Patient Care Pathway, Generic or Specialist – Adults

WINNER

The DIADEM Project: Improving the Management of Diabetes and Dementia

by Sandwell and West Birmingham NHS Trust

The DIADEM project was devised to address the knowledge gap in managing patients with diabetes and dementia. The aim was to assess all patients admitted with both conditions and focus on medication review, 'de-intensification' or simplification, and an individualised care plan. The combined co-morbidity and cost of diabetes and dementia is increasing, but current evidence, especially clinically-relevant studies, is poor, with no clear understanding of ‘real-world’ management.

Judges' comments:

"The DIADEM Project is a great, innovative idea, with good identification of the stakeholders involved. It is sustainable and has strong dissemination. It is fantastic to have a specific team for this group of patients and this lovely project is ahead of its time."


HIGHLY COMMENDED

The Cornwall Community Pharmacy Patient Activation Service – Type 2 Diabetes

by Cornwall Local Pharmaceuticals Committee (LPC)

‘Patient activation’ describes people’s knowledge, skills and confidence to manage their own health. Scores are closely linked to clinical outcomes, the costs of health care and patient experience. NHS England purchased Patient Activation Measure (PAM) licences to be used in Vanguard sites across the county to measure patient activation. Cornwall (NHS Kernow CCG) partnered with NHS South West Cardiovascular Clinical Network and Cornwall & Isles of Scilly Local Pharmaceutical Committee (LPC) to pilot a PAM service in community pharmacies in Cornwall for patients with Type 2 Diabetes Mellitus (T2DM). A total of 315 patients were recruited to the service; 234 completed the full intervention; 29 formally withdrew, and the remainder were lost to follow up. Of those who completed the service, 98% either achieved (72%) or partially achieved (26%) their goals. PAM scores increased in 77% of patients by a mean of 8.64 points.

Judges' comments:

"The Cornwall Local Pharmaceuticals Committee’s project is a significant part of the patient care pathway. The judges liked the patient empowerment element and it demonstrates transferable skills, with excellent use of pharmacists and their expertise."


COMMENDED

A 3-year Experience of Sandwell and West Birmingham Patient-Centered Collaborative Diabetes Model – The Way Forward?

by Sandwell and West Birmingham NHS Trust

Sandwell and West Birmingham (SWB) CCG has a substantial ethnic minority, a socially deprived, non-compliant population, high rates of diabetes as well as a disjointed diabetes management between the community and hospitals. SWB CCG, in collaboration with secondary care providers Sandwell and West Birmingham Hospital Trust (SWBH) and Birmingham Community Healthcare (BCHC), commissioned a community diabetes service named Diabetes in Community Extension (DICE). The CCG also commissioned a Diabetes Local Improvement Scheme (LIS) to complement the DICE service in primary care. In the last three years, nearly 5,000 patients have been seen in DICE clinics, resulting in 2,500 fewer outpatient appointments. The DICE model has upskilled primary care staff, delivered effective care closer to the patient’s home, improved satisfaction and brought significant cost savings.

Judges' comments:

"The Sandwell and West Birmingham diabetes model had amazing outcomes and patients were clearly at the heart of the project. They upskilled HCPs and showed the impact it has made, whilst saving money. Also great to see that it has generated interest internationally."


QiC Diabetes is partnered by:
Supported by: