Maria Medina – i2i Diabetes Award Winning Case Study

Brief summary of the project

I started my diabetes clinic in April 2017, but it was a little bit later when I used the ABCDE methodology to set my scope of practice, aligning with the studies for the certification as an independent prescriber . Despite being challenged with results that are sometimes only obtainable several months or maybe years after the interventions placed, I was still confident that a pharmacist-led diabetes clinic would produce sufficient data to demonstrate the optimisation of costs, generated or foreseen, which in the UK accounts for around 11% of the annual NHS budget with 51.5 million items dispensed in 2016 for the management of diabetes in primary care. My main long term objectives were reducing part of the 80% currently spent on managing complications of the disease with the implementation of a structured education programme for patients and the implementation of an optimisation clinic, that would ensure an individualised diabetes management plan at all stages of the disease for all the patients registered at the service (88 at that time). Short term objectives would include reducing the expenditure of the service derived from the transport of patients outside the prison to the diabetes centre at the hospital and the wait that security issues may have imposed before they could be transported for assessment. The practice currently pays an average of £200-£250 for 24-hour escort and about £1,100 for bedwatch cover, expenses that could be easily reduced by ensuring that patients had access to a diabetes service on site.

Implementing the ABCDE methodology

Agreed Scope 

Deliver a diabetes clinic with the objective of reducing the need of prison transport to the hospital for review of complex cases.

Buy-in 

This was an easy process as the department was very supportive of me gaining the certification as an independent prescriber. I also had to involve the diabetes centre to understand the type of patients they received referrals for and the team of local nurses and HCAs, who would play an important role in supporting the diabetes clinic by helping with the assessment of patient’s observations (weight, blood pressure, blood tests), and support to facilitate patient engagement after being seen for a medicines optimisation review.

Conduct Preparation 

The preparation was very much aligned to every step of the course for my certification as an independent prescriber and included a very thorough personal review of the skills that I needed to enhance to ensure safe practice and a needs assessment review of the service to identify the gaps that would require input and by which member of the team to ensure the provision of a holistic diabetes care service

Deliver 

I was very lucky to work with Soar Beyond in the design and edition of a diabetes review template and clinical searches, so I could  start early on working with this fantastic support system that has also marked which methodology I would follow for the implementation of other clinics in the future.

Evaluate Outcomes

The clinical searches have been key to identify what was still needed, which care processes were usually missed, which types of patients the practice would need to focus on, but maybe the most significant outcome has been to guarantee that all diabetic patients were appropriately coded in the system, which at the same time will help organise the diabetes consultations after generating clinical audits for review of the 9 key care processes recommended by NICE and the national service framework for diabetes.

Clear and measurable patient / medication-related outcomes

All diabetic patients can now be regularly reviewed to ensure that they receive the 9 key care processes recommended by NICE and the national service framework for diabetes.

Patients that did not have access to a structured diabetes education programme will soon attend our first session planned to start this year.

I am now responsible for the initiation and optimisation of insulin regimens at the service, which was previously done at the diabetes centre outside the prison, or done locally with the support of the diabetic centre. The difference is now that I am able to provide a more personalised service with more regular follow-ups and tailored support without the need for transport outside the prison.

A template for the monitoring of blood glucose levels is now in use and has been a fantastic introduction that has helped during the optimisation of insulin doses (previously it was difficult to understand if the, sometimes very sporadic, levels were pre-prandial or not, the insulin dose that had been administered (if changed) and even changes in exercise, diet that could affect the levels. During the diabetes clinics it has also helped to show patients their personal graphs of glucose levels (their trend) and how far/close they were from the targets.

How did the i2i Network help you achieve these outcomes?

My interaction with the i2i Network has been invaluable, not only the methodology that I can now more confidently use to design and implement new clinics, but the networking opportunities that have allowed me to work and learn from other practice pharmacists has drastically enriched my professional perspectives and skills whilst giving me the support I needed to more assertively set my scope of practice, better prepare for the services planned and be the motor to promote and put into action the required changes at the practice. I cannot be more grateful to the i2i Network!