A short-term Diabetes Specialist Outreach Team (DSOT) was established by York Teaching Hospital NHS Foundation Trust to address the needs of those people with diabetes at the highest risk of complications for any reason. Despite a high-quality diabetes service in the local area, certain people at high risk of hospital admission and diabetes complications do not use or benefit from services as they stand. This project aimed to complement and fill in the gaps in the existing service, preventing complications in the longer term, as well as illness and hospital admission in the shorter term. The project was based on remote searches of GP records to identify people whose outcome measures were falling short of targets and criteria-based direct referral. The project team improved individual measurement of HbA1c (when not taken for over 15 months), achievement of three target measures (HbA1c, blood pressure [BP] and cholesterol), and decreased HbA1c in those over 100mmol/mol (11.3%). In addition, intervention led to a saving of 21 diabetes-related hospital admissions in the first year.
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