In 2017, the Young Adult Service at the Royal Liverpool University Hospital won a QiC award for a significant reduction in non-attendance rates, increased numbers achieving glycaemic targets, reduced diabetes-related emergency admissions and substantial cost savings. This was achieved through restructuring the service pathway, improving communication and engagement with young adults (YA), and establishing a peer-support platform. This submission highlights further changes that have resulted in continued improvements in service-related and clinical outcomes for young adults with diabetes. NICE has highlighted it as an example of best practice and NHS England has used it in defining standards of care for young adults.
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In Year 1, changes made included: a clinic structure revision, including the introduction of a clearly defined structured pathway for the journey of the YA through the service, joint-multidisciplinary clinics and flexible drop-in sessions, pre-clinic questionnaires for people with diabetes and the incorporation of data download facilities. In order to improve communication, pre-clinic telephone reminders were added to standard letters and texts and patients were encouraged to contact healthcare professionals through emails (9am-5pm). Access to support was extended with the formation of LIVT1D – Liverpool’s first peer-support group for type 1 diabetes. This comprised social media platforms, social get-togethers between members and evening educational sessions supervised by healthcare professionals. In Year 2 and 3, further changes were introduced, including a dedicated, twice-a-year ‘Joint-Young Adult Insulin Pump clinic’ to align care given to young adults on insulin pumps with the well-established protocols of the adult (>25-year-olds) cohort under the ‘Royal Liverpool Insulin Pump Service’. This also served as a platform to discuss challenging cases and clinical conundrums. Primary care colleagues caring for university students were invited to attend young adult diabetes clinics. This reassured them about the care students with T1D received in a specialist service and further strengthened relationships across the healthcare spectrum. FreeStyle Libre education sessions were introduced following the national implementation of flash glucose monitoring prescription. While this was applicable to the entire T1D service, significant numbers in the cohort were YA. While in 2020 this is a standard part of the service, in 2017 this was not the norm. A partnership was established between LIVT1D and Everton in the Community, the official charity of Everton Football Club. This laid plans to increase awareness of T1D in the community, provide access to fitness classes and a platform for peer-support meetings. A dedicated diabetes psychologist was employed to manage YA recently transferred from paediatric care or moved onto insulin pump therapy who might be living with diabetes-related distress or other psychological conditions. Letters to university staff and employers were given to YA to hand in at their college/university or workplace to highlight the challenges of living with T1D and the importance of allowing them to attend their planned clinic appointments. Once an ethos of regular reflective practice had been established, these annual outcomes were measured: DNA rate and % of clinic cohort attending ≥2 clinics/year; Median HbA1c of clinic; the percentage of patients achieving median HbA1c <58 mmol/mol, as well as the percentage of patients admitted with diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH).
The results from 2015 were compared to those of the three consecutive years following the clinic changes (2016-2018). A significant reduction in the DNA ratewas seen from 2015 (47%) to 2018 (21%, p<0.001) and the percentage of people with diabetes attending two or more clinic appointments per year peaked in 2018 (70%) in comparison to 2015 (41%, p<0.001). A steady fall occurred in the median HbA1c for the clinicbetween 2015 (76mmol/mol) and 2018 (68mmol/mol, p=0.009). Additionally, by 2018, nearly a third of young adults (30%, p<0.001) had achieved a median Hba1c <58mmol/molcompared to 2015 (9.7%). This was above the national median for people with T1D in the same age group (22.7%) and similar to the observed median in the UK for people with T1D across all ages (29.9%) (National Diabetes Audit, 2015-18). Hospital admissionsfor DKA dropped to 3.3% in 2018 (15% in 2015, p=0.004) and none of the young adults attending the service was admitted with SH (4% in 2015, p<0.001). Feedback from young adults about the clinic and LIVT1D meetings have been encouraging, with satisfaction rates of 85% and 100%, respectively. Furthermore, LIVT1D has expanded steadily over the last three years, with over 250 members supporting each other across Merseyside.
Sustainability and Spread
The outcomes achieved by these steady and cost-effective changes were significant and sustained from 2016 to 2018. Three components were central to this. The first was the decision to differentiate ‘expert people with diabetes’ from ‘specialist healthcare professionals’. The experts were the guiding force in co-designing the changes through invaluable feedback to the specialists, who merely implemented and delivered these in the structured pathway. The second was the development of a culture of reflection through regular outcome measurement. This allowed the team to consolidate the positives and improve on the negatives, embedding the belief that, if the wider MDT concentrates on areas of control and worries less about areas beyond control, the positive impact on care delivery can be considerable. The third component was the identification of changes that could be simple and cost-effective to implement. The core principles of this service have been to engage closely with patients and colleagues (paediatric, primary care and wider MDT), management through the use of appropriate language, plus identifying changes that can be implemented with marginal changes to job plans. The changes highlighted have not required substantial additional funding. In fact, aside from funding for peer-support group educational sessions and contribution to clinical psychology sessions, no additional funds were required. Evaluation of the outcomes in 2019 was commenced earlier in 2020 and preliminary results showed continued improvement. This evaluation was halted temporarily by the COVID-19 pandemic.
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