Summary
Diabetes differentially harms the poor, homeless, frail elderly and people with drug and alcohol problems and poor mental health. Most of the morbidity, mortality and misery diabetes inflicts on the most vulnerable is preventable. The aim was to repurpose existing resources to improve health and care for these people via a full embedded Outreach project, supporting existing systems and staff to provide timely, effective care and a positive patient experience.
Innovation/Novel approach to an existing problem
Diabetes self-management education was not working for the most deprived in the area. A move to digital education worsened attendance. A survey of 1,000 local people found 32% of respondents had no access to a computer or smart phone. The team surveyed local care homes, mental health inpatient wards and GP practices where many staff reported feeling ill-equipped to meet patients’ diabetes care needs. After brief training in a pilot, staff knowledge and confidence improved. In another pilot, sessions in a local homeless charity brought diabetes screening and complication surveillance. Informed by these pilots, the goal was to redeploy existing diabetes specialist resources. This was a collaborative project in which local people with diabetes, the local authority, the independent sector, primary care networks, the CCG and the local teaching hospital worked in partnership to co-create more joined-up care. The goal was to move from crisis management to timely and supported self-management, specifically targeting vulnerable people. Homeless, housebound, care home inpatients, mental health inpatients, people with drug and alcohol problems, and challenging patients in primary care were prioritised.
Equality, Diversity and Variation
With ICS-diabetes network support, the team met with St Helens patients and carers and clinical and non-clinical staff from: NHS St Helens CCG/LA, public health team, four primary care networks, learning difficulties services, LGBTQ+ community, Salvation Army, YMCA, Teardrops (homeless), gypsy and travelling community, MIND, asylum seekers and refugees, St Helens CGL (drug and alcohol), mental health services, Healthwatch, The Hope Centre, BAME, St Helens living well (LD) community, the Chrysalis Centre and a local GP with special remit for hard-to-reach groups. In addition, 32 local care homes and rehabilitation units were consulted. Consensus from these meetings informed co-design of a formal written strategy with aims, SMART objectives, risk assessments, measurement tools and milestones. A PDSA approach was taken. The multi-pronged approach improved (timely) access to care. Now the homeless can access diabetes advice and care directly without having to navigate complex systems. If the team cannot address all of the patient’s needs in the hostel or support centre, a team member coordinates appropriate care. The housebound receive specialist care at home. Direct care is provided for those in inpatient mental health settings, and the workforce is upskilled. Those with drug and alcohol problems are seen at CGL, the Salvation Army or the YMCA. All clients said this had improved their health and care experience and helped with self-care. Positive health outcomes include people with pre-diabetes returning to normal glucose tolerance, improved HbA1c, insulin pump access, plus sight and limb-preserving foot and eye checks and follow-on care.
Impact to Patient Care
The pilot study training at care homes improved staff knowledge and confidence. The subsequent care home staff education package is being prepared for Royal College of Nursing accreditation. Education sessions took around two hours and were tailored to staff needs. After the early work with the homeless charity, Teardrops, new monthly clinics at the YMCA, CGL, Salvation Army and Hope House (previously Teardrops) have been praised for improving patient care. Since 2021, 423 service users have attended clinics at these venues. Advice and support have been provided on 124 occasions to two inpatient mental health units. Previously, these units relied on transfers to A&E to resolve diabetes-related issues. There have also been 2,475 contacts with GP practices. Providing specialist diabetes review in GP practices removes the need for referral to secondary care clinics. For the email and telephone advice to GP practices, 97% of queries were responded to within 24 hours.
Results
The Outreach project was co-designed and co-produced with patients and colleagues and is fully embedded in the team and local community. Over 53 months to March 2025, there were 10,360 contacts supporting professionals and 4,454 supporting patients and carers directly. Three telephone advice and guidance (A&G) lines took 5,674 calls. Contacts included all target groups: GP practices (2,349), frail and elderly home visits (332), frailty/district nurse joint working (302), supporting homeless and those with drug and alcohol problems (473), inpatient mental health (123), pharmacists (41) and care home support (309). Between 2023 and 2024 there were 356 joint face-to-face reviews and 34 joint telemedicine reviews in primary care and 36 patients received urgent face-to-face assessment to avoid A&E attendance. From 2023, there were 269 contacts with care homes, including 61 group staff education sessions. There were 26 face-to-face training sessions for district nurses and a rolling programme of education for community nursing teams. Since 2023 the team has responded to 91 requests for support from inpatient psychiatry, and there have been 10 group education sessions for staff. The team provides regular (monthly or bi-monthly) sessions at the YMCA, Salvation Army, Hope House, Teardrops and a centre for drug and alcohol problems. There have been eight group education sessions in local urgent treatment centres (UTCs) helping avert A&E referrals. The aim was to support existing systems and staff to provide timely, effective care and a positive patient experience for vulnerable and disadvantaged local people with diabetes and evidence suggests that this has been successful. Note that this was a redeployment of existing specialist resource to support existing community systems and staff to address inequalities. Over the past year, Outreach has taken on eRS GP referral assessment (2,079 referrals) and A&G has reduced outpatient waits from c.18 weeks to 1-2 weeks.
User Feedback
In an anonymous survey of 49 professionals (GPs, practice nurses, ANPs, pharmacists, and physician associates), encompassing email, telephone advice, 1:1 education, joint reviews, case note discussions and staff group education, 100% expressed complete satisfaction with the support and 95% felt more confident managing their patients’ diabetes.
