Refocus is a new group education programme from Dorset Healthcare NHS Foundation Trust that provides both clinical and psychological benefits to people with Type 2 diabetes. Interim data from the diabetes transformation project year showed a significant improvement in patient activation level and reduction in diabetes distress after three months. Patients also experienced significant intentional weight loss and a reduction in HbA1c comparable to the introduction of a new diabetes medication, in comparison to a control group that experienced a rise in HbA1c.
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Before the Refocus programme the provision of Type 2 diabetes structured group education stopped a year after diagnosis in Dorset. Patient feedback showed that newly-diagnosed patients wanted the opportunity to return to a group refresher later. Audit of the initial programme showed that patients continued to experience a drop in average HbA1c up to a year after attending structured education, but three years on there was a 26% increase in patients with off-target HbA1c. Criteria for those selected for Refocus included: those with Type 2 diabetes one year or more post-diagnosis, HbA1c >58mmol/mol, on one or more glucose-lowering agents (not insulin) and with a BMI >23mmol/l (overweight, including a lower BMI bracket for South Asian communities). The ethos of the programme was: to coach information from patients rather than to tell them; to allow the patients to influence the agenda and do lots of the talking; to use open questions, affirmations, reflections and summaries, and to listen to answers, clarify facts and dispel myths. The curriculum provided a modern forum of patient-led education and peer support. At the start of the session, patients prioritised topics as gold (highest priorities), silver (to cover if time available), or bronze (low priority) and dictated the order of the session. The dietitian covered mindful eating principles, including how to recognise hunger and satiety, other influences on eating and tools for managing these situations. Emphasis was taken away from self-judgement over right and wrong food choices, to a learning experience.
A new referral and booking pathway was set up. Healthcare professionals could refer by post or electronically. Refocus was advertised by posters sent to every Dorset surgery to put in waiting rooms and clinic rooms and handed out at locality multidisciplinary team (MDT) meetings. A5 flyers were available in both primary and secondary care venues. Email updates were sent to primary care staff. A Refocus administration pathway was created to enable future teams to duplicate the service. HbA1c, cholesterol, blood pressure, eGFR, weight, height, diabetes medications and medical history were checked by the dietetic lead prior to the session. Either a patient activation measure (PAM) or PAID survey was given at the start of the session to measure baseline activation or diabetes distress. A second copy was posted at three months with a blood form to repeat HbA1c and cholesterol. Patients were asked to self-report blood pressure and weight at three months.
Of 596 referrals (June 2018 – March 2019) from Dorset GP practices, 53 (8.7%) were rejected as they did not meet the criteria. The total number of attendees was 207 (38% of those invited) and ages ranged from 18-80. To date 68 patients have completed the three-month follow up. The full data set continues to be collated. HbA1c has reduced by 8mmol/mol from a mean average of 67mmol/mol to 59mmol/mol (p=0.01) (n=68). Patients that did not attend the session they had booked numbered 27 in the first 22 Refocus sessions. Mean average HbA1c of patients that did not attend increased by 9mmol/mol (n=15) from 71mmol/mol to 80mmol/mol. Eight of the 21 patients (38%) that did not attend Refocus had also missed an appointment at their surgery in the past eight months (average HbA1c was out of target at 68mmol/mol). There was a 2.62kg (5.8lb) average reduction in weight (n=67) over an average of 16 weeks post-intervention. PAM scores for the first 59 patients that completed pre and post surveys were analysed, with 24 (40%) patients increasing their activation levels, 30 (51%) staying the same and five (9%) decreasing activation level. These patients were offered other support. The previous pilot curriculum had seen an average reduction of 2% in diabetes distress. However, the new, patient-led curriculum edition (n = 13) showed a higher average reduction of 7.7% and, of those experiencing severe diabetes distress (scoring over 40, n = 7), all resolved, with an average drop of 19.6%. There was no significant change for cholesterol and blood pressure between baseline and three months when analysing the first quarter of patients (n=50).
Sustainability and Spread
In regions with ongoing ICPCS funding, Refocus has continued and has been expanded to patients on insulin (called In-focus) and in-target patients (called Focus on diabetes), with a single referral process. The other localities continue to receive Refocus sessions from current diabetes care providers in Dorset, but funding is needed to make this sustainable and to provide for demand. Nurse and dietetic staff have been trained to deliver Refocus across the county. Educators from the four Dorset Trusts were involved in writing the curriculum and meet regularly, the aim being to make them partners in the programme to ensure its continuation after the funding for project lead finished. The educators collaborate on the ethos of the programme and ensure consistency in the messages being taught. A key requirement from Dorset CCG is to have consistency of message and standardised quality of education across the county. The next step is to incorporate online education to the Refocus programme, in the form of HELP, which is being funded by NHS England nationwide.
Refocus outcomes were presented at the WISDOM conference in June 2019. They will be presented at the next Wessex Diabetes Clinical Forum meeting and submitted for publication. An application for QISMET accreditation is underway.
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