Intended Audience
Patients that do not access health services, have not had an annual review in the last 18 months with poor control and those who have repeat admission or attendance at hospital.
Background
The Public Health and Diabetes Services identified a need for a specialist practitioner to establish a whole system approach to improve patient outcomes in the areas of particularly high social deprivation.
As part of a strategy to address health inequalities, NHS North East Essex created a new post to give extra support to people with diabetes closer to their homes.
The project, addressing the inequalities of health in the Jaywick and Pier Wards, was set to run for 18 months, with key performance indicators to include the management of blood pressure, lipids and diabetes. The initiative would involve joint working with primary and secondary care, Public Health and local authorities and people with diabetes. Collected data would be audited, with a quarterly assessment of key performance indicators.
The project has had a significant impact on the local population in terms of improved clinical outcomes and reaching people with diabetes who previously did not access services, thus in turn improving the lifestyle and motivation of people to self manage their long term condition.
How this service improves
In six months the project has resulted in the following:
- Reduction of 33 admissions to hospital
- 4 admission avoidance
- Clinical guidance sought from Lead Consultant giving a reduction of 18 new referrals to secondary care
- 48 Non medication prescriptions initiated resulted in improvement in glycaemic control
- improvements in 25 patients HbA1c (diabetes indicator) with an average drop of 2.2%
- Improvements in 10 patients’ lipids results
- 25 referrals to lifestyle interventions
- 100% of patients feeling more in confident in managing their diabetes
Why this service is a good example of shared practice
The key to success was flexibility of appointment times and locations. Home visits were offered as well as using alternative consulting rooms in pharmacies within the wards. Appointments were at times which suited the patient and ideally were offered on the same day of contact.
The contact was made by an experienced Diabetes Specialist Nurse (DSN) who was able to work autonomously and make instant changes to medication. Patients responded well to the continuity of care. The DSN worked closely with people in the community, consultants and DSNs from the Acute Trust and GP practice staff.
Service Provided
Outreach work by Diabetes Specialist Nurse in a specific area of deprivation.
Accountability
The project is monitored through the commissioning framework.
Evaluation
All outcomes have been achieved through the clinical and motivational support given by the DSN. The patients that accessed the service found the support informative and either required a change in the medication or sign posting to lifestyle interventions.
The reduction in admissions was calculated by the monitoring of the baseline admissions 6 months prior to the intervention and again at 6 months post intervention.
Resources
WTE 1.0 Band 7 DSN
WTE 0.3 Band 3 Administration assistant
Education equipment hall hire
Learning
The team has learned that some communities require more tailored learning and support mechanisms put into place. Also the continuity of care from healthcare professionals is valued and leads to greater trust.
Additional Information
An example of some of the positive feedback received from users is:
“I never believed in myself, I always thought I was destined to have poor diabetes control like my mum and older brother until Jan encouraged me to have hope. I now feel the best I can ever remember and want to help Jan spread the word.”