Practice Baseline Questionnaire/Practice development Plan

for Consultant/DSN meeting

Please complete this questionnaire and return it 3 weeks prior to the date of your practice visit.

There are 6 sections to the questionnaire.

  1. Practice Details
  1. Diabetes Patient Demographics
  1. Updated review of patients discussed at previous practice visit. There are 10 pages included in this section. Please complete for patients previously discussed, and feel free to make further copies if you have more than 10 patients to include.
  1. High risk case register - please conduct a search for high risk patients using the criteria listed. Patients from this register may be discussed during the visit (see section 5).
  1. Patients for case discussion and formation of action plan. Please provide the relevant information for 10 patients you would like to discuss at this practice visit.
  1. Practice Development Plan for Diabetes - please include a copy of your previous years plan for discussion and signing off by the Consultant. A plan for 2015-2016 will be agreed during the visit.

SECTION 1:PRACTICE DETAILS

Name of Practice

Date of Meeting:

Contact details of practice staff who you would like a copy of this questionnaire to be sent to when completed.
Name: Role:
Email Address:
Name: Role:
Email Address:
Lead GP (Name)
Do any other GPs run Diabetes Clinics?
Lead Nurse (Name)
Does the Practice run designated Diabetes Clinics?
How frequently are patients with Diabetes reviewed?

SECTION 2:PATIENT DEMOGRAPHICS (at date of questionnaire)

Diabetes Patient demographics
Total ADULT Practice Population:
(> 17yrs)
Number of ADULT patients with Diabetes:
What is current prevalence of diabetes? What was it the previous year?
Update on screening CVD risk checks
e.g.:
NHS Health Checks,
Over 75 Checks,
Obesity Register.

SECTION 3.REVIEW OF PATIENTS DISCUSSED AT LAST VISIT

(Use separate page for each patient - 10 pages included in questionnaire, but feel free to make additional copies if more pages are needed)

Please refer to the list of patients discussed at your last Consultant visit, and document briefly the agreed action points and relevant outcomes.

Patient Discussed At Previous Practice Visit:
  1. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
2. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
3. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
4. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
5. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
6. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
7. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
8. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
9. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:
Patient Discussed At Previous Practice Visit:
10. Name:
DOB:
Issues / concerns identified at previous practice visit:
Action taken by Surgery:

SECTION 4. HIGH RISK CASE REGISTER

Please attach the list of patients on the high risk register according to the criteria below. Patients only need to meet one criterion to be included on the high risk case register.
N.B. The list must identify those cases that only fulfil the criteria within the past 15 months, not those who have “ever” attained these criteria.
  1. HbA1c > 75
  1. HbA1c < 50 on insulin or sulphonylurea
  1. Obese age < 60
  1. DNA Hospital and / or GP appointments
  1. T2DM diagnosed before the age of 40
  1. Evident non concordance with medication
  1. Emergency Hospital Admission (DKA, Hypoglycaemia, Foot Admission)

SECTION 5:

PATIENTS FOR CASE DISCUSSION AND FORMATION OF ACTION PLAN

Please use the 10 pages below to provide clinical background information on patients you wish to discuss during the Consultant visit. A management plan (final section of each page) can be agreed for each patient during the visit.

1. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
2. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
3. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
4. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
5. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
6. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
7. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
8. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
9. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised
10. Name, DOB
Age
Duration of DM
BMI
Smoking Status
HbA1c
BP
Lipids
Creatinine
ACR
Foot Risk
Retinal Complications
Treatment
Issues / Concerns
Management Plan Advised

SECTION 6:

PRACTICE DEVELOPMENT PLAN FOR DIABETES 2015-2016

As a result of the Consultant/DSN diabetes visit, the practice identifies the following learning points for improving patient care:

  1. ......
  1. ......
  1. ......
  1. ......

The practice will translate this learning into improved real patient care in the next 12/12 by:

  1. ......
  1. ......
  1. ......
  1. ......

This Practice Development Plan for Diabetes will be submitted to the CCG as part of the Commissioning Framework returns proforma in 2016.