Improving patient involvement in diabetes management – Case Study

 

Overview

Improving self-management of type 2 diabetes is a strategic priority for the NHS due to the increased number of people diagnosed with type 2 diabetes and the impact of devastating and costly complications that can be prevented. Good diabetes management and improving lifestyle factors such as weight and activity levels can reduce the risk of complications. However, while structured education courses can help people learn to manage diabetes, attendance rates are very low.

Clinical Commissioning Groups (CCGs) in North West London are working with three innovative digital health companies, OurPath, Oviva andChanging Health to provide digital solutions for patients with diabetes to improve self-management of diabetes.

Changing Health is on the 2017-18 DigitalHealth.London Accelerator programme, while Our Path and Oviva took part in the 2016-17 programme. The Accelerator is a partnership between London’s three AHSNs (Health Innovation Network, Imperial College Health Partners and UCLPartners), MedCity, CW+, and Guy’s and St Thomas’ Charity. The companies went through a rigorous application process with evaluation by clinicians, commissioners, and patients.

OurPath is a 12-week digital behavioural change programme aimed at preventing the onset of type 2 diabetes, along with helping people living with type 2 diabetes, through education, healthcare tracking, and health coaching via an app.

Oviva Diabetes Support is a 12-week education and behaviour change programme for people with type 2 diabetes, delivered by a diabetes specialist dietitian and supported by online learning resources and the Oviva app.

Changing Health provides behaviour change programmes for Type 2 diabetes, pre-diabetes, and weight management over 12 weeks or 12 months. The service combines personalised health coaching rooted in behavioural psychology with evidence-based digital education, focusing on sustaining long-term lifestyle change.

Impacts / outcomes

“What we have done is demonstrate the power of near real-time analytics on improving the health of populations.” Dr Tony Willis, clinical lead for diabetes for the North West London Collaboration of CCGs

83% of people in trials completed the OurPath programme and submitted information on weight loss and increased activity levels, both recommended steps to delay the progression of diabetes. At the date of analysis, of those patients that had taken part in the programme for three months, 61% had submitted a weight reading and achieved a mean weight loss of 6.7%, and increased their activity levels by 22%. After six months, 52% had achieved a mean weight loss of 8.2%. Data on the reduction of DNA rates is still being collected and analysed.

The OurPath pilot aims to replicate these successes, helping patients to better manage their disease and ultimately improve their quality of life.

Oviva Diabetes Support has demonstrated high uptake rates, and impact on weight loss, blood glucose and other clinical markers. From 1,453 referrals to date, the programme has achieved approximately 70% uptake. In terms of clinical outcomes at six months post-completion, average reduction in HbA1c (an indicator of blood glucose levels) is 13 mmol/mol  and bodyweight loss is 4.5% (n=85). Initial evaluation of clinical outcomes in North West London indicates that these outcomes are replicated in this pilot, and collection of outcomes is ongoing.

Changing Health saw high levels of self-referral (60% of users recruited), which was useful for case-finding specific patient cohorts with minimal administrative burden for the GP practice. After 12 weeks of service use, active users’ Patient Activation Measures (PAM scores) increased on average by 10 points, from a mean pre-enrolment score of 56 to a mean post-participation score of 66. A one point increase in PAM score correlates to a 2% decrease in hospitalisation and a 2% increase in medication adherence.

At 12 weeks, Changing Health users reduce their HbA1c by an average of 6.8 mmol/mol (0.6% reduction), with an average reduction in body weight of 3.1% over the same period. At six months, this weight loss is sustained. 70% felt their coach helped them identify barriers to change, while 85% of users are confident Changing Health will help them achieve their goals.

It is intended that the findings of the OurPath, Oviva and Changing Health pilots will be replicated across the CCGs, and will lead to significant change in the way patients manage their condition.

The North West London Collaboration of CCGs commissioned an independent evaluation of the pilot, which was undertaken by Imperial College Health Partners

Read the full Evaluation Report: Diabetes Digital Behaviour Change Programmes: North West London Pilot

View the Poster: Diabetes Digital Behaviour Change Programmes: North West London Pilot

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Introduction of a nurse supplied medication programme at Nottingham University Hospitals NHS Trust – NHS England case study

Leading change

A ward manager in the Cancer and Associated Specialties Division at the Nottingham University Hospital NHS Trust led change by introducing a nurse supplied medication programme on the ward. A review of processes, led by the nursing leadership team identified unwarranted variation in the practice of drug collection upon discharge from services which led to concerns regarding patient outcomes, experience and also the cost implications of unused medications. The programme demonstrated better outcomes, better experience and better use of resources.

Where to look

Nursing staff conducting a process review observing that many antibiotic drugs were not effectively dispensed at a patient’s discharge using the existing patient pathway. The unwarranted variation in the collection procedure, including whether they were collected or not, had subsequent patient outcome implications both in terms of well-being but also extending their need for hospital care, following initial discharge.

What to change

The Cancer and Associated Specialties Division admitted approximately 40 to 50 emergency cases per week, with an average length of stay of 1.5 days. With this high level of patient turnover, a safe, timely, efficient and effective patient discharge process is paramount. The nurse ward manager identified the need for change. Under existing processes, the on call pharmacy would dispense medication from another site in the Trust, making the out of hours dispensing of medication less efficient and impacting on patient experience. The ward manager and other nursing staff noted that this led to:

• patients frequently returned home and then needed to return to the hospital to collect their medication
• a proportion of patients never returned for the medication
• some patients were readmitted
• some patients were kept overnight to ensure they were discharged with their medication

In order to improve performance for discharge drugs the team developed a timely out of hours pathway for the Trust.

How to change

The introduction of a nurse supplied medication programme was agreed and a joint venture between the ward manager and the head of pharmacy to create a local agreement, risk assessment and training packages, alongside ensuring an effective medication pathway was undertaken.

A training package was created to enable nurses to supply and check a specified list of medication for specific conditions and as per prescribing guidelines. The aim was to enable patients to receive the correct medication within an hour to facilitate discharge home and prevent unnecessary prolonged hospital stay and prevent readmission. In addition, a further benefit was improved patient flow and an increased bed capacity to facilitate admission of emergency patients.

Link to full article here 

Addressing unwarranted variation in physical restraint use across adult acute mental health inpatient wards – NHS England case study

Leading change

A mental health nurse leader at Salford Royal NHS Foundation Trust has identified and addressed unwarranted variation in the use of physical restraints in mental health services. Introducing additional training and supportive techniques to reduce the use of physical restraints across seven pilot trusts has provided evidence for this work to be rolled out further across the North West of England.

The nursing leadership team have advocated partnership working with patients and carers to reduce the need for physical restraint use as well as empowering staff through additional training, which has tackled the triple aim outcomes of better outcomes, experience and use of resources.

Where to look

A mental health nurse, working both at ward level and as an academic mental health researcher, identified unwarranted variation in the use of physical restraints in mental health services, based on the evidence in the MIND report (2013). Across the country there was variation (from <40 to >3000 restraints used annually per Trust). Salford Royal NHS Foundation Trust, in the North West was in a geographical area where the levels of restraint use were amongst the highest in the country.

What to change

Having identified the unwarranted variation, the mental health nurse leader recognised the opportunity to strive for positive behaviour change on the mental health wards. Nursing teams, supported by Advancing Quality Alliance (AQuA), a regional quality improvement organisation, and by an experienced nurse improvement advisor, led on implementing strategies to observe, challenge and engage the teams in behaviour change management. There was a target to shift the culture of the wards teams in their use of physical restraint as a technique, to avoid use where appropriate to do so, and replace this approach with restraint reduction based techniques.

Guidance has been published aimed at reducing the use restraint of across health and social care (gov.uk website; 2014 Lamb Review). The NICE Guidance (2015) also states “Health and social care provider organisations should ensure that all services that use restrictive interventions have a restrictive intervention reduction programme to reduce the incidence of violence and aggression and the use of restrictive interventions.”

Ward champions within nursing teams worked with patients on the ward to support the development of a ‘My Safety Plan’, a self-management tool to help patients identify triggers, early warning signs and strategies to calm themselves down if they were able, aiming to work closely with patients and carers in a personalised, partnership way.

The mental health nurse leader also supported other nurses and colleagues to use visual data (e.g. safety charts and statistical process charts (SPC)) which helped them to have a broader understanding of the real-time context on the ward. This has helped teams to identify variation and seek solutions to reduce it.

The learning from this restraint reduction programme aims to be rolled out across 5 wards per trust in the North West, supporting an evidence based approach to reducing restraint reflecting a focus to lead and drive research to evidence the impact of what we do, reflecting Commitment 7 in LCAV.

How to change

This quality improvement programme was supported by funding from the Health Foundation. It allowed Salford Royal NHS Foundation Trust to identify ward champions from within the nursing teams to lead on implementing the improvements in prevention, restraint reduction and empowering staff to feel confident in decision making around whether restraint was needed.

The mental health nurse leader was affiliated with the University of Central Lancashire as a clinical academic. Seven mental health trusts across the North West were involved in rolling out the restraint reduction approach; Cumbria Partnership NHS Foundation Trust, Lancashire Care NHS Foundation Trust, Five Boroughs Partnership NHS Foundation Trust, Manchester Mental Health and Social Care Trust, Merseycare, Cheshire and Wirral Partnership NHS Foundation Trust and Pennine Care NHS Foundation Trust.

The nurse leaders (champions) implemented a range of tools from debriefs, safety plans, handovers, community meetings, comfort rooms and increased activities on the wards with an aim to reduce physical restraint on acute mental health wards by 80% by June 2017.

Link to full article here

Improving patient experience through introducing flexible visiting hours hospital-wide – NHS England Case Study

Image: Google images copyright free

Leading change

Nursing staff as a part of a multi-disciplinary team at Aintree University Hospital NHS Foundation Trust identified and addressed unwarranted variation in visiting hours offered to patients and visitors, which was having an impact on patient, carer and staff experience. The nurse leaders have introduced new, flexible visiting hours based on several key factors, initially motivated by feedback received from patients and visitors.

Where to look

Nursing staff gathered information from patient feedback and complaint forms, a divisional engagement event and also through seeking thoughts and feedback from staff. This evidence showed clear unwarranted variation – a distinct difference in visiting hours from ward to ward across the Trust.  Some wards particularly had visiting times which were reported not to be effective for patients, relatives or staff.

The multi-disciplinary team decided to address this unwarranted variation in practice by piloting new visiting hours on two wards whilst working closely with patients, relatives and staff throughout to ensure feedback was adequately captured.

What to change

This lack in consistency of visiting times was proving confusing for patients and relatives, notably if they were being transferred to another ward, which had different visiting hours. Nursing team members in this pilot wanted to get it right for every patient, every time – to take a standardised approach across the hospital on visiting hours.

By identifying this unwarranted variation, the team were able to take steps to address it and to make experiences better; not only for patients, relatives and carers, but for many members of staff too.

How to change

As a result, new ‘core’ visiting hours were introduced across the Trust. The new visiting hours were 1.30pm to 7.30pm and the expected benefits for both staff and patients, which was more patient-focused and demonstrated personalised care tailored to the needs of the patients. The work was implemented as a pilot and gradually rolled out across the Trust.

Link to full article here

Developing a safeguarding application to provide a direct point of access for frontline healthcare staff to the local authority – NHS England case study

Leading Change

The Patient Experience and Quality Manager for NHS England – Midlands and East identified unwarranted variation in the provision of consistent guidance for managing safeguarding concerns, for frontline healthcare staff. The Patient Experience and Quality Manager, and a nurse-led reference group, successfully rolled out an application (app), initially across the East region but then nationally adopted, providing safeguarding support for all staff in the right place, at the right time.

Where to look

The protection of those at risk is a vital part of nursing, midwifery and care staff roles and responsibilities and therefore safeguarding underpins the quality and safety of all health and social care services.

The nursing team identified that staff from a range of organisations were using printed resources to access safeguarding advice, updates and guidance. Due to the changing nature of safeguarding legislation and practice, the printed resources required frequently updating, creating cost implications as well as confusion as to which printed resource was the most current.

The Patient Experience and Quality Manager and subsequently the nursing led reference group recognised that the risk of not having current printed material could be mitigated and resources saved by utilising an electronic application.

The group designed a new app to:

• Enable free, quick and easy access to any local authority safeguarding process
• Enable staff to have immediate access to vital safeguarding information and guidance that was up to date, such as a direct link to any Local Authority safeguarding information
• Minimise delays in accessing information and support and therefore mitigating risks and providing prompt safeguarding support

What to change

The success of the programme was steered by the Patient Experience and Quality Manager working in collaboration with specialist nursing leads from across the adult and child disciplines of safeguarding. This expert clinical reference group provided the driving force for the content and focus of the app as well as significantly supporting the marketing strategy and subsequent national roll-out of the app.

The group developed the app to cover the following three areas: Safeguarding Adults, support on Mental Capacity issues, Safeguarding Children and a staff focused page supporting personal welfare and wellbeing. The end product, a resource that is free for healthcare staff can be easily updated centrally, thereby ensuring that everyone has access to current and key information at the point of access reducing unwarranted variation.

How to change

The app was originally developed for the East region, where the initial pilot of the app was undertaken. The pilot participants, predominantly consisting of the expert group and close working colleagues, reviewed the function of the app and any technical issues regarding functionality. The pilot was very successful, with few significant alterations. The app was then advertised across the Eastern region, where uptake and utilisation increased substantially.

The Patient Experience and Quality Manager identified an opportunity to expand the use of the app and approached the national safeguarding team for NHS England. The app was recognised as a vital safeguarding resource and plans were made to adapt the app ready for national roll-out. The national adaptation was undertaken by creating a wider national nurse, midwifery, care staff and allied health professional safeguarding expert reference group from across England. This wider group enabled access to Local Authority safeguarding information from across England. The app was then advertised via the national safeguarding team and the lead nurses from across the country.

Link to full article here

Improving dementia care through care navigation and social prescribing – NHS England case study

Leading change

Practice nurses at Oxford Terrace and Rawling Road medical group in Gateshead played a pivotal role in setting up an innovative Primary Care navigator role to help support the needs of patients and carers living with dementia.

This is new way of working, in which healthcare assistants (HCAs) are leading changes in practice to deliver a range of positive outcomes for both patients and carers, including increased access to health and social care services, improved dementia screening, individualised care plans and social prescribing.

Where to look

The Gateshead practice serves about 15,000 patients in a largely deprived urban area. Both nurses and GPs realised they needed a new approach to deal with the pressures they were facing, particularly for the growing numbers of patients with dementia. Nationally there is unwarranted variation in the services and outcomes for people with dementia. At this practice there was a higher than average level of unplanned hospital admissions, associated with the complexity of patient conditions in the local area.

What to change

With more people receiving a dementia diagnosis, senior nurses and GPs began to seek an alternative approach to the conventional ten-minute appointments. Many of these patients’ needs related to social care and wellbeing rather than acute clinical issues. Carers weren’t being identified and appropriate support wasn’t being received. Most case finding was undertaken by GPs and senior nurses. Some patients and carers were becoming frustrated, and the quality of care was at risk of being compromised.

Nurses and colleagues decided to develop a bespoke practice-based model by redesigning roles and developing new skills.

How to change

Working with the National Association of Primary Care, the practice manager and her team developed a Primary Care navigator role – targeted to support dementia patients, their families and carers. The aim was to improve their access to the health and social care system, including signposting to wellbeing services through social rather than clinical prescribing.

This was a new departure in General Practice, with no additional funding. Existing health care assistant and receptionist roles were redesigned to undertake this function. Staff were trained to prepare them for the change.

The purpose of the Primary Care navigator role is to:

• Communicate with patients and carers, asking questions and actively listening
• Guide people to sources of help and support, from the most local to national
• Support case-finding through clinical referrals and opportunistic screening
• Develop a directory of services of third sector and other community support available for people with dementia and their carers

Additional patient support includes fortnightly calls or visits, invitations to “catch up” events, contacting support organisations for those who can’t do themselves, and making contact within three days of discharge from hospital.

The practice has now extended the navigator role to support all social prescribing for patients with complex needs. It will be the foundation for implementing a ‘House of Care’ approach to long term conditions, to support self-care and self-management. Gateshead CCG has included the initiative in its primary care strategy.

Link to full article here

Arts for health and wellbeing

Engagement with the arts can make a powerful contribution to a
person’s mental health and wellbeing. This briefing provides an
overview of the ways that NHS Wales is realising this opportunity
and improving outcomes for patients.

Link to article here