Working with hard to reach groups to improve diabetes outcomes

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The challenge

In 2003 King’s College Hospital NHS Foundation Trust introduced a psychiatrist to its diabetes team. By 2009 audit findings showed those people with diabetes who utilised the psychiatry services as part of their diabetes care had improved HbA1c levels. The audit, plus other studies showed that integrating psychological and social care with diabetes care for those with multiple health and social problems, led to an improvement in biomedical outcomes. For instance, by early and rapid facilitation of housing, managing debt or childcare, a case worker can reduce the social drivers contributing to a person’s difficulty in prioritising diabetes. A multidisciplinary group comprising staff from Kings College Hospital and two third sector organisations, Thamesreach and HearSay Charitable Trust were funded by NHS London Regional Innovations Funding Scheme to set up and run a community based service that would address individuals medical, social and psychological care to improve glycaemic control and other diabetes (and non-diabetes) health outcomes.

The aim

The main objective of 3DFD (3 Dimensions of Care For Diabetes) is to deliver a community-based model that integrates medical, social and psychological care to improve glycaemic control and other biomedical outcomes in complex cases.

What did they do?

The team needed to set up the 3DFD service from scratch. They followed a clear process to deliver the new model. Firstly they ensure that key stakeholders were on board with the project and had the opportunity to comment and get involved. They then ensured the right team was in place to deliver the new model, this included recruiting some new staff and seconding some from other organisations involved in the project. The next step was to find the space to hold sessions with patients and for multidisciplinary team meetings. The team then worked with IT departments to embed the service in the hospital’s electronic patient records system. Following this they developed a model of care from referral to ongoing joint working to achieve individual goals. Once the service was ready to go the team spent time marketing themselves to potential patients and healthcare professionals. Finally the team ensured they had adequate data collection and evaluation in place and a steering committee to carry out independent monitoring of the service.

What happened?

Within the first three months of a 3DFD intervention, patients achieved on average a 1% reduction in HbA1c. The team also identified a number of unmet social and health needs including poverty, profound social isolation, undiagnosed psychosis, high levels of risk to self and others such as active suicidal ideation and self harm, co-morbidities such as rheumatoid arthritis, undiagnosed TB and diabetes complications such as painful neuropathy. The level of patient satisfaction has been unanimous - substantiated by patient testimonials. The model has been adopted by the Guy’s and St Thomas’ Diabetes Modernisation Initiative which is redesigning services in Lambeth and Southwark.

Key outcomes

• 1% reduction in HbA1c
  
• Able to identify a range of unmet needs in vulnerable and hard to reach groups
  
• Model adopted by neighbouring trust