Khalida Ismail & Carol Gayle · Khalida Ismail & Carol Gayle 8 th March 2016. King’s Fund, London. Rochelle..... • female, late 20s, single parent • son age 4 years & daughter

3 Dimensions for Diabetes (3DFD)

Khalida Ismail & Carol Gayle8th March 2016

King’s Fund, London

http://hww-kingsweb/news/display.asp?itemID=25532http://hww-kingsweb/news/display.asp?itemID=25532http://www.guysandstthomas.nhs.uk/Home.aspxhttp://www.guysandstthomas.nhs.uk/Home.aspx

Rochelle.....

• female, late 20s, single parent

• son age 4 years & daughter age 18 months

• type 1 diabetes in second pregnancy

• HbA1c 108 mmol/mol• Undetected severe post

partum depression

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

Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. Diabetes Care 2007:30;1473-9Winkley K, Sallis H, Kariyawasam D, Leelarathra L, Chalder T, Edmonds M, Stahl D, Ismail K. Diabetologia 2012;155:303-10

Funding: Wellcome Trust

Diabetes is associated with nearly every psychiatric disorder

ICD-10 Chapter F categories Relative risk

General popn/no psych disorder reference group

Dementia 2.0

Schizophrenia 3.0

Substance use ~?

Depression 2.0

Eating disorders 2-3.0

Chien et al Compr Psychiatry 2011; Anderson et al Diabetes Care 2000

Social problems

3DFD: a blank canvas

Parallel versus integrated services

Diabetes

Social

Mental Health

Diabetes

Social Mental Health

Active ingredients of 3DFD

•diagnostic assessment•risk management•psychotropic •brief psychological

treatments•family work

• patient-led MDT meeting• increase self efficacy for

diabetes • HbA1c• Patient reported outcomes

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

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

Social interventions

Diabetes Management

Liaison mental health

services

Patient

3 Dimensions For Diabetes (3DFD) 1,2,3

Social Interventions

Diabetes management

Liaison mental health

services

Patient

Primary care Specialist care

1 BMJ Best Diabetes Team Award 20142 Doherty et al International Journal of Psychiatry in Medicine 20163 NHS Regional Innovation Fund London 2010

Challenges and Opportunities • Defining the model? Whatever it was-it had to be simple• Full integration into diabetes teams, community and hospitals• MDT, Education and training

De novo service

• ‘luxury service’• Pathways – Improving Access to Psychological Services (IAPT)• Commissioners

Organisational resistance

• Cross sector steering group with Diabetes Modernisation Initiative

• Evaluation, business case, dissemination & awards • Hospital charities and CCG funding• Commissioned service but needs scaling up

Sustainability

3DFD characteristicsYear 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)

0

5

10

15

20

Glicazide Gliptin Dapagliflozin Lamb/Swk DICT(n=472)

3DFD (n=185)

Impr

ovem

ent i

n Hb

A1c,

mm

ol/m

ol

Agents producing improved glycaemic control

Improvement in HbA1c, mmol/mol

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)

Psychiatric morbidity

0

20

40

60

80

100

120

Nil Knowndiagnosis

Newdiagnosis

New relapse

N

Psychiatric Diagnosis

Psychiatric diagnosis: new, known or relapse

Chart1

BPAD

Psychosis

Depression

Anxiety Disorder

Dementia

Eating Disorder

Alcohol dependence

Adjustment Disorder

Personality Disorder

Learning disabililty

Medically unexplained syndromes

Mild psychological

Number of patients with diagnosis

Psychiatric diagnosis

n

Psychiatric diagnoses*

3

13

87

22

5

9

15

29

11

10

8

31

Sheet1

Number of patients with diagnosis

BPAD3

Psychosis13

Depression87

Anxiety Disorder22

Dementia5

Eating Disorder9

Alcohol dependence15

Adjustment Disorder29

Personality Disorder11

Learning disabililty10

Medically unexplained syndromes8

Mild psychological31

243

Social Needs

Social Needs

0

5

10

15

20

25

Support worker assisting patient with type 2 diabetes with her housing situation

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

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

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

Cost-benefit analysis

Costs £94k/borough/year• 0.5WTE Consultant liaison psychiatrist• Community outreach worker• Admin support and infrastructure

Savings £127k/borough/year (-on-year)• Short term: reduction in

unscheduled care• Long term: reduction in developing

diabetes complications

3DFD net saving £33K/100 patients/borough/year recurrent≈ 35% return on investment per year

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%

Quality in Care Awards 2011

BMJ Awards 2014Diabetes Team of the Year

Mary McKinnon Lecture DUK 2015

NHS Innovation Challenge Prize 2015

3DFD

Translation of research

Cross sector

integration

Health inequalities

Cost effective

DisseminationOxford Surrey

HillingdonEdinburgh

Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012, p35.

3DFD

The Future

• Scaling up– Identifying low vs high risk groups– Other long term physical conditions – Across the mental health trust

• Health Foundation Scaling Up Bid 2016 – Shortlisted to final round– Results next week – Watch this space

Regional Innovation

Fund

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

3 Dimensions for Diabetes (3DFD)Rochelle.....Slide Number 3Diabetes is associated with nearly every psychiatric disorderSocial problems3DFD: a blank canvasParallel versus integrated servicesActive ingredients of 3DFD3 Dimensions For Diabetes (3DFD) 1,2,3�Challenges and Opportunities �Slide Number 11Slide Number 12Slide Number 13Slide Number 143DFD outcomes – HbA1c Psychiatric morbidity Social Needs Social NeedsSupport worker assisting patient with type 2 diabetes with her housing situationQuantitative outcomesMain 3DFD outcomes - economicCost-benefit analysisPatient testimonialQuality in Care Awards 2011Slide Number 25The Future Regional Innovation Fund

Documents

Khalida Ismail & Carol Gayle · Khalida Ismail & Carol Gayle 8 th March 2016. King’s Fund, London. Rochelle..... • female, late 20s, single parent • son age 4 years & daughter