Innovative Appendix-Chronic Disease Management
This appendix lists innovative ideas/pilots from across General Practice to give examples of the opportunities that exist to deliver care differently.
We would like this to be a developing electronic resource moving forwards and would value your input and ideas to share with colleagues across Wessex. Please complete this link with the details of your innovation. If you encounter any issues with the link or to discuss an innovation further please email: email@example.com
Chronic Disease Management, example Diabetes Care
Practice X has 10,000 patients and of those 300 have Type 2 Diabetes. The practices have taken the opportunity of the Covid-19 crisis to redesign the pathway of care for this group of patients, aiming to make care more efficient, effective and improve outcomes.
Patient A is a 45 year Type 2 Diabetic – they are invited to have an annual review of their Diabetes.
1. There is a need to collect some data which includes, weight, blood pressure and blood tests (specifically UEs, Cholesterol, HBa1c). The patient is encouraged to undertake their own BP monitoring and weight measurement but if not submitted can be undertaken at same time as the blood test.
2. The results are then used to risk stratify the patient.
- All results are within an acceptable range and medication is reviewed by their GP – no further intervention is needed (foot check and retinal screening is carried out separately) - patient has a video consultation with the practice diabetes nurse lead.
- The results are not within an acceptable range, blood pressure is high, UEs deteriorating, Cholesterol > 5 or HBA1c raised – patient has a video consultation with GP or Practice nurse to address the abnormal results.
- The results are abnormal, and the management is complex – patient is contacted, and a video consultation takes place with the GP, Practice Diabetic Nurse, Diabetes Specialist Nurse or Diabetic specialist medical team.
3. Management plans are recorded on their notes, but the patient is also encouraged to use the Diabetes App which support better self-care and will support better ongoing education and management.
4. The Community Diabetes team and the practice/PCN holds a regular MDT using Microsoft Teams to discuss complex patients.
5. Patient education is facilitated via group consultations using Zoom or other suitable tools.
Additional resources on group consultations.