Skip to main content

Implementation of an integrated neighbourhood holistic diabetes service to address the complex needs of patients with cardio-renal-metabolic diseases in Salford 

A Joint Working Project between Boehringer Ingelheim Limited and Salford Care Organisation (part of the Northern Care Alliance NHS Foundation Trust), in conjunction with Eccles and Irlam Primary Care Network (PCN) and Broughton Primary Care Network (PCN) to design and implement an Integrated Neighbourhood Holistic Diabetes Service (INHDS) within two Primary Care Networks (PCNs) in Salford. 

This collaboration will support high-risk Diabetes patients with indicators of cardiac disease and renal dysfunction in an INHDS within Broughton PCN and Eccles and Irlam PCN. The project aims to validate a novel method, creating a blueprint for integrated diabetes care provision within the PCNs, improve patient health outcomes, create a primary care workforce for the future, and transform the traditional care model. 

The collaboration will identify, through agreed inclusion and exclusion criteria, the most appropriate patients to benefit from intervention and optimisation through the newly created integrated service. This is expected to reduce referrals to the Acute Specialists and Community Diabetes Service and improve health outcomes for patients, demonstrating proof of concept for wider system transformation. 

This project will aim to mobilise resources for a period of 18 months from January 2023 until end of July 2024. 

Boehringer Ingelheim Limited is pleased to collaborate with The Northern Care Alliance, Broughton and Eccles & Irlam Primary Care Networks to design and deliver this innovative Joint Working Project. 

Completed Outcomes 

Over an 18-month period Boehringer Ingelheim, Salford Care Organisation (part of the Northern Care Alliance NHS Foundation Trust), in conjunction with two PCNs Eccles and Irlam and Broughton have designed and implemented an Integrated Neighbourhood Holistic Diabetes Service (INHDS) within two Primary Care Networks (PCNs) in Salford. This approach focused on a very complex Type 2 Diabetes patient cohort, many of whom had disengaged with their diabetes care and management. 

This collaboration has successfully validated an integrated care model, establishing a workflow in cardio-renal-metabolic medicine to meet the complex needs of the Type 2 Diabetes patient population. This proof of concept for system transformation focuses on:

  • Addressing health inequalities, reducing variations in care, and improving access to expertise delivered by a specialist team within the community.
  • Optimising diabetes care to reduce the risk of complications and providing individualised care planning and management.
  • Developing the culture, skills and resources necessary to promote service integration centred around the individual.

The benefits realized from delivering this service include:

  • Earlier diagnosis of complications and delay of or reduced disease progression.
  • Early intervention and optimised medication management.
  • Improved outcomes for patients with Type 2 diabetes.
  • Enhanced integration and knowledge sharing among primary care and locality workforce.
  • Increased patient engagement and empowerment.
  • An increase of patients with a comprehensive care plan increased from 13% to 100%. Do we need to state these are interim results?
  • An average HbA1c reduction across the population seen of 15mmol/ml 53% of  patients  fell into the High-Risk category due to a HbA1c > 70mmol/ml . As a result of this service this cohort of patients HbA1c was reduced on average from 87mmol/ml to 59 mmol/ml ,a reduction of 28 mmol/ml1
  • Reduction of 7.4 mg/g in ACR (increased level of ACR is an indicator of kidney disease) . 50% more patients achieved an uACR <3 mg/mmol on discharge compared to pre-clinic. 1
  • The number of patients achieving blood pressure targets doubled during the project. On average there was a reduction in systolic BP of 12 mmHg and a reduction of 6mmHg in diastolic BP1. 
  • Non HDLc levels dropped across most patients, on average by 0.4 from 3.1 to 2.7. 23% more patients achieved the target of non-HDLc <41.
  • Average weight loss of 2.6kg (although weight management was not a specified goal)1. 

This project has now been commissioned Locally by Broughton PCN and Eccles and Irlam PCN until March 2025. 

 

References 

  1. Data on File 

 

 

NP-GB-104853   August 2024