BLMK NG28
EMBRACE PROGRAMME

EMBRACE (Empowering Medical Best Practice Reviews Assuring Clinical Excellence) has been developed as part of a Joint Working initiative between Bedfordshire, Luton and Milton Keynes Integrated Care Board, ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement - Prescribing Services Ltd), a company providing population health management and risk stratification systems, with financial support from AstraZeneca UK.

Enhanced Phase 2 Practice Pro-Forma

Project overview:

The EMBRACE programme is an exciting initiative to improve the care of people with Type 2 Diabetes in BLMK. Using Eclipse, and applying criteria agreed with BLMK ICB, patients with Type 2 Diabetes and modifiable risk factors for cardiovascular disease will be highlighted for review. These reviews can be conducted by the practice team if there is sufficient additional capacity available or can be conducted remotely by Putting Patients First (the clinical arm of Eclipse) if preferred. Note that reviews are most effective if all required information for clinical decision-making (e.g. HbA1c, BP, weight) are recently recorded at time of review.

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 Quality and Outcomes Framework 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, risk-stratify and prioritise patients with the greatest opportunity for clinical improvement using the Eclipse platform

  • 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 

  • Eligible patients not currently on a statin who have indicated interest in starting treatment

  • Eligible patients benefiting from additional hypoglycaemic agents who would like to receive treatment optimisation of metformin, DPP4s, SGLT2is, GLP-1, pioglitazone or gliclazide

  • Patients who are non-compliant with their medications and would like to receive a structured medication review with the pharmacist

Outcomes Improved:

  • Proportion of patients with diabetes at HbA1c target

  • Overall time to HbA1c target

  • Overall time to appropriate initiation of NICE guidance recommended therapies

  • Optimisation of CVD risk factors as defined by NICE NG28

  • Projected patient outcomes including reduced acute hospital admissions and health care utilisation

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 with any clinical decision remaining with the clinician. 

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 (EMBRACE-NG28-Service-Flow.pdf)

  • HBA1C >=59 mmol/mol or  

  • Systolic Blood Pressure > 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.