Identification and optimisation of care for adult patients with type 2 diabetes across Moore Green Lane Medical Centre (and affiliated practices) in Birmingham and Solihull Integrated Care System (ICS) through delivery of a data-led quality improvement programme and Multidisciplinary Team (MDT)1 in primary care.
This project between Boehringer Ingelheim Ltd (BIL) and Moor Green Lane Medical Centre (and affiliated practices) aimed to improve patient health outcomes and reduce unscheduled diabetes related healthcare resource use.
The Joint Working project helped to address the strategic objectives of the wider healthcare system through piloting a community-based diabetes MDT model across Moor Green Lane Medical Centre and affiliated practices. The PRIMIS GRASP-DIABETES risk stratification tool identified the patients who would benefit the most from access to review by the MDT in improving their ongoing diabetes management and outcomes.
The project aimed to:
- Improve attainment of the three diabetes treatment targets (HBA1C, Blood pressure, Cholesterol) by optimisation of medicines and lifestyle advice and/or referrals
- Enable access to practice education and quality improvement skills and support
- Improve patient experience and quality of life
- Encourage patient empowerment and ownership of their health
- Reduce demand on secondary care services
- Inform future integrated diabetes service redesign and wider quality improvement initiatives
The pilot started in July 2021 and completed end of March 2023.
Project Outcomes Summary:
The programme ran across 5 GP practices, rolled out over a period of time. A broad range of skills came together in the MDT to review and support identified high risk patients, with a personalised care plan to support their ongoing needs.
During the project, the multidisciplinary team were able to share their knowledge and expertise with each other. This enriched the skills of the MDT and practice staff involved, to optimise the care of patients with Type 2 Diabetes. Subsequently, patients were increasingly empowered to make lifestyle and health changes that were seen in improved attainment of diabetes treatment targets (as a surrogate marker of improved outcomes).
198 patients were managed through the MDT. The population whose cases were discussed and managed by the MDT had a mean age of 60.34 (SD 12.26), were predominantly male and with proportionally higher representation from patients of ethnic minority backgrounds.1
HBA1C: 179 patients had elevated levels. Meaningful reductions were achieved for patients in all groups with an overall mean reduction of 7.5mmol/mol. For patients in the group with the highest levels of HbA1c (>75mmol/mol), this group saw a mean reduction of 11mmol/mol.1
Blood pressure: 44 patients were identified with above target BP. Following MDT review mean reduction in systolic BP of 16mm/Hg and diastolic of 5.1mm/Hg were achieved.1
A number of patients also saw meaningful reductions in their cholesterol levels and BMI.
In a sample of 34 patients who attended the MDT clinic, it was found that onward referral to diabetic outpatients was prevented in 30 (88.24%) of patients. Assuming this rate is reflective of the entire MDT cohort (179 patients) 158 onward referrals to diabetic outpatients were prevented, with a total saving of £28,914 in referrals.2
Boehringer Ingelheim Limited was pleased to collaborate with Moor Green Lane Medical Centre and affiliated practices, and specialists from the University Hospitals Birmingham NHS Foundation Trust, to design and deliver a data-led quality improvement programme and diabetes MDT community-based model to improve patient outcomes in diabetes.
References:
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2023 – BSOL Joint working project Data Evaluation (Data on file)
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2023 – BSOL Joint working project Outpatient Impact (Data on file)
Footnote:
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The MDT included: Diabetes lead GP, referring GP, Diabetes Consultant, Practice nurse, PCN pharmacist, dietician, health coach, social prescriber/link worker
NP-GB-103788 August 2023