This is a Future Hospital case study of how Newham University Hospital improved its Transitional and Young Adult (TYA) diabetes service. The team explain how they improved care through three major incremental changes.Key recommendations
- Patient Champions and peer-to-peer support are crucial to success.
- Support services suitable for 16-19 year olds may not necessarily be suitable for 20-25 year olds; where possible these services should be separated.
- Collaborative working among all partner organisations (including local employers, leisure industry, etc) is essential and requires a high level of commitment and support from staff.
- Flexibility of service is key to engaging 16-25 year olds, as is increased use of digital and social media.
The challenge
A paediatric diabetes service had provided excellent diabetes care for children in Newham since 1986. However, the transition to adult services was poor. The complex needs of adolescents and young adults with a chronic illness like diabetes was difficult to address in routine clinics and non-attendance rates were high with increasing levels of patient and staff dissatisfaction.
The solution
We therefore established a monthly diabetes clinic from 12-6pm, which is staffed by paediatric and adult diabetes consultants with specialist nurses and a dietician, and run flexibly during the afternoon in a community centre. Young people approaching adolescence are seen jointly by paediatric and adult diabetes consultants and gradually transferred to the TYA service. Appointments are made at times convenient to patients and carers - like holidays, lunchtime or after work.
A specialist nurse support service is available Monday to Friday at the Diabetes Unit, which is based in a community centre. All newly diagnosed patients between 16-25 years are referred directly from primary care, or by parents, or in some cases as self-referrals to the Diabetes Unit. Evening clinics, walk-in services and regular follow up appointments are offered. Telephone, text and Skype contact is offered routinely. Near patient blood testing for Hba1c is offered in the clinic and retinal screening facilities are available on site.
Building on the success
We were invited to participate as one of 14 National Pilot Sites for the You’re Welcome project in 2010. Through three focus groups we identified a need for improved ease and flexibility of access to acute services, peer support groups and a more holistic model of care.
In response to this feedback we embarked on a programme of work to re-shape our service to better meet the needs of our patients. In November 2010, we held a multi-agency stakeholder workshop (including patients, carers, local colleges, commissioners, public health and the police) to develop a five-year plan for local Young People’s Diabetes Services.
We have also recently developed an information leaflet on what to expect from a consultation, which is sent out with appointment letters. An online discussion forum, where patients can share experiences and provide peer support, is in development.
Innovating for the future
Thanks to a UCLP Guttman Academic Collaboration Grant we have explored the scope and feasibility of a peer-supported diabetes self-management programme for 16-25 year olds, using a “story sharing” model. Working with a range of local partners, including the local leisure centre, we ran monthly, evening drop-in groups for two hours at local community venues, which were co-designed with young people. Young people were able to discuss a range of health and non-health issues. The findings from this work are being used to redesign the service with the help of local commissioners. We have also explored the potential for diabetes appointments to be done via Skype.
In detail: Providing young adult diabetes support via Skype
Building on a project supported by the Health Foundation, we have now received funding from the NIHR for a piece of work to examine the clinician-patient dynamics and organisational impact of providing online care.
Challenges faced
Newham has one of the youngest populations in the UK, with 30% of the population aged under 20. 42% of children under the age of 16 live in poverty. In 2008/9, the DNA rate for the TYA diabetes service was between 37-50%. There was frequent A&E use by patients aged 16-24. Findings from local focus group and community surveys pointed to disengagement, poor self-management and dissatisfaction with health services.
More than two-thirds of the local population is from BME groups, largely South Asian. The dual impact of genetics and environmental factors has led to a higher than national prevalence of type 2 diabetes in young people.
Service size
The service works with any patient between the ages of 16 and 25 years with diabetes in the borough, currently around 215 people.
Project
All patients between 16-25 years are offered online follow up via Skype where clinical examination is not required. Patients who repeatedly failed to attend the Young Adult Diabetes Clinic, based on information from the diabetes database and the hospital EPR system, are also identified and offered the option of online consultations. Patients are encouraged to contact the service via Skype in an attempt to improve engagement and self-management.
Service implications
- 1644 Skype appointments (Diabetes Specialist Nurse and Consultant) involving 104 patients after two years.
- Overall DNA rate is 13% for scheduled appointments, a reduction from a baseline of 25%.
- Some indication of a trend towards lower A&E use among people receiving Skype consultations.
- Initial promising results showing that of the patients who had over two webcam appointments, the average Hba1c reduction was 5 mmol/mol suggesting increased use of medication as prescribed and improved self-management.
We gathered feedback through focus groups, interviews and questionnaires:
- [Skype is] “great for diabetes. Previously it meant taking a day off university to come to clinic.”
- “I don’t think the consultant or the nurses actually realise, their whole attitude changes when they are in the consultation clinic, they have got the papers in front of them, they are fiddling with that, they are reading through it, but when they are on Skype they just look straight at you and they talk at you.”
- “Skype has helped to change my mind set in terms of management. There’s no excuse for missing appointments now.”
- “I feel better controlled since using Skype and less anxious.”
The Royal College of Physicians’ Future Hospital Programme aims to promote new models of delivering medical care in hospital and community settings. The programme is seeking to collect and share examples of teams and individuals who are delivering care in innovative ways to improve patient care. You can read all the case studies at: https://www.rcplondon.ac.uk/projects/future-hospital-tell-us-your-story