3 Dimensions of care for diabetes: Working with hard to reach groups to improve diabetes outcomes

Summary

In 2003 King’s College Hospital NHS Foundation Trust introduced a psychiatrist to its diabetes team. By 2009 audit findings showed those people with diabetes who used psychiatry services as part of their diabetes care had improved HbA1c levels.

The audit, plus other studies showed that integrating psychological and social care with diabetes care for those with multiple health and social problems, led to an improvement in biomedical outcomes. For instance, by early and rapid facilitation of housing, managing debt or childcare, a caseworker can reduce the social drivers contributing to a person’s difficulty in prioritising diabetes.

A multidisciplinary group comprising staff from Kings College Hospital and two third sector organisations, Thamesreach and HearSay Charitable Trust were funded by NHS London Regional Innovations Funding Scheme to set up and run a community based service that would address individuals medical, social and psychological care to improve glycaemic control and other diabetes (and non-diabetes) health outcomes.

Challenge

The main objective of 3DFD (3 Dimensions of Care For Diabetes) is to deliver a community-based model that integrates medical, social and psychological care to improve glycaemic control and other biomedical outcomes in complex cases. 

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