Optimising a patient pathway and outcomes using Accu-Chek Care

Profile

A Community Specialist Diabetes Service in the Lancashire and South Cumbria Foundation Trust has used Accu-Chek Care to make timely and effective clinical interventions remotely.

The Specialist Diabetes Service has a caseload of over 1,000 patients. The service runs 15 clinics per week for its patients, who are above their target blood glucose range and need additional, specialist support. The service offers home visits and supports district nurses.

Challenge 

Prioritise and manage high-risk patients remotely in between appointments

Before using Accu-Chek Care, patients would have their first 1-hour appointment, followed by an appointment every 8-9 weeks, with no review for medication titration or clinical intervention in between.

The lack of timely and accurate blood glucose data made it difficult for the Diabetes Specialist Service Team Lead and her colleagues to monitor patients in-between appointments, and made clinical interventions sub-optimal. This delayed the time it took to achieve optimal diabetes management, often leading to patients staying in the service longer than necessary.

The typical patient pathway below illustrates how the average discharge from service is 9-12 months.

Results 

Improvement in remote management of patients after using Accu-Chek Care

With access to accurate, real-time diabetes data on Accu-Chek Care, members of the Diabetes Specialist Service Team were able to make timely and effective clinical interventions remotely. 

The team were also able to better risk-stratify patients, using the Platform to highlight patients with the highest need, enabling early remote intervention. 

One patient in the service, after the Service Team identified them as high-risk using Accu-Chek Care, was able to be intensively managed with four in-person and remote appointments within an 11 week period. The patient demonstrated an improvement in the percentage of blood glucose values in range from 14% to 71% in five months. 

After eight weeks, and following medication adjustments, 30% of the patient’s blood glucose values were in range and their HbA1c levels decreased from 80 to 69 mmol/mol. Previously, the patient would not have been seen during this eight week period.

The patient pathway below illustrates how the healthcare professional intensively managed this patient using Accu-Chek Care.

Overall, implementing Accu-Chek CAre has resulted in healthcare professionals in the Community Specialist Diabetes Service being able to identify high risk patients, and provide these patients with timely and effective remote clinical interventions. This has led to patients being discharged from the service sooner.