Older people with diabetes are receiving an improved standard of diabetes care in NHS Sefton (previously Sefton PCT) as a result of the development of a structured care process. The service was developed to address the needs of patients with diabetes who are housebound, in nursing or residential homes, or have difficulty accessing care for their diabetes generally.
Need for the initiative
NHS Sefton has a higher percentage of people over 65 years than the North West average: 22% of the total population of 277,421. Furthermore, projections for 2029 show that this is likely to remain the case versus both the North West and nationally (see Figure 1).1 A large proportion of these older patients have co-existing physical and mental health problems, with poor mobility, thus making access to all areas of healthcare difficult.2,3 The geographical area also has a large number of nursing and residential homes, which is associated with a higher proportion of patients with diabetes.4
An external service review of diabetes services in North Sefton highlighted deficiencies in the care afforded to older housebound or residential care patients. The complex needs of these patients with diabetes was often confusing for home staff, who were rarely given education in how to deal with diabetes, until a patient was admitted to the home. Existing service provision meant there was insufficient time for experienced personnel to visit care homes on a routine basis, and visits were usually called for in response to an urgent medical need.5 Furthermore, a local audit of people with diabetes who were living in nursing or residential homes found only 57.7% had completed annual screening for diabetes within the previous 12 months.6 The audit also found that, of 21 general practices, only one-seventh could identify their housebound patients with diabetes.
These findings support evidence that structured care provision in older people with diabetes, particularly those who are housebound, or in residential or nursing homes, is wanting.7,8
The provision of care and access for people with diabetes who reside in nursing or residential homes, or who are housebound, should be on an equitable basis with those who neither live in care homes nor are housebound.9–12 Patients with diabetes who have difficulty in accessing structured care for this condition are more likely to have poor control, which, in turn, leads to poorer outcomes and prognosis.10 Elderly patients with diabetes have higher levels of microvascular and macrovascular disease and are two to three times more likely to need hospital admission than their counterparts who do not have diabetes.5 There is some evidence available of excessive mortality rates in elderly patients with diabetes, with cardiovascular and cerebrovascular disease being the cause in a significant number of cases.13
Figure 1: The percentage of people in England, the North West, and Sefton aged over 65 years in 2006, and projected values up to 20315
|Data obtained from National Statistics–subnational population projections for England. www.statistics.gov.uk/statbase/Product.asp?vlnk=997|
A pilot study was undertaken in 2002 to address the difficulties identified in relation to the large number of housebound or residential care patients with diabetes, who had difficulty accessing care.14 Results of the pilot enabled:6
- development of an on-site assessment incorporating annual review
- design of the assessment format
- development of a database to maintain assessment and onward referral records
- identification of people with diabetes in nursing/residential homes.
The pilot study demonstrated the feasibility of the initiative and provided evidence that on-site nurse assessment, at home and in nursing/residential homes, could contribute to equitable care for older people with diabetes without insurmountable costs. It also highlighted the need to increase knowledge levels and skills of staff in care homes.
The structured care service
A proposal was developed to employ three full time equivalent nurse practitioners. The aim was to develop diabetes services for those people with the condition who were in nursing or residential homes, or who were housebound. The objectives of the service were to:15
- identify all those diagnosed with diabetes who were housebound (permanently or temporarily), or in nursing or residential homes
- initiate annual reviews for these patients; to be undertaken either by diabetes nurse practitioners or by suitably trained healthcare professionals
- manage diabetes control and pharmacological review as per agreed protocols for the optimisation of treatment, depending on individual circumstances
- implement early interventions for patients newly diagnosed with diabetes
- manage referral to, and liaison with, the wider diabetes management team, and other social support and healthcare professionals
- educate and support patients and their carers, to increase perceived empowerment, satisfaction, and quality of life
- improve education of staff groups, including those within nursing and residential care homes, to increase skills and confidence in diabetes management and undertaking of annual review.
The skills of the specialist diabetes team, district nurses, and senior staff in care homes are are now being utilised effectively so that people with diabetes who are housebound or in nursing or residential homes are managed in a systematic and structured manner. Referral criteria and an information leaflet have been developed to ensure wider understanding of the service and appropriate referrals.
The pilot study, which was initiated in 2002, was rolled out across Sefton PCT (now NHS Sefton) in 2004, and an audit of the results was performed in 2005-2006. The audit demonstrated that 100% of people with diabetes who were aged over 65 years, and were either in nursing or residential homes, or were housebound, had undergone an annual review. This was carried out either by a diabetes specialist nurse, or at a GP surgery or hospital; this compares with 57.7% of people prior to the development of the service.
In the first year of the service, glycated haemoglobin (HbA1c) rates improved in the target population: 68% had an HbA1clevel of ?7.4%.
The service has ensured that all identified patients now undergo a comprehensive diabetes annual review, followed by a management plan, and a minimum of a 6-monthly follow up with HbA1c measurements if appropriate. Both acute and chronic disease can be managed, with particular emphasis on the impact of diabetes on the individual. Referrals for further care or investigations and early intervention (e.g. GP, dietician, or for fundoscopy, chiropody) are made, and drug treatment changes are recommended to the GP.
Building links with nursing or residential care has increased direct referrals to the specialist service and led to improved treatment and understanding of diabetes by staff members. This has enabled the vulnerable housebound and nursing/residential home patients to access wider healthcare and specific diabetes care more easily, thereby reducing GP visits. Liaison with the patient’s GP and primary healthcare team is maintained and a joint approach is working well. Improved recording and awareness of housebound patients in general practice has also been a positive result of our interventions, with most surgeries now actively looking to identify and code this group of patients.
In 2006, the reconfiguration of Sefton PCT (now NHS Sefton) has led to service changes across the borough. A review of provision of services for people with diabetes in the borough is in progress and the aim is to redesign services in order to provide an equitable service for all people with diabetes, including those who are housebound, or living in nursing or residential homes.
- National Statistics website. Subnational population projections for England. www.statistics.gov.uk/statbase/Product.asp?vlnk=997 [accessed 23 January 2009]
- Sinclair A. Diabetes mellitus in senior citizens—a major threat to personal independence. Br J Diab Vasc Dis 2005; 5 (1): 3–5.
- Gregg E. Review: physical disability and the cumulative impact of diabetes in older adults. Br J Diab Vasc Dis 2005; 5 (1): 13–17.
- Sinclair A, Gadsby R, Penfold S et al. Prevalence of diabetes in care home residents. Diabetes Care 2001; 24 (6): 1066–1068.
- Tattersall R, Page S. Managing diabetes in residential and nursing homes. BMJ 1998; 316 (7125): 89.
- Stott A. Addressing care deficiency issues in diabetic patients residing in nursing and residential homes. Available at: www.cmtpct.nhs.uk/bestpractice/VLTC.htm
- Sherriff P, Allison J, Large D et al. Out of sight—out of mind? Elderly patients with diabetes in nursing homes. Pract Diabetes Int 2000; 17 (3): 73–76.
- Benbow S, Walsh A, Gill G. Diabetes in the institutionalised elderly: a forgotten population? Br Med J 1997; 314 (7098): 1868–1869.
- Department of Health. The NHS plan. London: DH, 2000. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002960
- Department of Health. National service framework for diabetes: standards. London: DH, 2001. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002951
- Department of Health. National service framework for older people. London: DH, 2001. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066
- Department of Health. National service framework for diabetes: delivery strategy. London: DH, 2003. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003246
- Morrison L, Cunnington A. Macrovascular disease at diagnosis in elderly diabetics. Diabetes Today 2; No. 1 Spring 1999.
- Stott A, Seed S, Fischer S. Pilot study of care in nursing and residential homes. Diabetes Primary Care 2001; 2 (4): 107–110.
- Department of Health. Improving diabetes services: the NSF four years on. London: DH, 2007. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_072812 G