Telehealth Projects

Drs Peter Winocour and Andrew Solomon DSNs Anne Currie and Dawn Hardy Project Manager Karen Moore-Haines Young Adult Support Worker Claire Renshaw Diabetes Telehealth Team NDA 2014-15 findings in England ( and ENH) : Completion of 8 care processes 40% (35%) HbA1c < 58 mmol/mol (< 7.5%) 31% (34%) Offered structured education 33% (35%)

150 standards in NICE T1DM guidelines !! These include diagnosis, CYP care , pumps , CGMS , education , hypo awareness , other AI screening , psychology , pregnancy , microvascular and macrovascular complications , emergency care , exercise , driving , occupational and higher education issues Target HbA1c now set at 48 mmol/mol (6.5%) Comparing HbA1c outcomes across Europe

McKnight et al, Diabet Med 2015 In children and adolescents with established T1DM No impact on HbA1c at 12 and 24 months Low uptake , high cost Previous studies of psychological interventions in those with poor control found no impact Christie et al . BMJ Open , 2016 Retinal screening DNA rates : 15-30% aged 16-19 and 25-38% aged 20-25

Referable retinopathy after DRS : 4.5% aged 15-25 and 8.2%* aged 25-34 *Highest of all age categories Higher prevalence in 18-30 than < 18 yrs old NDA registrations T1DM were 8% < 15 , 6.5% 16-20 and 14% 20-30 Many T1DM diagnosis aged > 18 never under paediatric care BpT operates till age 19 then .. ! Audit of 77 T1DM transferred from transition

to adult care in 2006-12 Delays in YAC appointments , high DNA rates 20% lost to follow up at transfer 2016 review 25 of these 77 cases aged 22-28 years old remain disengaged For HCP to understand their individual issues that hinder engagement - dont make assumptions !

Individualised person-centred care planning Relationship building and needs-based assessment Problem solve difficulties in self-management ? Peer support mentoring through transition Telehealth support and appts, inc out of hours Proactive information issues, events, developments Young adult support worker to navigate through the system Avoid negative directive consultations and offer gender appropriate care if requested DUK 2016 Meeting healthcare needs of young people with type 1 diabetes

? Estimated 2600 with T1DM ? 800 aged 16-30 Currently 1342 under acute specialist care of whom 413 (31%) aged 16-30 Potentially 200 (48%) of these were identified from records initially and

considered disengaged Ashwell Baldock Courtenay House Orford Lodge Portmill Regal Chambers Knebworth & Marymead Birchwood Garden City Nevells Road

Sollershott Whitwell East and North Hertfordshire CCG Map Bedwell Medical Centre Canterbury Way Chells Way King George Manor House Shephall Way St Nicholas Health Centre

Stanmore Medical Group Symonds Green Health Centre Burvill House Lister House Potterells Medical Centre Wrafton House Bridge Cottage The Garden City Hall Grove Peartree Lane Spring House

Puckeridge Buntingford Medical Centre Orchard Castlegate Hanscombe House Wallace House Ware Road Watton Place Haileybury College Hailey View Amwell Street

Park Lane Church Street Dolphin House The Maltings The Limes Church Street Parsonage South Street The Health Centre Central Surgery

The Maples Cromwell and Wormley High Street Stockwell Lodge Warden Lodge Cuffley and Goffs Oak Abbey Road Stanhope Disengaged - Young Adults Objective

Contact with a member of the health care team via the Young adult support worker or DSN. Improved attendance for clinics Improved attendance for routine blood tests and other screening tests including retinal screening. Reduction in hospital admissions with DKA all DKA admissions reviewed by project consultants. Improved patient experience. At least 10% Engagement Getting Started

Identifying patients for inclusion (initial estimate 250 pts) Criteria for inclusion - Admitted with DKA, - Not attended Retinal Screening, - No Bloods or Micro albuminuria taken in last 15mths, - Not attended 2 consecutive appointments, - Hba1c higher than 75mmol/mol, - Benefit from a more flexible approach Contacting the practice for engagement Practice meetings / discussions for further knowledge on patient history Invite leaflet sent out to patient (includes process to Opt out) Baseline form completed on patient

Wellbeing and DAWN questionnaire completed 6 month follow up form completed Final 12 month form completed Practice Engagement Excellent engagement from practices identifying young adults suitable for the project. Focused initially on the localities closer to the Lister and New QE2 hospital. Approximately 1-5 patients included in the project, per practice. Figures to date:

Total Total Number of Young Adults reviewed 341 Reviewed and not included 160 Currently identified Young Adults for Project

181 Total number of Young Adults sent invite leaflet 181 (100%) Patients removed from Telehealth 16 (9%) Total number of patients to Opt out

5 (2%) Total number of patients who have had initial engagement & baseline proformas 81 (51%) Gender Age

Key Messages to date: Very low number of patients Opting out of the project (2%) Very positive response so far from YAs who are keen to reengage. Increasing uptake in medical technologies and carb counting course, 28 patients out of 81 (35%) Patients are very keen to communicate via text and phone, a few interested in using Skype or Skype messaging. Some have shown interest in Whats App but current Trust policy does not allow this technology.

Role of the Telehealth DSN

Offer a flexible approach to patient management Agree patients priorities Agree clinical criteria for improvement Improve engagement with HCP Use of different methods of communication Use of apps 3hr carbohydrate awareness course Access to newer insulins Offer flash glucose monitoring (Libre) or Dexcom CGMS Use of Diasend for remote consultation

Initial summary of patients needs / requirements Patients want face to face consultations at times convenient to them A general feeling of low morale Diabetes is not top of their agenda Interested in new technology Large proportion of patients with mental health needs High proportion of disengaged patients following transition Issues with appointments trust cancellation policy Wanting a cure for Diabetes!!

Role of the Young Adult Support Worker To work holistically with young people. Provide a support service focusing on everyday lifestyles. Ensure patients are aware of current support aimed at young adults provided by the local county council, NHS Trust such as Diabetes education programs . Ensure patients are aware of current support aimed at young adults provided by national based support such as Diabetes UK and JDRF. Assisting with self-help approaches with diet control, glucose monitoring, clinic appointments and emotional support. Signpost young adults to appropriate services and assists with completing forms and making contact with services on behalf of the young adult, if appropriate.

Communication with the Young Adults to the YA Support Worker will be via phone calls, text messaging, SKYPE, email and face to face contact. Case Study Young Adult Support Worker Pre Telehealth Diagnosed diabetes in 2013 Single parent Minimal family support Poor mental health

Year of diagnoses HbA1c 65mmol 5 months later 95mmol HbA1c levels between 65 118mmol 2014 2017 15 admissions Post Telehealth 2017 1 admission (January pre telehealth) Post telehealth 83mmol No admission & full engagement

Admissions to hospital Any Questions?

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