improving student diabetes care peta navein diabetes nurse consultant
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Improving Student Diabetes Care
Peta NaveinDiabetes Nurse Consultant
Brownlow Health Practices
4 x Practice sites:• Brownlow;• Student Health
Centre;• Student Health
Advice Centre;• Ropewalks.
BH Registered Population
30,000 people:• Established Liverpool
families;• 17,000 students (62%);• 1000 vulnerable adults:
– Substance misusers;– Homelessness;– Asylum seekers;
• New city dwellers, a mix of young and retired professionals.
GP Practice of the Year 2014
FACING THE CHALLENGES & FINDING NEW SOLUTIONS
Good Diabetes Care
was our next healthcare challenge
BackgroundNationally we is known that:• Young people (YP) with
diabetes least likely to get their diabetes health checks;
• Do not engage with HCP;• May suffer preventable
complications as a result;• 30% report a deterioration in
the quality of their diabetes service when they move their specialist care;
Locally we knew that:• 3,500 new students
registered in AcY 2013/14;• But not how many had DM:
– 67 students had diabetes;• 55 T1DM• 9 T2DM• 3 MODY
• Twice the number we found on previous years search – not coded ‘Student’
Diabetes UK(2014) Type 1 Essentials for children & Young people www.diabetes.org.uk; accessed 14/07/14Johnston P et al: (2006) Audit of young people with T1DM transferring from paediatric to adult serviceJefferson IF et al (2003) ) Diabetes services in the UK: third national survey confirms continuing deficiencies. Archives of Diseases in Childhood. 88:53-6;Royal college of Paediatric & Child health (2014) National Paediatric Diabetes Audit Report 2012-13;Diabetes UK (2014) State of the Nation (England) Challenges for 2015 and beyond;Myint KS et al (2015) Transitional diabetes care fro UK iniversity students . Poster at DUK professional conference March
BH: Invested in an Extended Primary Care Diabetes Care Model
OBJECTIVE: Can a practice-based diabetes nurse consultant (DNC) service for students with diabetes, at university, help make a difference to their healthcare outcomes?
DIFFERENT DIABETES:• Type 1 Diabetes (T1DM)
– Auto immune disease that cause destruction of the beta cells and so they cannot produce insulin;
– Approximately 10% of diabetes
• Type 2 diabetes (T2DM)– A combination of Insulin resistance, so that the insulin cannot work properly & an inability
to make not enough insulin ;– Approximately 85-90% of diabetes;
• Maturity Onset Diabetes of the Young (MODY)– Is a monogenic diabetes with a single gene mutation cause for the diabetes and there is
mostly a strong family history of diabetes in at least two of three generations and a mixture of T1DM and T2DM diagnoses
– Approximately 1-2% of diabetes?
• Secondary Pancreatic Diabetes – (T3c) include:– Chronic Pancreatitis; Cystic Fibrosis; Hereditary Haemochromatosis; Pancreatic cancer;
Pancreatectomy.
– Approximately 5-10%?
Brownlow Health Diabetic Population
On the Diabetes Register:• 34% Type 1 diabetes• 66% Type 2 diabetes• MODY?
– Not identified/coded
• Secondary Pancreatic Diabetes?– Not identified/coded
Back to Our Student Population
One my jobs is to help get correct diagnosis; coding & treatment for patients
Students have far more challenges and complexities to their diabetes care than a typical practice population:
• Managing alone, without familiar family and friends;
• Significant major life changes/stresses making it more difficult for them to engage in their diabetes care;
• In Liverpool for just 30 weeks of the year;
• No familiar specialist team care contact in an emergency.
Student Challenges:
Student Diabetes Project 2013-14
FUNDING: Novo Nordisk UK Research Foundation
• Majority students chose to keep their specialist diabetes care at home (62%);
• They forget/chose not to tell their hospital team of the university GP address – so we get no communication;
• 30% of those who move their specialist health care to the university city think the quality of their diabetes service deteriorated;
THE CHALLENGES:• Many appointments clash with
university timetable;• Students don’t see a need to
attend practice LTC reviews as well as hospital care;
• Some are not confident in the diabetes skills of a primary care team;
• When they have problem with their diabetes management - can just go to A&E across the road;
• Most of our GP’s and PN’s do not feel confident managing T1DM
Diabetes Care: Important Health Checks
• We do not do well in getting these recorded;
• New students - we have just 5 months to get these before YE;
• At a busy time for team e.g. flu and university & winter illnesses
HbA1c; Blood pressure; Cholesterol; Kidney function (eGFR; ACR); Eye screening; Foot screening; Structured Education; Flu vaccination.
Annual Review Checks
Student Diabetes Service Plan:
• Get them registered quickly;– Get their medications sorted;– Get their diabetes risk sorted;– Get them coded correctly;– Get individual care plan:
• What they want;• What we want for them.
• Raise awareness amongst team of new Diabetes Nurse Consultant service;
• Designer – YP attractive marketing materials;
• Update website• Audit of outcomes October
2013-March 2014;
NEW STUDENT SERVICE LAUNCH:World Diabetes Day November 2013
The Service & It’s Launch• Additional monthly DNC
clinic at SH 4-6.30pm;• Welcome letters;• DNC contact details:
Text/Phone/email contact;• Postcards: staff to hand out;• Posters in Halls of Residence• World Diabetes Day launch;• Lots of follow-up calls:
– Students;– Out-of-area Consultants;– Out of area Practices;– Other HCP’s.
ON CAMPUS PROMOTION
Using Social MediaStudent’s View’s & Ours - What works & what doesn’t.
• Students largely favoured texting phoning & email;
• We did not pursue a Facebook or Diabetes Twitter option because:– Student feedback suggested they would not want to engage with their clinician using Facebook;– Medico-legal issues and complexities of using Twitter and the giving of non specific patient
advice through social media (GMC advice);
• We did put general information on our new website, which was specifically for students with diabetes
• We also direct them to other bona fide websites and Twitter service e.g:• www.runsweet.com; for managing sport and exercise; • www.diabetes.uk.org; • @parthsakar; ‘Twitter’ Dr Partha Kar Consultant, Portsmouth Hospital
Using Our IT TeamTo Help Improve The Quality of Student Diabetes Care
Setting up the systems:
• A Student Diabetes Register:– So the DNC can be proactive in liaising with students and following up on their care
needs i.e. ‘text reminders’
• Monthly updates of newly registered patients with diabetes:• Welcome letter re DNC service and contact details
• Flag all emergency hospital admissions and A & E attendances:• So that the DNC can make timely contact to follow up on care and prevent reoccurrence
where possible. E.g. Hypoglycaemia, DKA or new diagnosis of diabetes.
• Audit QOF Clinical Outcomes and quality of care
Diabetes Nurse Consultations
• Over 4 - months:
• 4 x additional clinics SH:– 21 x consultations
different students T1DM;
• Recorded text/phone/ emails:– 55 consultations;
QOF clinical measure % of students with documented evidence that they met this target
BP ≤ 150/90 91%
BP ≤ 140/90 86%
Cholesterol ≤ 5 75%
Microalbuminuria testing done 95%
Protein or Microalbuminuria + ACE 1.5%
IFCC HbA1c ≤ 59mmol/mol 60%
IFCC HbA1c ≤ 64mmol/mol 69%
IFCC HbA1c ≤ 75mmol/mol 81%
Evaluation: QOF Year End 2014- 5 months of New Service
QOF clinical measure % of students with documented evidence that they met this target
Had retinal screening 91%
Foot Risk Assessment 95%
Dietary review 95%
Given Flu vaccine 83%
Structured Education Course within 9 months of diagnosis (3 new diagnosis)
67%
Evaluation: QOF Year End 2014: - 5 months of New Service
Research & Audit Activities:• 4 students are taking part in national research:
– Address 2: a database of newly diagnosed T1DM patients and their siblings to help support research into the causes T1DM;
• Working with Exeter University & NW Genomics centre: – Finding the missing MODY patients and get them on the right treatment;– Offer MODY patients opportunities to take part in national research;
• In partnership with Aintree University Hospital to inform students of research opportunities that they may want to take part in:– Joint clinical & research venture;
• Medical Education:– We have engaged the help of medical student’s and GP registrar’s in auditing
clinical outcomes and our practices in diabetes care.
What Else Have We Done?…To Improve Student Diabetes Care
• Diabetes Nurse Consultant service:– funded by Partners;
• Early contact with home Consultants: – Admin support to contact and copies of the students out-of-area
clinic consultations so that we have:– up-to-date information on the care given and needed and – can support student with these whilst in Liverpool;
• Early/Proactive contact with students at start of academic term;
• Our different approach of: – Being flexible; providing continuity; offering timely access DNC; – Being culturally sensitive to the students needs and challenges;
• Timely follow-up of students when things go wrong: – To provide extra, specialist support and prevent reoccurrence.
What Are We Wanting To Continue?…To Improve Student Care
• Continue more clinics at SH; text/phone/email;• Set up remote access to EMIS for DNC so all consultations
can be recorded in real time;• All the team to help with informing students of the
service;• Re-audit QOF YE 2015: have we done any better?• Redesign services student needs:
– Different re-call system for students;– Extra DNC late afternoon clinics on campus Oct-March (and not
in holiday and exam times);– Help them achieve better outcomes than last year.
What Are We Doing Next?To further Improve Student Care
Looking Out For Rarer Monogenic Diabetes
Neonatal Diabetes• Like Sarah - diagnosed under the age of 6 months;
AND
MODY Diabetes• Like Georgia - 3 key characteristics of MODY:
• Diagnosed under 25 years (1 or 2 family members);• Family history of diabetes in every generation (at least
2 or 3)• Mixture of T1 & T2DM in the family (Most are not
clinically classic presentations of T1DM or T2DM.)
In Summary
• At BH we have improved the care of our student population with diabetes;
• It has been a huge team effort to reach all our students;
• We have plenty more to do still, but we need to provide better care and support for this vulnerable population;
• At least one student has appreciated the service …
Text from John – 11 06 2015
‘Hi Peta, I am coming back to China tomorrow. Really thank u for your kindness this year. U know I feel nervous when I arrived here with knowing nothing about practice. However your patience let me feel warm and problems like my prescription and other things all fixed by you. Sometimes words just can’t explain. Just hope u could have an amazing and happy summer! Maybe See u in Nov
