within the community.

Health professional education.

Consultant to GP support for urgent advice.

Smarter ways of working for example patient education groups for various aspects of their

care that may routinely be offered in a one to one appointment.

Services for black, Asian and ethnic minority groups are culturally appropriate and delivered

in different community settings e.g. mosques, Gurdwaras and female only clinics.

The contractor shall ensure that the following specific service elements are provided :

Integrated, multidisciplinary diabetes community support

The Contractor shall ensure that:

An integrated approach is established with options to access medical, nursing, dietetic,

podiatry and psychological care which are offered as core functions within the team.

Simplified Access


of 25

Patients have access to consistent, coordinated care via a diabetic care coordinator.

Patients are provided with a diabetes care plan which is agreed with them and reviewed

annually.

Where care co-ordination is already in place for an individual then this resource is fully

informed of progress.

Where it’s feasible community clinics may be provided alongside diabetic eye screening

community clinics (commissioned via Public Health, NHS England) to support

implementation of one stop shop clinics for annual reviews, foot care and dietetics.

There is a patient centred approach in place to minimise the number of diabetes related

appointments in order to achieve the optimal care.

Dedicated specialist diabetic advice is available to health professionals on a routine and

urgent basis.

Systems are in place for patients under this service to access responsive advice about their

condition.

Referrals, trends and demands on community and hospital services is captured and reported

to commissioners.

Combined clinics in primary care


General practices are offered mentorship and support for annual reviews, case finding,

personalised care planning and patients with difficult to manage disease via combined

clinics. The focus within these clinics shall also be on identifying problems earlier to reduce

the onset of complications.

GP’s and practice nurses are supported in their holistic assessment approach.

Health and Social Care professional education


There is a range of rolling, locality based education, e-learning and training workshops

provided that offer an interactive learning environment. Training should address as a

minimum the following areas:

- Practice diabetes reward scheme

- Setting and achieving HbA1c and blood pressure targets

- Complication awareness

- Cardiovascular disease risk assessments

- Foot and eye health

- Dietary management

- Insulin initiation, titration, escalation and on-going management

- Effective medication reviews

- Personalised care planning, self-management and behaviour change

- Motivational interviewing and mindfulness

- Raise awareness of diabetes patients smoking and/or obese and the link to depression.

- The use of CCG approved guidelines are universally embedded.

There is a standardised level of diabetic related skills and knowledge for staff working in

primary care in line with the Integrated Career and Competency Framework for Diabetes

Nursing (Trend UK) and The Podiatry Competency Framework for Integrated Diabetes Foot

care.

Support and training is available for other professional working within healthy lifestyle

of 25

change initiatives.

Support for those identified at risk of Pre-Diabetes


The service promotes early intervention.

Those at risk of developing diabetes are referred onto a local lifestyle change programme

where eligible.

The service supports and promotes national and local awareness campaigns.

Patients who are smokers or obese are screened for depression.

Those who are identified as being pre-diabetic or with a history of gestational diabetes are

offered Impaired Glucose education and regular assessment of education requirements.

Equipping patients to Self-Manage The Contractor shall ensure that:

Patients and carers are equal partners in decisions about their care and have more control in

the management of their own health, care and treatment.

Primary responsibility of the development and implementation of the Care Plan shall be with

the patient and it will be documented in a universally agreed format.

There is a joint approach to the development and provision of individualised care plans

which may involve GPs and CST care coordinators.

There are interventions and programmes jointly agreed and aimed at helping individuals to

achieve their personal goals.

Structured education is equitably delivered across SDCCG in line with National guidance and

at every stage of the pathway.

Structured education that supports behavioural change for patients should broadly cover

the same topic areas as professional education and should be delivered in an equitable

manner delivered across SDCCG locality.

Patients have annual education update offers.

Pre-pregnancy awareness for women with diabetes of child bearing age is raised across

Southern Derbyshire.

Women with diabetes who are planning a pregnancy are provided with knowledge and

support to prepare them for pregnancy.

Peer/social support networks are established in localities and in communities with differing

cultural needs across Southern Derbyshire to offer opportunities for people to meet others

with diabetes to share knowledge and experiences. Such networks are delivered in different

ways that are sensitive to need and locality.

Psychological support


Robust partnerships are in place to provide specialised Psychological support services.

At the point of diagnosis patients’ psychological needs are screened and supported on an

on-going basis according to need.

Where risks indicate the patient is screened for depression.

Specialised psychological support is integrated at every stage of the pathway.

Dietetics


of 25

Robust partnerships are in place to provide specialised Dietetics services.

Diabetic dietary advice and management is equitably available for all patients who require it.

There are a variety of methods by which patients can be provided with dietary support.

Podiatry


Robust partnerships are in place to provide specialised Podiatry services.

Patients with low, medium and high risk of foot are reviewed according to NICE.

There is a proactive focus on prevention to reduce diabetic related amputations.

There is a seamless pathway to a specialist multidisciplinary foot care team for patients

identified with a foot care emergency and/or foot ulcers.

Patients discharged from hospital following a diabetes foot care related admission are

appropriately followed up.

See appendix A for the diabetes foot care pathway.

Retinopathy screening


There is a seamless pathway to the Diabetic Eye Screening service to ensure that all people

with diabetes who are eligible for screening are offered annual screening for diabetic

retinopathy.

Triage of secondary care outpatient referrals


All referrals made to secondary care outpatient clinics are triaged to confirm

appropriateness. Inappropriate referrals shall be returned with clinical advice.

There is an increase in access to community outpatient clinics.

Admission avoidance


There is a proactive review of care plans for patients who frequently attend acute hospital

services and that support is provided to manage their condition together with community

and social care partners.

A model is developed for the early identification of risks regarding diabetic related,

unplanned admissions and accident and emergency attendances with a view to reducing

avoidable non-elective admissions and facilitating early discharge.

Patients with diabetes who are identified as being at risk of admission are provided with an

enhanced care plan that offers additional support to help improve self-management to

reduce hospital admission.

Pathways and robust communication links are established with local care coordinators to

support the reduction in non-elective hospital attendances/admissions, including patients

who fail to attend diabetes annual reviews.

Prescribing

The service/provider will supply or prescribe medication where;

A medication needs to be continuously prescribed by a specialist.

of 25

A medication needs to be initiated and stabilised for a patient before requesting primary

care prescribing.

A GP has concerns regarding competence about prescribing a requested medication or

where a medication is needed urgently, in line with JAPC guidance.

Urgent drugs are classified as those required within 5 working days; 28 days will be supplied unless a

shorter course of treatment is indicated.

The service/provider will comply with the Derbyshire Joint Area Prescribing Committee Specification

which is available on: www.derbyshiremedicinesmanagement.nhs.uk/non_clinical_guidelines.

3.2i Potential Contracting and Sub-Contracting of Services (General condition 12)

Commissioners must be in full agreement of any contracting or sub-contracting agreements.

3.2ii Integrated IM&T The Contractor shall ensure that:

There is a robust information technology infrastructure in place to allow for:

- Timely communication between members of the integrated team and other health

professionals.

There is IT connectivity for all providers across the entire pathway.

Any IT infrastructure developed allows care plans to be shared across all providers involved

in diabetic care inclusive of patients.

Information Governance (IG) Data sharing and reporting measures are in place within the life

of the contract.

3.2iii Branding The Contractor will ensure that NHS Southern Derbyshire Clinical Commissioning Group is

acknowledged in accordance with NHS contracting General Condition 23 (GC23).

3.2iv Intellectual Property Rights

Please reference NHS contracting General Condition 22 (GC22).

3.2v Staffing

The service shall be delivered by appropriately qualified, skilled and competent staff. As required in

NHS contracting General Condition 5 (GC5).

3.3 Population covered The contractor shall ensure service availability to:

Adults from the age of 16 with a diagnosis of Diabetes Mellitus (Type 1 and Type 2)

registered within SDCCG.

The Contractor shall liaise closely with paediatric diabetes services to ensure that there is a seamless

transition of care between adolescent and adult services.

The Contractor shall support all practices within the CCG and patients who are registered with a

practice in the CCG.

http://www.derbyshiremedicinesmanagement.nhs.uk/non_clinical_guidelines

of 25

3.4 Any acceptance and exclusion criteria and thresholds All diabetes related care inclusive of prevention, screening, Type 1 and Type 2 diabetes

management shall be included within the integrated care model with the exclusion of:

Diabetic retinal screening service.

Children with diabetes under the age of 16.

Antenatal diabetes.

Initiation of Insulin pumps.

In-patient care

Other exclusions include:

General practice Quality and Outcomes Framework across Southern Derbyshire GP practices.

Local Enhanced Schemes.

The service will need to establish robust links with the above services to ensure a seamless transition

of care is provided for all diabetic patients.

Equity of access to services

The Contractor shall ensure that its service is accessible to all patients who meet the eligibility

criteria regardless of race, age, gender identity, disability, sexual orientation, religion or belief and

that it deals sensitively with all service users and potential service users their families/friends and

advocates.

Diversity


There are relevant pathways and skills available to meet the cultural needs of people with

diabetes such as older people, those with mental health conditions, housebound, learning

disabilities, black, Asian and ethnic minority communities to ensure equity of opportunity

and reduce health inequalities.

The provider will be aware of local initiatives such as Local Area Co-ordination that supports

community asset development.

Settings will be culturally or gender appropriate as required.

Operational hours

The Contractor shall operate services flexibly to meet demand and be able to increase availability as

appropriate to the needs of the people accessing the services delivered. There may be a need to in-

corporate services to deliver seven days a week according to demand and local developments.

The Contractor shall be sensitive to future developments in care delivery, out of hospital care in the

community and out of hour’s services.

3.5 Interdependencies with other services/providers The integrated service shall be interdependent with the following other services:

Public Health – Health and Wellbeing Board and Local Authority

Community and voluntary sector organisations

of 25

GP practices

Community pharmacies

Retinal screening service

Wider inter-agencies e.g. orthotics, interpreter services

Derby and Derbyshire County Council Social Care Services

Derbyshire Diabetes Network

Diabetes

Sight Support Derbyshire

Acute care service providers

Local support groups / patient forums

Community service teams

Single Point of Access

EMAS

Community care coordinators

Community matrons

District Nursing

Improving Access to Psychological Services (IAPT)

The Contractor shall ensure that pathways and communication links are established with hospitals

that are located outside of SDCCG boundaries (Burton, Kings Mill and Nottingham).

Referrals

Referrals can be taken by SDCCG SPAs (Single Point of Access solutions). Also, directly to this service

from Primary Care, Acute and other Secondary Care providers, Community Health providers, Social

Care partners and providers, relevant third sector partners, Self-referrals, and Family and/or Carers.

3.6 Review and Audit The Contractor shall have the overall responsibility for ensuring that the following key service

outcomes are achieved and reported on in accordance with NHS contracting General Conditions

(including GC 8, 15). The CCG reserves the right to audit and requires monthly quality report

(schedule 6)

The Contractor agrees to allow NHS Southern Derbyshire CCG:

To have reasonable rights of audit and access to any of the Contractor’s premises,

personnel, The Contractor’s systems, sub-contractors and their facilities and premises and

the relevant records (including the right to copy) and other reasonable support as the

commissioner may require whilst the service is being provided and for twenty four (24)

months following the end of the contract in order to verify any aspect of the service or

provider’s performance.

3.7 Implementation

There will be a phased implementation approach over the initial three years of the contract. The

implementation of this service will need to broadly encompass the following aspects of the pathway:

Year one Year two Year three

of 25

Equity of access.

Health professional

education.

Integrated IM&T

infrastructure.

Admission avoidance.

Patient education pathway.

Dietetics.

Specialist Nursing.

Psychological support.

Insulin initiation.

Helpline.

Care planning.

Podiatry.

Peer support networks.

Triage of secondary care

referrals.

GP to consultant urgent and

routine advice.

Combined clinics.

Pre-conception care.

Medication reviews.

Ethnic minority screening.

Awareness raising.

4. Applicable Service Standards

4.1 Applicable national standards The service shall meet the National Standards within the following:

NICE quality standards for Diabetes (2011)

The National Service Framework for Diabetes (2001)

The National Diabetes Audit

NHS Diabetes Commissioning without Walls (2009)

NHS Atlas of Variation in Healthcare for Diabetes (2012)

NHS Commissioning Excellence in Diabetes (2012)

Our Health, Our Care, Our say (2006)

NHS Confederation Healthy Mind, Healthy Body (2009)

4.2 Applicable local standards NHS Southern Derbyshire CCG Integrated Care Strategies.

NHS Southern Derbyshire CCG Strategic Objectives.

of 25

5. Applicable quality requirements and CQUIN goals

5.2 Applicable CQUIN goals & Local Incentive Scheme (See Schedule 4)

In accordance with options within the NHS 14/15 standard contract, CQUIN will not be applied to

this contract. However a local incentive scheme will be applied. Initially this will be at 10% of the

total agreed contract value and up to 20% within the life of the contract. The Local Incentive Scheme

indicators are expected to be varied over the life of the contract.

The indicators for this incentive scheme in year 1 will be fully set out in schedule 4 based on:

1. Improved access to diabetes community services. The service will achieve equity of

opportunity of access across SDCCG.

2. Improved clinical leadership and increase in the number of health professionals working in

practices who have undertaken quality assured diabetes management training.

3. Development of robust integrated IM&T system and reporting processes.

4. Reduction in non-elective activity.

5. Increase in the number of patients having the nine basic care processes of care provided.

Year 2 and 3 are to be determined dependant on performance and mindful of section 27.16 in

technical guidance.

See appendix C for the full breakdown of the Local Incentive Scheme for year 1 and appendix D for

the Local Quality Requirements Schedule.

Consequences of breach

See Schedule 4.

6. Location of Provider Premises

The Contractor’s Premises are located at:

The Contractor shall have a centralised point of contact located in Southern Derbyshire. Localised

patient access to the service across Southern Derbyshire CCG is a contractual expectation.

of 25

Appendix A: Diabetes foot care pathway

PRIMARY CARE ANNUAL REVIEW

Fully trained, competent health professionals (via integrated team support)

LOW RISK (Normal sensations, palpable pulses)

Agree foot care plan including education

INCREASED RISK (Neuropathy or absent pulses or other risk factors)

Regular review every 3-6 months

HIGH RISK (Neuropathy or absent pulses plus deformity or skin changes or

previous ulcer) Frequent review every 1-3 months

Rap

id r

efer

ral i

f ri

sk in

crea

ses

EMERGENCIES / FOOT ULCERS (New ulceration, swelling, discolouration, foot ulcers)

Refer to multidisciplinary foot care team within 24 hours.

of 25

Appendix B: Health Outcomes

People who have diabetes will be expected to achieve the following:

Treatment and clinical outcomes – expected to achieve 3 out of 5

Person centred outcomes – expected to set between 2 and 4 outcomes and achieve at least 1

The Contractor is expected to demonstrate improvement to the short term interventions as set out below using validated measures or questionnaires in each case in at least 60% of patients.

Reporting for the below outcomes needs to include the number of patients who have achieved the desired health related outcomes as follows:

Outcome Indicator

Improved treatment outcomes Improvement in knowledge and understanding of condition using a validated measure Improvement in behaviour change and self-care using a validated measure

Improved clinical outcomes Improvements in clinical management outcomes: HBA1c – 6.5 to 7.5 % Blood Pressure Cholesterol eGFR BMI Retinopathy

Improved person centred outcomes As set by the individual and could include stopping smoking, weight reduction for example.

Has the patient achieved 3 or more of the treatment or clinical outcomes?

Has the patient achieved 1 or more of their personal outcomes?

YES

NO

Record as ‘not achieved outcomes’

YES NO

Record as ‘not achieved outcomes’

Record as ‘achieved outcomes’

of 25

Appendix C: Local Incentive Scheme (Year one)

10% of contract value

Personal Health Budgets (PHP): To accommodate personal health budgets there is a need to collect adequate data within year one of this contract, successful applications for PHP will be monitored by the CCG. If required and to avoid parallel payments the CCG reserves the right to under the national contract to renegotiate payment options to cost and volume.

Local incentive scheme description

Total Value

Method of measurement Payment

Q1 Q2 Q3 Q4

Improved equity of access to diabetes community services.

20% of LIS

Agreement between commissioner and provider relating to the number of service access points across SDCCG prior to contract signature.

25% payment (Based on target set agreed between provider and commissioners).



Reconciliation of payment based on an agreement of appropriate level of access reached.

Improved clinical leadership, practice engagement, sign up and health professional quality assured training (one health professional per practice).

20% of LIS

Provider report to include: - Details and evidence of practices who have signed up to the pathway. - Details and evidence of identified diabetes link lead per practice and standardised associated quality assured training undertaken in year one.

Target: 25% practices signed up with identified link lead and training undertaken.

Payment: 25% payable on achieving full target within the quarter.

Failure to achieve the target will be at the discretion of the commissioner.

Target: 50% practices signed up with identified link lead and training undertaken. Payment: 25% payable on achieving full target within the quarter.


Target: 75% practices signed up with identified link lead and training undertaken.

Payment: 25% payable on achieving full target within the quarter.


Target: 100% practices signed up with identified link lead and training undertaken. Reconciliation of payment will be made on the basis that the provider has achieved the full target over the year.

of 25

Local incentive scheme description

Total Value

Method of measurement Payment

Q1 Q2 Q3 Q4

Development of integrated IM&T systems and reporting processes

20% of LIS

Evidence of agreement and sign up of IT infrastructure across 57 GP practices, the service and secondary care.

Reporting template submitted by provider and agreed with commissioner. Following agreement the reports are to be fully compliant with the local quality requirements as defined in appendix D.

A mid-year report will be required to provide the CCG with assurance on progress.

Full payment for year will be made dependant on quality of data available to commissioner.

A reduction of up to of 5% non-elective admissions with a primary and secondary diagnosis of diabetes.

20% of LIS

Data will be obtained from SUS data (GEM).

Reduction of 5% non-elective admissions overall for SDCCG for the period 01/11/14 – 31/10/14.

Payment will be made for every 1% from baseline in reduction of non-elective activity up to a maximum of 5%.

Increase in the provision of nine care processes as defined in the local quality requirements in appendix D.

20% of LIS

MIQUEST query to be undertaken by 57 practices at the end of each quarter.

Increase in 25% from 2011/12 baseline for nine care processes being undertaken for Type 1 and Type 2 diabetes.

2011/12 baseline: Type 1 diabetes: 40.5% Type 2 diabetes: 67.8%

Target: 5% increase in the number of patients provided with nine care processes.

Payment: 25% payable on achieving full target.






Reconciliation of payment will be made on the basis that the provider has achieved the full target over the year.

of 25

Appendix D: Local Quality Requirements

Quality Standard

Measurement service quality report as in Schedule 6b

Baseline 2012/13 Year 1 target Year 2 target Year 3 target Consequence of Breach

1. Improved case finding and an increase in the number of patients being diagnosed earlier.

The provider will report on:

Percentage of high risk ethnic minority patients.

Percentage of high risk ethnic minority patents. referred onto a lifestyle intervention programme.

Percentage of patients who are smokers or obese who are screened for depression.

Percentage of patients identified as being pre-diabetic who are offered access to Impaired Glucose education.

Establish a number of awareness raising campaigns either alone or in partnership with others.

8,947 ethnic minority patients (indicative figure).

Monitoring targets to establish accurate baselines.

2 awareness campaigns within year 1.

Based on baseline with agreed increase.


Based on baseline with agreed increase.


G.C 8,9.

2. Improved access to diabetes community services. The service will achieve equity of opportunity of access across SDCCG.


Available level of access to the service.

Annual increase in the number of diabetic patients accessing the service.

Helpline implemented and continual increased use.

Achieve equitable access with increased access points.

Increased equity of opportunity across SDCCG.

Increased equity of opportunity across SDCCG.

Year 1 Schedule 3 LIS

G.C 8, 9.

3. Improved access to high quality structured diabetes education.


The number of qualified, competent educators that have delivered a minimum of two structured education programmes per annum.

The innovative education methods employed e.g. online.

Unknown

Monitoring targets to establish baselines

75% educators deliver two programmes minimum PA

100% educators deliver two programmes minimum PA

G.C 8,9.

of 25

Quality Standard



4. Improved provision of personalised advice on nutrition and physical activity.


The number of people who receive personalised nutrition advice from an appropriately trained dietician or as part of structured education.

The number of people who receive personalised advice on physical activity and smoking by professionals with specific expertise and competencies.

Monitor to establish baselines.

75% of patients provided with personalised nutritional, physical activity and smoking advice from professionals with specific expertise.

100% of patients provided with personalised nutritional, physical activity and smoking advice from professionals with specific expertise.

G.C 8,9

5. Improved care planning / self-management culture adopted across the programme area.

The provider will report on :

Percentage of patients with an agreed care plan in place that is regularly reviewed.

Percentage of patients achieving individual health and quality of life goals within their individual care plan.

Percentage of patients reporting improvements in behaviour change and self-care (PAMS international tool for measuring self-management behaviour).

Number of peer support networks established.

Unknown Unknown

Unknown

Unknown

At least 75 % patients with a care plan and agreed goals. 60% patients achieving goals

Monitor to establish baselines Establish locality based support.

80% patients with a care plan and agreed goals. 70% patients achieving goals

70% patients reporting improvements in behaviour change

100% patients with a care plan and agreed goals. 75% patients achieving goals

75 % patients with improvements in behaviour change

of 25

Quality Standard



6. Improved glucose control

The Provider will report on:

The number of people with Diabetes who agree a HBA1C and blood pressure target with their health professional and this is documented in their care plan.

The number of people achieving their HBA1C target.

The number of people who have received a review of treatment to minimise hypoglycaemia in the previous 12 months, in line with local JAPC approved guidance.

Unknown. Unknown. Unknown.

Monitor to establish baselines. Monitor to establish baselines.

Based on baseline. Based on baseline.

Based on baseline. Based on baseline.

Year 1 G,C 8,9 Year 2 Schedule 3 LIS Year 1 G,C 8,9 Year 2 Schedule 3 LIS

7. Improved medication usage


Percentage of people who have received a medication review in line with local JAPC guidelines.

Percentage of people who have received a medication review in the last 12 months in line with NICE and local JAPC guidance.

The number of people adhering to medication regimes.

Unknown.

Unknown.

Monitor to establish baselines. To determine stretch target.

Based on baseline. Increase based on year one.

Based on baseline. Increase based on year two.

8. Improved management of insulin initiation

The provider will report:

The number of people with Diabetes starting insulin therapy that is initiated by a trained healthcare professional.

The number of people with Diabetes who receive on-going structured support to manage insulin.

The number of health professionals who have documented appropriate training and competencies for initiating and managing insulin.


To establish baselines. To establish baselines. To establish baselines.

Based on baselines. To establish baselines. To establish baselines.

Based on baselines. To establish baselines. To establish baselines.

G.C 8,9

of 25

Quality Standard



9. Improved management of pre-conception care for women with diabetes and reduction in still births/ abnormalities

The provider will report:

The number of women with diabetes of child bearing age who receive advice regarding preconception glycaemic control and any risks including medication that may harm an unborn child.

The number of women with diabetes planning a pregnancy who receive specialist preconception care from an appropriately trained health professional.

The number of women of childbearing age with diabetes not planning a pregnancy who are offered advice in contraception.


To establish baselines. To establish baselines. To establish baselines.

Based on baseline.

To establish baselines.

To establish baselines.

Based on baseline.

To establish baselines. To establish baselines.

G.C 8,.9

10. Improved management of people with diabetes will contribute towards a reduction in admissions for incidents of complications.

The Provider will report:

The number of people with diabetes who are assessed annually for the risk and presence of complications of diabetes (retinopathy, neuropathy, nephropathy and cardiovascular disease) and managed appropriately.

CCG figures:

There will be a reduction in admissions arising from an emergency for diabetic patients

There will be an overall reduction in diabetes related non-elective admissions for complications

Monitor. 395 primary diagnosis admissions 816 secondary diagnosis admissions. 2,909 complication associated admissions (angina, heart attack, heart failure, stroke and renal failure).

Establish improvement targets. 5% reduction from 2012/13 baseline.

5% reduction from 2012/13 baseline.



Review with an expectation of 15% reduction.

Review with an expectation of 15% reduction.

G.C 8,9

Schedule 3 LIS year 1.

of 25

Quality Standard



There will be a reduction in non-elective admissions for Hypo and Hyperglycaemia / ketoacidosis from 2012/13 baseline

200 non elective ketoacidosis admissions (primary and secondary diagnosis) 109 non-elective admissions for Hypo-glycaemia.

5% reduction from 2012/13 baseline

10% reduction from 2012/13 baseline

Review with an expectation of 15% reduction

11. Improved management of people with diabetes who require psychological support.


The number of patients who are screened for psychological problems at the point of diagnosis and on an on-going basis.

The number of people with Diabetes and psychological problems successfully referred to IAPT (IAPT for LTC attendances)

Unknown. Unknown.

Monitoring targets to establish baselines.

Monitor to establish baselines.

100% patients screened for psychological problems.

To establish targets.

100% patients screened for psychological problems.

The provider will equal the national best quartile for referral rate into IAPT for LTCs

G.C 8,9 year 1

12. Improved management of people with diabetes who have foot ulcers will help contribute to a reduction in lower limb amputations.


The number of people at risk of foot ulceration referred to a qualified specialist podiatrist with a knowledge in diabetes.

The number of people who receive a regular review by a qualified specialist podiatrist with a knowledge in Diabetes in accordance with NICE.

2013/ 14 baseline 53 amputations for SDCCG area. Unknown.

Monitoring targets to establish all baselines. Monitoring targets to establish baselines.

To establish targets. To establish targets.

There will be no less than a 10% reduction in diabetes related amputations. To establish baselines.

G.C 8,9 year 1

of 25

Quality Standard



13. Improved offer rate for retinopathy screening.

The number of patients who are offered annual screening for diabetic retinopathy.

26,795 invited 80% appropriate patients in the service are offered screening

90% appropriate patients in the service are offered screening

100% appropriate patients in the service are offered screening

14. Significant reduction in secondary care outpatient referrals.


The number of people attending all outpatient appointments.

10,207 attendances within current system

Develop triage / alternative system to reduce outpatient referrals to secondary care settings.

25% reduction in outpatient referrals.

50% reduction in outpatient referrals.

G.C 8,9

15. Improved management of people with diabetes and increase in the number of people receiving the NICE recommended care processes.


The number of people who have agreed treatment targets in place.

The number of people receiving NICE recommended care processes.

Unknown

2011/12 baseline (NDA) Type 1 – 40.5% Type 2 – 67.8%

Monitoring targets to establish expected baselines 25% increase on baseline.

Based on baseline. Targets to be established.

Based on baseline. Targets to be established.

G.C 8,9 Schedule 3 LIS year 1.

service specification diabetes integrated service nhs ... fileservice specification diabetes...

Documents