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Community diabetes project

Community diabetes project. Mandy Hunt Lead Diabetes Nurse West Suffolk Hospital Trust. AIMS. Aims of the project. How the project was set up. Benefits of the project so far. Identified changes to diabetes management so far. Further possible benefits / developments. Aims of the project.

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Community diabetes project

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  1. Community diabetes project Mandy Hunt Lead Diabetes Nurse West Suffolk Hospital Trust

  2. AIMS • Aims of the project. • How the project was set up. • Benefits of the project so far. • Identified changes to diabetes management so far. • Further possible benefits / developments.

  3. Aims of the project • Where possible to see patients with diabetes in their surgeries. • To improve communication between the surgeries and diabetes centre. • To reduce hospital visits and admissions. • To explore insulin and GLP-1initiation in the 4 surgery's in the project.

  4. The project • Initiated by the West Suffolk CCG. • 4 Identified practices. • Each practice supported by DSN. • 22 mentored clinics each 4 hours (avg 8 patients per clinic). • April 2013 – Aug 2013. • Progress meetings ccg, practice staff and DSNS. • Audit trail for each consultation, being reviewed by ccg.

  5. Observations • We have all learnt from the mentored clinics. • Good recall at surgeries. • Good Annual reviews / aided by templates. • Patients seen on time by Practice Nurses who treat them holistically. • Patients being given good lifestyle advice. • Good awareness of testing guidelines.

  6. Developments • More aggressive titration of OHA’s / sometimes reduced. • More timely follow-up, including telephone calls. • Improved treatment of hypoglycaemia. • Advice on pre conceptual care. • Shared care / education for previous non attendees to diabetes centre eg; those with type 1 diabetes / during end of life care. • Attendance at meetings education eg Merit courses to support initiation of insulin / GLP1’s. • Insulin starts / insulin conversions/ GLP1 starts (including group start of 3 patients).

  7. Insulin starts • 3 surgeries practice nurses are being supported with insulin initiation. • 11 patients new to insulin / 2 insulin changes from once daily to bd regime. • 3 insulin starts in surgery by DSN. • Insulin advice and adjustment for patients who no longer attend diabetes clinic.

  8. GLP-1 STARTS • 6 mentored starts, at least 6 more planned. (one group start 3 patients). • Attendees at Merit course from practices. • Guidelines for GLP-1 Initiation. • Clear criteria for continuation of therapy. • No ongoing titration required.

  9. Summary • Better communication between primary and secondary care. (we are only a phone call away) • Agreed pathways for patients. • Increased confidence of practice teams. • Improved shared care / education for some more complicated patients. • Audit results should confirm less referrals to secondary care. • Initiation of injectable therapies in primary care.

  10. Next steps • Extending the project across the CCG. • Continued support to surgeries in the project. • Results from the audit. • Possible DSN links for each surgery. • Continued further education / support for general practice.

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