The Improving Contact, Improving Care project aims to improve the care received by young people aged 15 to 23 years with diabetes in east Dorset. To achieve this, funding for young patients aged 15-19 years from the paediatric Best Practice Tariff (BPT) was used to redesign the Poole Young People’s Diabetes Service (YPDS), with the intention of extending the core principles of the BPT for diabetes to those aged 20-23. The success of the project has seen improvement in diabetes control in patients aged 15-23 years, with the most marked benefits in those aged 20-23. A project with flexibility, frequent contact, an embedded philosophy of outreach and a service focused on young people has demonstrated that it can achieve great improvement for patients living with diabetes.
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The project team embedded a culture of continuous improvement and made many changes in the initial 12 months after establishment, which have been sustained. The team’s adaptiveness and swiftness to respond to both success and failure has been central to the development of the project. It introduced: flexible communication with the team, including phone, text and email, offering a combination of virtual reviews/clinical advice and appointment reminders; assertive outreach – understanding the caseload and responding to their needs, while building in flexibility to fit around the patient; a 19+ nurse-led clinic to enable more frequent team contact; fortnightly psychosocial multidisciplinary discussions about complex patients, which facilitated the embedding of psychological skills into consultations; a menu for patient education, recognising that education takes many forms, allowing patients choice in how and when they want to receive education through the education choices questionnaire; taking a developmentally appropriate approach to transition from paediatrics to the YPDS and then to the adult service to help young people reach their potential, both in their diabetes management and more widely. These innovations give patients a breadth of choice from a multidisciplinary team whose members work closely together to ensure high standards of care.
Self-care for diabetes falls markedly in the 20-24 age group, so the service was redesigned to better meet the needs of this older group. The Poole YPDS recruited a dedicated transition diabetes nurse specialist, diabetes specialist dietitian and clinical psychologist, and received increased consultant cover. The goal was to implement truly patient-centred care while achieving the BPT for patients aged 14-19 years and extending this standard of care up to age 23 within the BPT resource. The service focused on clinic support, outreach, communication and education. A weekly clinic for young people was introduced with additional urgent slots available, plus a monthly evening clinic to offer flexibility for college and work-aged young people, with annual review appointments offering a ‘one-stop shop’ for consultant, dietetic and psychological review. A fortnightly 19+ nurse-led clinic was also set up. Psychological skills were introduced into consultations, with a weekly psychologist clinic, offering evidence-based psychological therapies, a fortnightly psychosocial meeting and psychological skills training for staff. A patient database monitored outcomes and flagged those of concern. Outreach involved active case-finding for patients not attending or disengaged from the service, and home visits. Communication was improved with text and email reminders for clinic appointments, a text, email and telephone helpline for patients, a quarterly newsletter and a website for patients. Education delivery was tailored to what patients wanted and a college clinic group education session offered with a curriculum aligned to type 1 diabetes. To help with transition a Consultant Paediatrician joined the YPDS team, a Diabetes Holistic Assessment Tool (D-HAT) was created to aid biopsychosocial assessment of newly transitioned patients, and there were quarterly handover meetings with the Adult Diabetes Service and the Trust Safeguarding Lead.
The Improving Contact, Improving Care project has seen a mean reduction in HbA1c from 80mmol/mol to 73mmol/mol over a four-year period for all patients aged 16-23. This project uniquely extended the principles of the BPT to those aged 20-23. Looking beyond the BPT, this group saw the most marked improvement, with a reduction in HbA1c from 94mmol/mol to 75mmol/mol. Although the latest results of the National Paediatric Diabetes Audit are awaited, the service has delivered lower HbA1c than the national average since its inception, a trend extending to the 20-23 age cohort. Those with particularly concerning HbA1c have also improved, with males benefiting particularly over the four-year period (19.35% with an HbA1c of > 100 in 2014/15, now 7.29% in 2017/18). The number of females with an HbA1c of over 100 has also reduced from 6.45% to 2.08%. Non-attendance at clinic is associated with adverse outcomes. The assertive outreach approach has resulted in improved ‘did not attend’ (DNA) rates, with a 4.3% reduction in clinic DNA rates over the past three years. Furthermore, the percentage of patients who DNA at least once reduced from 45% (2015/16) to 40.4% (2017/18). There are also fewer multiple DNAs from individual patients compared to three years ago.
Sustainability and Spread
The Improving Contact, Improving Care project was set up to extend the Poole YPDS to improve care for all young people with diabetes. Results have been shared with poster presentations at Diabetes UK 2018. After identifying significant variation in the quality of the service provided across the county, the team is working with Dorset Clinical Commissioning Group (CCG) and the two other acute providers to share the work. The ambition is to extend throughout the region in line with the CCG plan to develop a single diabetes service across the region. A stakeholder day is planned for September 2018 to showcase results and inform further service design across Dorset. The project demonstrates that the BPT can be extended by reinvesting this money into diabetes services. The benefits of this reinvestment, and the extension of the service to young people aged 20-23, are clear from the improved HbA1c and greater engagement achieved.
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