The EMBRACE Type 2 Diabetes Optimisation Service
Practice pro forma
The EMBRACE programme is an exciting new initiative – providing a virtual clinical review and medical optimisation programme for your patients with type 2 diabetes. The service has been commissioned by Bedford, Luton and Milton Keynes Integrated Care Board and is a collaboration between the ICB and Eclipse, a population health management company, with financial support by AstraZeneca pharmaceutical Ltd.
Aims:
To engage with higher risk patients with type 2 diabetes to educate and invite them for a diabetes review.
Where desired, to provide triage of patients in need of additional monitoring requirements prior to review.
To produce a holistic report for patients with type 2 diabetes, in line with NG28 guidance and local formulary for: monitoring (nine key care processes); medication optimisations and signpost to local services.
Background
This is a virtual review service that seeks to ensure that patients identified as being in need of a diabetes review are appropriately engaged with, educated and consented to a formal diabetes review to optimise their healthcare in accordance with their personal preferences.
As part of the initial clinical review that will be conducted for your patients, the EMBRACE service will seek to identify any missing diabetes monitoring requirements (as per QOF diabetes review) and highlight these to the practice.
Ideally these reviews will be undertaken following up-to-date monitoring requirements. The ICB diabetes steering committee have decided that the following investigations should have been done within 6 months prior to review: HbA1c, blood pressure, weight.
For those practices that can commit to providing the above investigations within a two-month time frame, a deferred clinical assessment phase is available in order to get these up-to-date results (see flow diagram).
For those patients that have recent results, a combined assessment will be carried out as per the flow diagram. Please note that those practices that cannot commit to the two-month time frame, the combined assessment will use the most recent results on file, so long as these were taken within the preceding 12 months.
An individual EMBRACE diabetes evaluation report will be sent to practices for every patient reviewed. This will outline the full review including latest results, compliance and concordance data, summary of patient engagement responses and any medication optimisation suggestions based on the local formulary and patient preferences in regard to available and suitable local services.