What was the aim?

The selected cohort of 120 people have diabetes and are housebound. The objective of the project was to make them more visible to all health and social care organisations and improve their quality of life. 

These patients are recognised as being socially vulnerable – in many cases their carers also need support to help them better care for their loved ones.

Using a population health management approach, we have been able to improve the health and wellbeing of a high-risk group of patients identified by our linked datasets as needing more support.

By using the data to understand more about the group and contacting the patients individually we have been able to offer them a menu of support including: 

  • a discussion about their health with a social prescriber
  • a health check at home
  • Covid-19 and flu vaccine
  • medicine reviews
  • diabetes support using an online tool
  • support using Diabetes UK resources.

Using linked data to understand what people need

The linked data used was general practice, nurse practitioners, social prescribers and the charity sector. It showed the key attributes of people we needed to focus on were:

  • people with diabetes 
  • people who are housebound
  • socially vulnerable.

We chose a cohort of 120 people with the above combined attributes that the data showed were at higher risk of worsening ill health, which has a huge impact on the person and NHS resources.  

  • Number of people seen.
  • Number of social care plans and medical plans created or updated.
  • Number of referrals made and type of referral (unmet needs).
  • Patient and staff feedback. 

  • Increased patient empowerment.
  • Increased access to health and social care practitioners.
  • Increased medicines optimisation and reduced polypharmacy.

  • Reduction in emergency crisis (A&E and hospital admissions).
  • Increased quality of life and healthy life expectancy.
  • Reduced social isolation and loneliness.
  • Reduced system costs.

How did we directly address health inequalities? 

Administrators at the five surgeries involved identified the patients – these patients were often frail and over 50. They needed their blood pressure and feet checked. Some of these patients had good support at home but all benefitted from a chat with the diabetic nurse. 

The nurse practitioner was asked to flag these people to other organisations to make sure their needs were explored, including updating their medicines.

The carer burden was also recognised. Many carers need support, education and training relating to the condition their loved ones live with. This is key to making sure health inequalities are not widened by this burden. 

Who did we engage with and why?  

A wide spread of health and care professionals took part in this project: Associate nurse practitioner, GP and practice staff, social care practitioners, pharmacist, community nurse practitioners, data analysis team from KMCCG, public health and the voluntary sector including Diabetes UK. 

We engaged with patients using the nurse practitioners and diabetes nurse. The social prescriber was able to visit many of the cohort at home enabling them to look at their home set-up, medication, diet and see first-hand how they were living and the support they had.

What did we do and why?

Patients were invited to a health check with a healthcare assistant who carried out a full assessment of their needs and wider determinants of health including food poverty, housing, safeguarding and isolation. Complex patients were referred to the diabetes nurse in the practice. Covid-19 and flu vaccinations were also given at the same time as the health check.

Medication reviews, including how to optimise the insulin dose, were carried out by the pharmacist.

Personalised care plans were completed for each patient including advice on using an online tool for self-management. 

What were patients and residents offered?

  • Health checks
  • Insulin reviews
  • Covid-19 and flu vaccinations
  • Guidance on how to use an online tool for diabetes management. 
  • Carer support, training and education.

How did we evaluate our impact and success and why?

80 per cent of the cohort were offered a health check and received their Covid-19 and flu vaccines at the same time. 

Community nurses and social prescribers worked together and by doing so were able to look holistically at the patient and their needs including the wider determinants of health. 

This integrated way of working resulted in an amazing network of professionals supporting each other, the patient, their families and carers. 

Ramsgate PCN Clinical Director Jenny Bostock said: “If you can keep these patients out of hospital and well that’s really important. It’s been good to focus on these patients proactively, rather than waiting until they are unwell or in hospital to assess them. It’s been great for the nurses to get out and about and do home visits because they have been able to meet people, look at their home life and the support they and their carers need. The project has been great and now we need to keep the momentum going.”

What were the challenges?

  • Time – follow-ups are taking time because this project has uncovered a range of unmet needs that now need addressing.
  • The right people are needed at the table for the project to work. 
  • What can we measure and what is important needs expert analysis – for example, impact on hospital admissions.
  • Commissioning model needs to support integrated work and multimorbidity, not individual components.

What were the learning points?

  • Evaluation takes time but is essential to know if the project was successful.
  • Realising the clinical director cannot do everything – need to draw on different strengths.
  • The right skills mix is essential for success.

Next steps

  • Evaluation questionnaire needs to be posted to assess patient satisfaction and health improvements – revisit this cohort in six months’ time to look at their results again (for example blood pressure) as often these results take time to change.  
  • Investment needed in the role of social prescriber, which will help prevent health deterioration.
  • Upskilling and training – more diabetes nurses needed.
  • Potential for new roles or hybrid roles and upskilling to allow for new ways of working.
  • Often carers need training – they are not qualified healthcare professionals but are expected to administer insulin.
  • Another group of vulnerable patients will be the next focus, for example patients with COPD.