Diabetes case management service: Recurrent glycaemia related re-admission prevention
by Cambridge University Hospitals NHS Foundation Trust
A new service was set up to provide social and emotional support to people with diabetes to help prevent readmissions from acute glycaemic events. The service received funding for 12 months and involved the creation of a process to identify at-risk in-patients who are then adopted into the programme. A case manager meets with the patient prior to discharge and identifies education and management issues. There is an intensive follow-up period involving home visits, telephone contact and consultant clinic review if needed, with a database of detailed information developed to allow review of progress and reaudit of outcome measures. Patients also have access to a psychological wellbeing practitioner who assesses their mental health needs and can provide psychological interventions. Analysis shows that readmissions have reduced by 60 per cent, glycaemic control and self-management has improved, and there is an estimated net saving of £91,804 per year.
"Impressive outcome data and a great example of multidisciplinary working with strong clinical outcomes achieved in a step-by-step approach."