Summary
While the structured education provided in diabetes for newly-diagnosed families has been well attended at Hillingdon Hospital, refresher education for those diagnosed more than one year has always been poorly attended. By taking an innovative approach to existing clinic time, this education was delivered within an existing clinic structure, utilising both room and staff availability and optimising patient attendance. Self-management education is known to improve outcomes, as well as saving the hospital costs of an admission due to complications.
Innovation
Attendance at structured group education sessions is difficult, especially for families who have been living with diabetes for many years. Their willingness/motivation to attend hospital appointments more than the required four or five times per year can vary significantly. Education is particularly pertinent for patients aged 9-11 years, who are transitioning towards high school and becoming more independent. In addition, patients who are very young at diagnosis often rely on the knowledge of their parents, who were given the initial education. The patient’s knowledge can be inadequate for several reasons: it may be outdated if evidence has changed since diagnosis; cognitive maturity will have changed, and parents may have misunderstood, developed bad habits, be using outdated information or be resistant to change. Clinic time is often used for immediate concerns rather than a preventative approach. Therefore, there is a gap in care provision, as the normal multidisciplinary team (MDT) clinic doesn’t always allow for in-depth educational updates and/or adjust information to suit both the adult and the developmental stage of the child. Structured group education can be hampered by resource availability such as physical space, MDT time and staffing capacity, as well as session planning time. To overcome these issues an annual group clinic was designed to take place during the first quarter of the year in normal clinic hours in the same space and with the same staff. The existing, roughly age-banded, clinic structure was used to deliver the group clinic to patients aged 9-11 and their parents. Individual, age-appropriate lesson plans were developed for parents and young people covering the same theme. This structure also facilitated the inclusion of siblings. At the end of the group activity, families were seen briefly for a one-to-one appointment. The remaining three clinic appointments for each family were left as traditional MDT clinics. Patients have the group clinic structure for three consecutive years between the ages of nine and 11, which allows them and their parents to develop relationships that may continue to provide peer support beyond the clinic experience.
Results
The consultation time in ‘normal’ clinics is limited to 30 minutes per family, with much of this time spent managing immediate concerns rather than taking a preventative approach. As well as improving the quality and quantity of structured education delivered to patients, the group structure provided efficiency by allowing 120 minutes of structured education to be received by seven families (840 minutes in total) within a 60-minute slot. While attendance figures may seem small, they account for 12% of the cohort, and it is envisaged that over 20% of patients will attend one or more group sessions over a three-year period. Only 3/21 patients cancelled or did not attend their appointments, which is a significant improvement on previous group education sessions. Parents reported that they learned a lot of new information, and that they enjoyed the format of the clinic.
Dissemination and Sustainability
As the clinic meets criteria for best practice funding of clinics, this is funded for the long term. The MDT stakeholders are committed to this structure as the standard of delivery while user feedback remains positive. The plan is to extend the group clinic to all age groups in time, making it a fully-integrated model. It is hoped that the 9-11-year-olds will become accustomed to the group experience, thereby facilitating engagement when they are older. Several paediatric departments in the hospital have expressed an interest in this style of clinic. The approach has been presented at the local paediatric diabetes network. This format opens up the possibility of caring for greater numbers of patients, once a culture of self-management education via group clinics is embedded.
Method
All children (n=21) aged 9, 10 and 11 were identified for this intervention. They were divided into three groups of seven patients, loosely clustered according to age for each group clinic. Dates were confirmed with the MDT and the clinic staff and lesson plans were developed using the Novo Goals of Education. On arrival at the group clinic patient measurements (Hba1c, height, weight, blood glucose) were taken and meters downloaded. Information was recorded using a specifically-designed data sheet. Families were separated into two groups: young people and siblings in one group and parents in the other. Structured education was delivered for 60 minutes and included two topics. The children had practical sessions on ‘what is diabetes’ and ‘eating out away from parents’; the first was delivered using an obstacle course where the children were either food or insulin and moved through the body. This approach facilitated their understanding of the interaction and journey of glucose and insulin. For the second topic they could use the internet and fast food chain web sites. The parents’ group focused on understanding both the physiological and psychological changes that occur during adolescence and how these impact on diabetes management. This included small group work and larger group discussion. Afterwards, everyone was asked to complete feedback forms. At the end families were seen individually for a 10-15-minute consultation with a consultant paediatrician. Following each group session, the team met to review the process and small adjustments were made to the following group.
