Summary

A new service was set up to provide social and emotional support to people with diabetes to help prevent readmissions from acute glycaemic events. The service received funding for 12 months and involved the creation of a process to identify at-risk in-patients who are then adopted into the programme. A case manager meets with the patient prior to discharge and identifies education and management issues. There is an intensive follow-up period involving home visits, telephone contact and consultant clinic review if needed, with a database of detailed information developed to allow review of progress and reaudit of outcome measures. Patients also have access to a psychological wellbeing practitioner who assesses their mental health needs and can provide psychological interventions. Analysis shows that readmissions have reduced by 60 per cent, glycaemic control and self-management has improved, and there is an estimated net saving of £91,804 per year.

Results

Acute glycaemia readmission has been reduced by 60%. In addition the pilot group demonstrates improved glucose control (HbA1c improvement), their self-management has increased, there are improvements in the take-up of mental health intervention, greater patient satisfaction (self reports-will be gathered via an end of pilot interview), reduced in-patient stays and cost savings to the Trust. For example, the average length of in-patient stay has reduced from 4.3 days to 2.5 days and the estimated subsequent financial savings are £265,032. Deducting the 12 months’ funding leads to a predicted overall saving of £91,804 per annum.

Furthermore, the pilot offers a streamlined patient pathway across hospital, ambulance and mental health services (by implementing the readmission prevention service) and safety is maintained through clinical governance from a diabetologist who maintains close links with the hospital service via multidisciplinary team (MDT) meetings.

Challenge

Audit of Cambridge University Hospitals (CUH) diabetes admission data from 2010/11 identified that of the 473 patients admitted with diabetic ketoacidosis (DKA), hyper- or hypoglycaemia, there were 168 (35.5%) predominantly with Type 1 diabetes readmitted within a year (approximately 15 a month). A significant proportion also experienced social or mental health problems and improving self-management for this client group poses particular problems. In addition, two young patients with recurrent hospitalisation for DKA had been found dead in bed over the previous three years and it was felt that home visiting by the diabetes specialist services might have prevented these deaths.

One of the main challenges this service has highlighted is the distinct lack of community based support for patients needing help to manage insulin administration at home. Community nursing time is limited and community social carers are not allowed to be involved with insulin administration, even with appropriate education and support.

Objectives

Funding was provided to support a one year pilot of a post-hospital discharge diabetes case management service, specifically for this group of patients, to prevent readmission. The project also aimed to reduce overall risk to the patients, increase treatment satisfaction and reduce the high costs associated with in-patient stays.

The pilot looked to develop a structured, co-ordinated service promoting and delivering safe and efficient healthcare. A comprehensive literature search suggests that such an intensive and wide-reaching service has not been trialled nationally.

The service was advertised internally to ensure that all appropriate patients were referred and their suitability was confirmed through chart review. The case manager meets with the patient before discharge to identify education and management issues. Some can be addressed immediately but others require longer term plans involving liaison with relevant agencies. Patients also have a 24 hour-out-of-hours contact number for additional support.

Solution

An innovative joint diabetes/mental health service to reduce readmissions from acute glycaemic events was funded for 12 months at a cost of £173,228. The service included two WTE diabetes specialist educators and pro rata time from a diabetologist, psychiatrist and psychological wellbeing practitioner (PWP).  
A management programme was implemented to identify in-patients with potential diabetes, social and mental health issues post-discharge. The intervention has been running seven months and 44 patients meeting the criteria have been identified. Twenty-three (52%) have a mental health issue so joined up working with mental health services is crucial.

The project is innovative in that it uses a ‘Barriers to Diabetes Care’ framework to reduce the problems that this group of patients has which impact on their diabetes self-management. The approach is wide reaching in terms of its links with a variety of outside agencies such as social services, welfare and benefits offices, citizens advice, county council housing departments and community mental health services, in order to provide holistic support.

Evaluation

A detailed database was established to capture baseline data which is regularly reviewed and updated on a range of outcome measures such as HbA1c and other biochemical data, length of stay and associated admission costs in the two years prior to the pilot and subsequently. A range of social data and mental health markers are used, such as scores on GAD7, PHQ9, PAID and Clarke Hypo questionnaires. Mental health diagnoses and uptake of mental health and other interventions, including social interventions, are also recorded. The pilot demonstrates positive outcomes in all areas, along with substantial financial savings.

In addition to a 60% reduction in readmissions, glycaemic control has improved. Five patients demonstrate improved self management, having attended a DAFNE course, while a further seven are being fast tracked to insulin pump therapy. We have improved access to mental health services and reduced the length of stay for those who are readmitted through facilitated discharge.

With appropriately skilled staff, and using our tools and pathways definition, this service could easily be adapted by other diabetes centres and also for other long term conditions.

Impact

A database of detailed information has been developed to allow review of progress and re-audit outcome measures. Diabetes case managers have access to back up from the consultant diabetologist at all times as required. Weekly MDT meetings with both the diabetes and mental health service staff are held to discuss individual cases and review activity, and a monthly steering meeting is held. The service also presents monthly at the diabetes service clinical governance meeting.

A weekly hospital clinic is available for diabetes consultant review after the weekly MDT meetings, when patients can be introduced to the PWP. The PWP assesses mental health needs and can either provide psychological interventions (such as sleep or cognitive behavioural therapy, CBT), or can refer to more complex CBT (step 3), psychiatric assessment or step 4 intervention (cognitive analytical therapy). The PWP maintains ongoing involvement where necessary, including joint consultations with the diabetologist as required.