BLMK NG28
EMBRACE PROGRAMME
In partnership with BLMK ICB and
ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement)
Enhanced Phase 2 Practice Pro-Forma
Project overview:
Phase Two of the EMBRACE programme offers an enhanced, digitally supported care optimisation pathway for patients with type 2 diabetes who have the most significant unmet care needs. The programme focuses on empowering patients to understand and act on their outstanding diabetes care elements, while supporting practices through reduced administrative burden and improved alignment with QOF indicators.
Aims:
Improve patient outcomes across the eight key care processes and treatment targets for diabetes
Reduce workload for general practice teams by streamlining review preparation
Support practices in achieving QOF and Primary Care Framework targets
Objectives:
To identify and prioritise patients with the greatest opportunity for clinical improvement using Eclipse data
To engage high risk patients with type 2 diabetes through digital engagement, education and virtual diabetes review
To provide a holistic, patient centred report and action plan for each patient, empowering them to liaise with their local services for implementation of key recommendations
To offer direct support to patients via virtual appointments with the review team
To regularly provide each practice with an updated summary grid of Eclipse-reviewed patients divided into outstanding patient-agreed key implementations, as generated through data insights, digital patient engagement and virtual clinic reviews. This includes:
Patients with outstanding investigations: blood and urine tests, foot checks, blood pressure readings, and weight measurements
Patient’s smoking status, with details on any support wanted by those who smoke or vape
Patients with an elevated BMI wishing to receive weight or dietary support
Patients with outstanding vaccinations who wish to receive them
Patients not currently on a statin who have indicated interest in starting treatment
Patients benefiting from additional hypoglycaemic agents who would like to receive treatment optimisation (SGLT2is, metformin, DPP4s, GLP-1, pioglitazone, gliclazide).
Patients who are non-compliant with their medications and would like to receive a structured medication review with the pharmacist
Background
This targeted programme supports high-risk patients with type 2 diabetes through a structured digital journey. It helps patients understand their current care status, engage with relevant education and support, and prepare for meaningful follow-up with their GP.
All recommended actions are based on NICE guidelines, practice preferences, and patient choice, and are securely shared back with the practice for implementation.
Selection of Patient Cohort
Patients are prioritised through Eclipse based on unmet clinical care needs, focusing on equity and clinical opportunity. Selection criteria for the patient cohort are unchanged from Phase 1:
HBA1C >=56 mmol/mol or
Systolic BP > 150mmHg or
QRISK3 > 20%
Not on insulin
Not on specialist care
EFI<0.25
Please follow this link to review the Workflow for this enhanced programme.
Evaluation
Outcomes will be monitored using Eclipse analytics, alongside patient-reported feedback to assess the experience and effectiveness of the new pathway.
Permissions
If your practice would like to take part: Please complete the below pro forma, expressing your interest and permissions for patient engagement. Please note that you will be notified prior to any active patient engagement, and your practice will be issued a guide, assisting with access to relevant data and documentation.