Summary
Diabetes, frailty and community nurse services in Hull collaborated to establish a diabetes frailty MDT based in the Jean Bishop Integrated Care Centre (JBICC). The MDT provides access to specialist advice for hard-to-reach service users without hospital visits. Thematic study data and stakeholder feedback indicate that transfer of skills and knowledge between services has changed the nature of referrals into the MDT and improved access to continuous glucose monitoring (CGM). Learnings from the diabetes frailty MDT have informed the development of other speciality MDT meetings at the JBICC.
Innovation
The establishment of the JBICC in Hull in 2018 provided opportunities to rethink care pathways for frail people with diabetes. In 2019 the frailty team invited the diabetes team to set up a joint MDT meeting. In 2022 the community nursing services joined the MDT. The 2019 objective was to facilitate an integrated approach to the management of diabetes in frailty, identifying patients through a comprehensive geriatric assessment process. The number of cases discussed increased from six within two hours to 14 within three hours. The core team is: an advanced nurse practitioner and MDT co-ordinator (frailty); diabetes specialist nurse and consultant (diabetes); community nurse and professional lead for community nursing. Meetings are held in the JBICC. During the COVID-19 pandemic meetings were held virtually and further referrals came from Yorkshire Ambulance Service, primary care network MDT, podiatry and diabetes inpatient team. A referral template was developed on SystmOne. Conclusions are documented and communicated to the GP by SystmOne task if medication changes are required. Referrals are made to other professionals electronically. Care for those with frailty and diabetes is focused on practical issues and quality of life, so evaluation is qualitative. Evaluation suggests that initial objectives have been realised, together with additional benefits, such as increasing access to technology, and transfer of knowledge and skills between teams. In 2023 a pathway was initiated for people with impaired mental capacity and intermittently declined insulin injections. There are other frailty hubs but it is believed that none has MDTs to enhance access to specialist care without bringing people to hospital. As many individuals are housebound or in care homes, the frailty team performs comprehensive geriatric assessments in these locations.
Equality, Diversity and Variation
The former Hull CCG area served by the MDT has a high level of urban deprivation, and the frail diabetes population is diverse, with individual needs. The MDT addresses these needs, having social workers with access to sensory teams, specialist mental health nurses and a GP with specialism in older people’s mental health. Equality of access is addressed by frailty team outreach. This proactive approach has expanded to the deprived coastal areas of East Riding, which have significant health inequalities. Risk stratification tools identify patients at risk of frailty and GPs refer them proactively. Patients are also referred by other health or social care practitioners, including the ambulance service, emergency department and fire service. The JBICC is in one of the most deprived postcodes in England. Free parking on site and hospital transport have improved access and reduced ‘did not attend’ rates compared to older people’s medicine clinics based at the acute hospital sites. The JBICC core MDT includes geriatricians, GPs with extended roles in frailty, advanced nurse practitioners, mental health nurses, physiotherapists, occupational therapists, social workers, carers’ supporters, pharmacists and pharmacy technicians, chaplains, specialist paramedics, clinical support workers and non-clinical coordinators. Other enhanced MDTs have been established following the success of the diabetes frailty MDT, including frailty and Parkinsons, COPD, dementia and heart failure. Ethnic diversity is relatively low in Hull but is rising, with 16.1%of people (2021 census) identifying as BAME (including white non-British), compared with 25% nationally. Translation facilities are available at the JBICC and Allam Diabetes Centre.
Results
The electronic records for the last 100 people referred to the MDT were reviewed as part of a service evaluation. The median age was 78 years (range 53-96 ) and the median Rockford frailty score was 6 (range 4-7 ). There were 59 females and 41 males. Following a thematic analysis of issues discussed by the MDT, codes were created for each theme. The subsequent coding of each MDT discussion used the electronic records of the diabetes team, the frailty team, and the community nursing team, all on SystmOne, including a template for MDT outcomes. A total of 169 codes were recorded. The most frequent themes were: hyperglycamia (25) or elevated haemoglobin A1c (15), indicating that high glucose levels remain the most common source of referral; cognitive/memory/capacity issues (25), including declining medication associated with capacity issues (9) and fluctuating capacity (6); consideration for comprehensive geriatric assement (23); consideration for CGM (23); advice on appropiatiate target level of haemoglobin A1c for an individual (15); deprescibing (11), and intensification of treatment (11).
User Feedback
Staff and patient experiences have been overwhelmingly positive. Staff retention rates and recruitment levels are high, in a traditionally hard-to-recruit region and discipline. Patient experience has been independently evaluated by the University of Hull through a non-randomised controlled trial, which demonstrated sustained improvements in patient-reported physical and psychological well-being.
Dissemination and Sustainability
Three services from two NHS organisations in Hull partnered on this project. The Humber and North Yorkshire Integrated Care Board Diabetes Steering Group is an interested stakeholder. The flow of referrals is now as much from the diabetes team identifying people with increasing frailty warranting a comprehensive geriatric assessment, as from the frail team requiring advice on diabetes management. The increase in referrals for CGM is noteworthy. The development of this service was made easier by a purpose-built integrated care centre, but no additional resource was used. Integration of specialities is as important as vertical integration between specialist and primary care. The increasing proportion of people identifying as BAME will increasingly impact on frailty services. Diabetes and community nursing teams need to increase the use of appropriate technology and support more carers to give insulin injections. However, the MDT approach is the best way to confront these challenges.
