Delivering value supplement: Clinical innovation case studies

More from the supplement

• New ways to manage diabetes care
• Get hip, pay less

1. Training frontline care home staff

The diabetes of care home residents can be very difficult to control. They are often elderly, physically and mentally frail, have comorbidities and functional disabilities, and lack a comprehensive assessment of their diabetes. This results in multiple admissions for hyperglycaemia and hypoglycaemia. Yet frontline care home staff are rarely offered structured diabetes education.

Rajee Baburaj, consultant physician for diabetes and endocrinology at Hillingdon Hospital Foundation Trust, decided to do something about this.

She says: “There is no mandatory requirement from the Care Quality Commission for diabetes training to be provided to all healthcare staff within these settings.

‘Though care homes often expressed willingness to take part in the project, we did encounter multiple cancellations due to staffing issues’

But a local audit highlighted that blood sugar was not properly monitored, staff had a low threshold for calling ambulances, and there was a need for education on diabetes.”

She received a £60,000 grant from the Outer London Integrated Care Project Innovation Fund. The fund supported the recruitment of a dedicated diabetes specialist nurse for 12 months to offer training and support to care home staff. It also enabled the development of a comprehensive diabetes programme based on the nursing skills competency framework staff training education programme - basic and advanced.

Healthcare assistants undertook basic training, while nurses and healthcare assistants with an interest in diabetes were given the advanced course. The Institute of Diabetes for Older People carried out an independent training needs analysis assessment. Another partner, Sanofi, worked with Dr Baburaj to manage the project.

Every care home in Hillingdon took part, except for a few that had no diabetic clients.

Dr Baburaj says: “Though care homes often expressed willingness to take part in the project, we did encounter multiple cancellations due to staffing issues.

“Many consultations were needed to get the initial engagement from care homes, but once started, they often saw the benefits and requested more staff to be trained.”

Previously, care home admissions and London Ambulance Service callouts were not coded, so no data for admissions prevention is available for comparison.

However, snapshot audits show timely advice and intervention from the diabetes specialist nurse prevented at least 25 admissions.

It will now be recommended that commissioners allocate community nurses to care homes.

2. Helping housebound patients

Housebound patients with diabetes can suffer higher than average unplanned hospital admissions and complications because of irregular medication reviews, foot checks, retinal screens and blood glucose tests.

As housebound patients are not included in quality and outcomes framework indicators, they can be missed. Integration of GP and acute care for patients with diabetes often bypasses those who cannot leave their houses, so care falls to community teams.

So Kent Community Health Trust decided to act. Paul Jhass, strategic projects lead at the trust, says: “We put ourselves at the table where these decisions are made. I contacted the consultants at the acute trusts, the GPs, medicines management and all the different service providers like podiatry.

‘We have so many competing priorities but I knew we could help address the issue if we all worked together’

“We have so many competing priorities but I knew we could help address the issue if we all worked together and they agreed that we all work together to improve outcomes for the housebound patients.”

Housebound patients with diabetes often have comorbidities and are on multiple drugs. Many require several injections and nurse visits a day. Both injections and visits could be reduced by offering once daily insulin to appropriate patients, as recommended by National Institute for Health and Care Excellence.

Mr Jhass says: “We focused on the nine care process[es] including the [NICE] guidance. We are supposed to consider giving once daily basal insulin for patients who require third party support. A steering group was set up, chaired by our medical director.”

The steering group has representatives from all service providers. A care pathway for housebound patients with diabetes has been established, supported by a competency framework for nurses looking after those patients. Plans are being drawn up to roll it out across the trust. The objective is to slow any deterioration in the patient’s condition with a focus on improving quality of life.

Mr Jhass says that, if a nurse visit costs £32.50, then cutting down the number of daily visits by one for 100 patients - £32.50 multiplied by 100 multiplied by 365 - could save around £1m a year.

Using once daily insulin with regular full medicines usage could improve patient care and reduce unplanned hospital admissions as well as save the NHS money, he adds.

3. Gamification for children with type 1 diabetes

Children with type 1 diabetes need to start managing their condition early, as failure to control blood glucose leads to complications later in life.

But currently only 15 per cent achieve their blood glucose targets. This is why an app was developed to make testing fun - the first gaming approach to diabetes care in the UK.

Monster Manor encourages children aged 6 to 13 to earn currency within the game by entering blood glucose readings, which they can then use to create monsters, unlock rooms and collect pets. The positive feedback is designed to keep players engaged with managing their diabetes.

It was developed by Ayogo, a Canadian company that specialises in “gamification” - the application of game psychology to self care, with Sanofi and Diabetes UK.

‘Some parents have said that since the game, testing has become less of a struggle’

Simon O’Neill, director of health intelligence at Diabetes UK, says: “Parents tell us that their children often find regular blood glucose monitoring very hard to accept and it can often become a source of tension in families.

“We often find children don’t mind doing injections but they don’t like doing the finger prick blood test because it hurts. This game is not to encourage them to test more, but to test at all.”

Oxford Academic Health Science Network has joined the partnership to evaluate the app. The results have not been finalised, but early findings indicate a quarter of those who played tested more often.

This could have a significant impact. Research shows that just a single extra test a day in teenagers leads to a 0.4 per cent reduction in glycated haemoglobin.

Mr O’Neill adds: “Some parents have said that since the game, testing has become less of a struggle. As a first off trial, we are quite pleased.” And, he says, there are also wider social benefits.

“Lots of children with type 1 diabetes feel quite isolated and that there is nothing specially for them - other diabetes apps for adults can be rather boring for children. It creates a positive identity for children with type 1 diabetes - they like having something specially for them,” says Mr O’Neill.