In a redesign of the diabetes treatment pathway, adult patients with diabetes now have a single point of access and are triaged by a diabetes nurse telephoning each patient. The service provides type 1 and 2 education and multidisciplinary clinical appointments throughout West Hampshire, in addition to a nurse-led telephone advice line open Monday to Friday 9-5pm. There is also a primary care education programme in place to support GP and practice nurse initiation and adjustment of insulin and GLP-1 therapies. The infrastructure is built around a remotely accessible IT package. Feedback about the education courses and appointments has been positive, while there have been improvements in the number of patients achieving glycaemic targets and a reduction in hypoglycaemia admission rates.
The West Hampshire Community Diabetes Service (WHCDS) was launched in 2010 in response to a health system that was struggling to manage the growing number of diabetes patients, and inequity of service provision.
A service was needed to prevent illness and maintain wellbeing, provide earlier diagnosis and better care to reduce complications, support patients in self-management and support and educate primary care staff, thereby encouraging care management back into the community.
A steering group included clinicians and managers from local service providers and the PCT. The service has challenged traditional delivery of patient care in acute hospitals and moved it to the community. Evidence from the Chronic Care Model was used to inform the steering group’s work and was key in identifying important areas for development.
A diabetes locally enhanced service also supported the launch of the service, which encouraged primary care to take on the initiation of GLP-1/Insulin therapy.
Qualitative targets included improving the patient experience, reducing the number of care providers to offer better continuity for patients, improving the availability of high-quality Type 1 and Type 2 diabetes education courses for patients, and delivering an education programme for staff. The project also aimed to develop a network of education meetings for staff along with a regular newsletter and to grow stronger stakeholder relationships with primary and secondary care and patient groups.
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