Diabetes case management service: Recurrent glycaemia related re-admission prevention


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.


Audit of Cambridge University Hospitals (CUH) diabetes admission data from 2010/11 identified that of the 473 patients admitted with diabetic ketoacidosis (DKA), hyper- or hypoglycaemia, there were 168 (35.5%) predominantly with Type 1 diabetes readmitted within a year (approximately 15 a month). A significant proportion also experienced social or mental health problems and improving self-management for this client group poses particular problems. In addition, two young patients with recurrent hospitalisation for DKA had been found dead in bed over the previous three years and it was felt that home visiting by the diabetes specialist services might have prevented these deaths.

One of the main challenges this service has highlighted is the distinct lack of community based support for patients needing help to manage insulin administration at home. Community nursing time is limited and community social carers are not allowed to be involved with insulin administration, even with appropriate education and support.


Funding was provided to support a one year pilot of a post-hospital discharge diabetes case management service, specifically for this group of patients, to prevent readmission. The project also aimed to reduce overall risk to the patients, increase treatment satisfaction and reduce the high costs associated with in-patient stays.

The pilot looked to develop a structured, co-ordinated service promoting and delivering safe and efficient healthcare. A comprehensive literature search suggests that such an intensive and wide-reaching service has not been trialled nationally.

The service was advertised internally to ensure that all appropriate patients were referred and their suitability was confirmed through chart review. The case manager meets with the patient before discharge to identify education and management issues. Some can be addressed immediately but others require longer term plans involving liaison with relevant agencies. Patients also have a 24 hour-out-of-hours contact number for additional support.

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QiC Diabetes Winner 2013
Best cross-organisational partnership – reaching out beyond the traditional team
Diabetes case management service: Recurrent glycaemia related re-admission prevention
by Cambridge University Hospitals NHS Foundation Trust


Sara Hartnell

Job title:
Diabetes Dietitian and Insulin Pump Educator
Place of work:
Cambridge University Hospitals

Quality In Care Diabetes

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  • 2021 KEY DATES
  • Open for entry:
    Tuesday 20 April 2021
  • Extended Entry Deadline:
    Monday 12 July 2021
  • Judging day:
    Tuesday 7 September 2021
  • Awards ceremony:
    Thursday 14 October 2021