Solutions for targeted groups of patients: Wolverhampton's CCG's diabetes management system

The Project was initiated when Wolverhampton health economy identified diabetes as a key local priority.

The CCG is working with The Royal Wolverhampton Hospitals NHS Trust to ensure clinicians in the hospital diabetic centre and in primary care services have a complete and up-to-date picture of a patient’s on-going care. This process is designed to empower patients to be engaged with professionals across the health economy and enable them to agree their own personalised care plan.

As well as using CareCentric as a health integration engine, bringing together data from multiple sources, Wolverhampton is also using CareCentric’s business intelligence solution to analyse and risk stratify data collected and combined from GP practices and the NHS Trust.

The CCG’s aim is to create integrated diabetes service between all healthcare providers and the local authority, delivering more efficient and patient-centred care.

Single integrated care record

Together CareCentric and the Royal Wolverhampton Trust’s Diabeta 3 system collect and assemble data from a number of sources to provide a single integrated care record. Data includes information such as blood pressure history and clinical results including HBA1c blood glucose, cholesterol and creatinine levels.

Wolverhampton has also developed a unique dataset, which provides a consolidated view of gaps in care and allows it to identify people who are failing to access services. The CCG is able to monitor, for example, whether a diabetic foot risk assessments and retinopathy screening have been conducted and recorded correctly within the patient record.

The combined information, pulling in data items from over 40 GP practices, means that clinicians are now able to access a full and up to date picture of a patient’s health and the management of their condition.

Diabetes risk stratification, data display and dashboards

Population level risk stratification is not always specific enough for disease level conditions or for specific application of local clinical projects. CareCentric BI is used to apply local algorithms across all interfaced data, analyse and display the data in dashboards. This enables targeted care across all providers.

Individual care plans for target patients – the WICKED project

Wolverhampton CCG and The Royal Wolverhampton NHS Trust has used the dataset as the core of its new model of diabetes care, called the Wicked Project (Wolverhampton Interface Care, Knowledge Empowered Diabetes Project).

Under this new model of service delivery , patients identified as a priority or amber-rated are given a personal care plan. This is a proactive plan devised in consultation with care professionals. For the patient, it contains details of latest clinical measures, with clear indications of whether they were normal or of concern. It also the focal point of a process of education and engagement in their own care. For the CCG, the aim is to optimise management of patients and prevent unnecessary complications. It is looking to reduce costs incurred on acute treatment and reduce capacity problems.

At year end 2013/14, 8,750 patients against a target of 6,750 had a care plan. Of these, 7,283 had engaged with a healthcare professional regarding their care plan.

The diabetes management system provides:

• An up to date view of a patient’s record for all professionals involved in a patient’s care 
• A consolidated view of gaps in care
• Reduced risk of patients being subjected to unnecessary investigations and tests
• A structure for engaging with patients, educating them and involving them into their own care 
• The proactive management of at-risk patients, with a view to optimising care and preventing unnecessary complications/admissions

Mike Hastings, Head of Business and Performance Management at Wolverhampton CCG, said: ‘By combining primary and secondary care data in this way we can see myriad opportunities to improve the health and wellbeing of patients, particularly those with long term conditions such as diabetes. By working with Graphnet, we have been able to convert the information we have available to us into a rich asset which informs the delivery of more efficient and focused services.”

Next steps:

Wolverhampton CCG is now looking at applying the same approach to give personal care plans and targeted care to patients with chronic obstructive pulmonary disease (COPD).

This is part of the CCG’s response to national targets for the treatment of the over 75s and patients with long term conditions. 

For more information or to learn how Graphnet Health can help integrate care in your community, please get in touch.