POPULATION HEALTH MANAGEMENT MODEL USED TO EMPOWER DIABETIC PATIENTS TO TAKE CONTROL OF THEIR HEALTH

Summary

A personalised care planning approach was introduced within the Sowe Valley Primary Care Network (PCN) to empower patients aged 20-39 with type 2 diabetes and a BMI over 30 to better manage their condition, aiming to reduce the risk of long-term complications, as well as minimise GP appointments and A&E visits. The project’s objective was to improve health outcomes by training social prescribing teams to guide conversations with patients and create tailored care plans. The initiative led to significant improvements such as reductions in blood glucose levels, diabetes distress, and weight loss. 

Why was change needed? 

The project was initiated to address the increasing number of patients with type 2 diabetes and related complications such as heart disease, eye problems and kidney disease within the PCN. Many individuals with diabetes face challenges in managing their condition, which often results in a cycle of frequent GP appointments and hospital admissions. By embedding a personalised care planning approach, the project aimed to help patients take control of their health through a more tailored, holistic approach. This was particularly important for the identified cohort; individuals aged 20-39 with type 2 diabetes and a BMI over 30, who are at high risk for long-term complications, including cardiovascular issues and diabetic neuropathy. The need for a more proactive and patient-centred approach was evident, as these individuals often struggled to engage with traditional care pathways. Additionally, by using a population health management model, the project aimed to reach individuals at risk and provide them with the necessary support to improve their long-term health outcomes. 

What did we do? 

The project involved multiple stages, starting with inviting eligible patients to participate. Guided conversations were carried out by the social prescribing team, providing each patient with a physical assessment and the opportunity to discuss their health concerns and goals. These conversations formed the foundation of the personalised care plans, which were co-developed with the patients. A variety of referrals followed these initial conversations, directing patients to the relevant services, including nutrition advice, diabetic nurse support, healthy lifestyle interventions, and mental health services.

Over the six-month period, the project tracked key metrics such as blood glucose levels, BMI, and weight. Participants showed promising results, with 53% experiencing a reduction in blood glucose levels and 52% demonstrating a decrease in diabetes-related distress. Furthermore, 38% had a reduction in BMI and weight, with some individuals experiencing significant weight loss.

The project also explored barriers to participation, particularly focusing on socio-demographic factors that may have influenced engagement, such as high deprivation areas and ethnicity-related challenges.

What's next? 

The next step is to expand this personalised care approach, focusing on improving engagement strategies, particularly for underrepresented groups, and refining the programme to include more targeted interventions that address specific challenges identified during the project.