ImprovingDiabetesManagementinCareHomeswithinSwaleCCG

AnEducationModeltosupportUnregisteredPractitionersinDiabetesCareandDelegationof

InsulinAdministration

June2016

Authors:SarahGregory,DiabetesSpecialistNurse(LeadFacilitator)-BeniKentKarenPaine–LeadNurseLongTermConditions–KCHT

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1. TheCaseforChange

Anincreasingnumberofpeopleareneedingsupporttomanagetheirdiabetesduetootherconditionsthataffecttheirabilitytoself-care,suchasdementiaandarthritis,ortheyarelivinginacarehomeandrelyingonCommunityNursingTeamstodeliverinsulin(DiabetesUK,2010).Communitystaffarelikelytohaveagrowingcaseloadofpeoplewhorequirethissupport-itisthereforeimportantthattheyhavetheknowledgeandskillstogivetherightcaretopeoplewithdiabetes,ortodelegateinsulinadministration.

In2010DiabetesUKpublishedadocumenttoimprovestandardsofcareinCareHomes(‘Diabetesincarehomes:Awareness,screening,training)toimprovethestandardsofcarewithinresidentialsettingsandtoreducethenumberofhospitaladmissions.Recommendationsfromthedocumentincluded:

• Individualisedcareplanning• Screeningfordiabetesonadmissionandeverytwoyears• Appropriatediabetes-specifictrainingforallstaffinthecarehome

SwaleCCG(coveringSittingbourne,SheppeyandsurroundingVillages)represents19GPsurgeries,providingcareto106,000patients.Swalehasanaveragepopulationofelderly(over75)althoughthisisexpectedtoincrease.Thereare3NursingHomeswithintheCCGand33ResidentialHomes(includingthoseforpeoplewithLearningDisabilities).SwaleCCGhavecommitted(throughtheirPatientProspectus)toreducehospitaladmissionsintheelderlypopulation,andtosupportcarehomes.IntheAutumnof2015,theLeadNurseforLongTermconditioncarriedoutaprocessmappingexercisefollowingareviewofthenumberofpatientsreliantontheCommunityNursingteamtoadministerinsulin.TheCommunityNursingteam,localitywidewereundertakingover50visitseverydayacrossthelocalitytoadministerinsulin.Mostinsulinvisitsaredelegatedtojuniorstaffgrades3and4.Howeverhighergradesdovisitbecauseofthevolumeofvisits,andthishadanimpactonresourcesandhowthepatientswerebeingmanaged.Therehadbeeninstancesofinsulinbeinggivenatthewrongtime,oronsomeoccasionsmissedaltogether,resultinginanincreaseindiabetesinsulinreportingfortheLocality.Patientschoiceandqualityoflifewasalsobeingcompromisedastheywereunablechoosetoeatwhentheywerehungry,oriftheydideat,duetothevolumeofvisits,andinsulinbeingadministeredlate,theywerehavinghypoglyceamic,andorhyperglyceamicepisodes.

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Theprocessofthemodelisdemonstratedbelow:

Figure1:ProcessMapping(KarenPaine,LeadNurse)

2. IdentificationofCareHomesIdentifyingthehomesinneedofsupportwasfairlystraightforward–throughsurveyingthehomes,CommunityNursinginputandconsideringtheopportunityforimprovement.Sixcarehomes(residential)wereidentifiedbytheLeadNurseasneedingsupportinthemanagementoftheirresidentswithDiabetes–particularlyinrelationtotheadministrationofinsulin,currentlybeingundertakenbytheCommunityNursingTeam.Poortimingofinsulin,orinadequatemonitoringofdiabetes,wasincreasingthenumberofhospitaladmissionswithinSwaleCCG,aswellascausinginappropriatechangestoinsulinregimesandincreasingGPvisitsandSpecialistnursinginterventions.Theprovisionofhighqualitydiabetescareisreliantoncarehomeshavingaccesstothelatestclinicalevidence(DiabetesUK,2010).Itisnotunusualforcarehomestohavenodiabetestrainingstructureinplace,andthisisprobablyduetobudgetaryissues.InSwaleCCG,therehasbeenminimalinputintocare

Karen Paine version 1

Why • Extensive use of agencies to undertake essential early morning visits

• Current workforce having to do overtime

• DATIX in Care Homes related to diabetic patients

• Homes dissatisfied with service provision - late visits

• Specialist nurses complaining about having to change regimes to accommodate nursing visits rather than patient need

• X number of patients in Care Homes needing visits

Actions • Met with PJ and DG to discuss KCHFT undertaking training in Care Homes • Requested support from HH • Discussed at all Lead Nurse meetings - accountability of competencies highlighted • Discussed with CSD MC - took to KCHFT legal dept • Disclaimer written by Legal Team • Funding application to Sanofi rejected • Funding application to Paula Carr accepted • Scoped Homes for Diabetic patients • Discussed carers administering insulin with Care Home managers • Discussed insurance with Care Managers • Sourced external training • Facilitated pharmacy technician observing competencies for further assurance • Added disclaimer to documentation • GP wrote prescription on home mar chart • Generic and record of drugs sheet in homes in addition

To Do • Residents remain on caseload • Rolling annual training programme • 6 month competency review • Escalation process for residents for quality and safety assurance • Evaluation of Project for Blood sugars, pressure and HBA1C

Diabetes

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homesregardingdiabetescare,andthishascomemainlyfromCommunityNursingteamswhomayalsolacktheexpertisetodeliverytraininginthisarea.CommunityMatronshavegenericknowledgearounddiabetesmanagementandcare,andwhiletheyareabletoadvisestaff,theyarenotcommissionedtodelivereducationinthissetting.CareHomeshavearesponsibilitytoensuretheirstaffaretrainedtomanagetheconditionswithwhichtheirpatientspresent,-howevergreaterclarityisneededaroundthestandardofeducationrequired.Thislackofclarityhasahugeimpactonpatientcareandoutcome,anduponthewiderhealtheconomy,namelyCommunityServicesAsisoftenthecase,budgetimplicationsmeantthatthehomesidentifiedasneedingtrainingandsupportwereunabletoallocatefundingtospecifictraining.FollowingnegotiationswiththeCommunityTrust,CCG’sandIndustry,theLeadNursesecuredfundingfromIndustrytosupporttheinitialtrainingmodules,withtheCommunityTrustagreeingtosupportthetrainingwithapharmacytechnician–tofollowuponthetheoryofthetrainingandto‘handhold’staffuntiltheyfeltfullycompetentinadministeringinsulin.Therefore,theprojecthadthefollowingpurposes:

• ToclarifytheroleandabilityofUnregisteredPractitionerscaringforpatientwithdiabetes• FortheCommunityNursingTeamtodelegateinsulinadministrationtoUnregisteredPractitioners• Toreducethenumberofhospitaladmissionsand999callswithinSwaleCCG• Tomakesureeachpersonisreceivingtherightdiabetescare–thecaseforchangeinSwalewas

triggeredbyapatientcasestudyoutlinedonPage5

Figure2–DevelopmentofProject

Identi+icationofCareHomesinneedoftrainingSept2015

Evaluationoftrainingandmodelwritten

Deliveryof4moretrainingmodules

March2016

MeetingwithTraining

CompanytodevelopamodelofeducatiionOct2015

Employmentofpharmactytechncians

FurtherfundingsoughtandMatronon

board

EvaluationofInitialTrainingNov2015

InitialTrainingdeliveredNovember2015

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CaseStudy–MrSmithMrSmithisanewresidentinoneofthecarehomes.Hehastype2diabetes,heartfailureandCOPD,aswellasadiagnosisofdementia.Heisindependent,andfrequentlytakeshimselfoutofthecarehomeenvironmenttotheshopsandlocalpublichouse.Hewakesveryearlyinthemorningandlikestohavehisbreakfastatabout5am.Hebuyslotsofsweetthingsandalsopartakesintheoddalcoholicbeverage,whichisallverynormal,andshouldnotbeanissueforsomeoneintheirownhome.TheCommunityNursingServicehadbeenvisitingthreetimesadaytoadministerhisdosesofinsulin,prescribedtocoincidewithbreakfast,lunch,andeveningmeals.Thevisitswerehappeninganytimeinthemorningbetween8amand10am,aroundlunchtimebetween12-2pm,andintheeveningsafter5pmandpto10pm,accordingtotheneedsofotherpatientsonthecaseload,staffresourcesandthevolumeofthepatientsthatneededemergencyandessentialvisits.Asaresultofthismismatchinfoodandadministration,MrSmithhadvaryingdegreesofhyperglycaemiaandhypoglyceamia,andwasadmittedtohospitalalmostweekly.Hewasalsogivenmanydosesofshortactinginsulintobringhisbloodsugarsintomoreacceptableparameters,whenhepresentedwithhyperglyceamia.Thisoftenresultedinreboundhypoglycaemia3. TheModelofEducationDeliveryDiabetesUK(2010)statethatitis‘vitallyimportantthatcarehomestaffhavereceivedsufficienttrainingforallstaffinvolvedinthecareofresidentswiththecondition’.TheLeadNursewasconcernedaboutthelackoftrainingthecarehomeshadreceived,andwaskeentodeliversomeevidencebased,uptodatetrainingwithcompetenciesattached.Thekeyfeaturesofthemodelhadtoinclude:

• Arobust,evidencebasedmoduleforimprovingbasicdiabetescareinNursingandResidentialHomes(TREND,2015)–includinghighriskareasofhypoglycaemia,hyperglycaemiaandfootcare.

• Anadvancedmoduleforthosecarestaffwhoselearningimprovedthroughthefirstmoduleandwerewillingtotakeontheresponsibilityofadministeringinsulin(asanUnregisteredPractitioner)

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• CompetenciesandSelfAssessmentevaluationforbothmoduleswhichallowsidentificationoftrainingneedsusingthe‘HowTo’model(DiabetesUK,2016)

• TrainingthatwouldmeettheCareQualityCommission(CQC)standards• AreplicablemodelwhichcouldbeappliedinanyotherCCG’s• CosteffectiveinreducingadmissionstohospitalandlessCommunityNursesupport• OngoingsupportfromCCG’s,CommunityHealthTrustsandSpecialistServices

Theuseofcompetencieshelpsindividualsplantheirdevelopmentinamorestructuredway–whethertheybeunregisteredorregisterednurses–andalsogivesmanagersqualitativeevaluationdatabyidentifyingindividualtrainingneeds

Figure3–ModelofTraining

Trainingofferedovertwomodules-Module1andModule2with

competencybasedassessment

Outlineaimsandobjectives

EnsureRobustpoliciesand

procedures,.CarePlanningforeachpatientshouldbe

robust

InvolveKeyStaffandStakeholders

includingpharmacy.Followupof

competenciesnpractice

Evaluationofprogrammeandcompetencies.

Ensureobjectiveshavebeenmet

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BeniKent–atrainingcompanyownedandrunbySarahGregory–wasaskedtofacilitateanddeliverthetrainingtothecarehomes.SarahGregoryisaDiabetesSpecialistNurse,whoworksinAcuteCare,aswellashaving15yrsexperienceasaDSNbothinPrimaryandSecondarycare,andthedeliveryofeducationprogrammestoqualifiedandunqualifiedstaff,includingGP’s,foundationdoctorsandnursingstaff.Tomeetthesefeatures,BeniKentmodifiedcurrenttrainingmodulestodelivertrainingtothesecarehomestaff.BeniKentusetheTRENDframework(2016)toguideparticipantsontheirrolesandresponsibilitiesinacreativeandflexibleway–aswellasidentifyingtheirboundariesandlimitations.

4. HowthechangewasachievedThemodelisfigure3demonstratesthekeyareasofthemodel:

§ Trainingofferedo Twomoduleswereofferedtothedelegates–Module1‘OverviewofDiabetes’andModule

2‘SafeAdministrationofInsulin’.AllstaffwhowishedtodoModule1hadtohavecompletedModule1andbeabletomanagediabetes,bloodglucosemonitorandmanagehypoglycaemia.NotalldelegateschosetoattendModule2.StaffwhoattendedModule2hadtocompleteawrittentestandthendiscusscompetencycompletionwiththeLeadNurseandPharmacyTechnician

§ CarePlanningandRobustPoliciesandProcedureso Thepharmacytechnicianwasemployedtohelpprovideassuranceinthesafetyofinsulin

administrationUnregisteredPractitioners.TherewasalsoanescalationprocessinplacesothatResidentialstaffcouldseeksupportasnecessary.CarePlansmustbeinplaceanduptodatebeforeUnregisteredPractitonerscouldcarryoutinsulinadministratin.

§ Involvingkeystakeholderso TheLeadNurseforLongTermconditionswasthekeyforintegratedworking,whothen

involvedtheMatronsandCommunityNursesinboththetrainingandfollowingupcompetenciesandcareplanningfollowingthedeliveryoftraining.

§ Evaluationo EvaluationwascarriedoutbyBeniKentandsharedwithstakeholdersaswellasattendees.

Theimpactoftheprogrammewasmeasurableinbothcompetencyimprovementsandareductioninhospitaladmissionsand999calls.Evaluationalsosawpositivefeedbackandcommentsfromdelegateswhofeltthattheirknowledgeandskillshadimproved.

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5. OutcomesAtthestartoftheproject,therewas18patientswithincarehomesthathadtheirinsulinadministeredbycarehomestaff,mostonthreetimesdailyregimes.ThiswasanenormousburdenonCommunityNursingresources,aswellaspatientsatisfactionandsafety.Followingthetraining,thecarehomestaffweredelegatedtheresponsibilityofinsulinadministration,withoutstandingimprovements.Simplybyadministeringinsulinattherighttime,intherightway,thecarestaffreducedupto378visitsperweekbyCommunityNursingteamsresultinginasavingofapproximately£18,900(basedoneachvisit@£50each)Aswellasthissaving,CommunityHealthCareprofessionalsnowhaveanincreasedcapacitytoreallocatetheirexpertiseinotherareasofneedfortheirpatients.Abigimpacthasalsobeennotedonpatientsafety-therehasbeenareductionofhospitaladmissionsacrossSwaleby65%andareductionof999callsby69%.(FiguresobtainedfromSeecamb,andsupportevidencefromtelecareinstalledinsomeofthehomes)

CaseStudy–MrSmithThestaffwithintheResidentialHomeattendedthetrainingmodules(Both1and2)andweretrainedindiabetesmanagement,injectiontechniqueandinsulinadministration,withfollowupsupervisionandsupportfromthepharmacytechnician.MrSmithsexperienceshavechangedsincethecarehomestaffhavetakenontheresponsibilityforhisinsulininjections.Hestillgetsupearlyandhadisbreakfast,andstaffareabletoadministerhisinsulinaccordingtohowitwasprescribed.Thisisthesameduringthedayandevenings.Hestillgoesofftotheshopsandpub,buttheimpactofhisbloodsugarswasmuchless.Hisbloodsugarswereatamoreacceptablelevel,hestoppedgoingintohospitalfordiabetesrelatedillness,andhisqualityoflifehasimprovedconsiderablyandheisabletodecideforhimselfwhenhecaneatandgoout.Staffareabletorecognizesignsandsymptomsofhyperandhypoglyceamia,andmanagethemaccordingly,andaremoreconfidentintheircare.GPvisitsandspecialistnurseinterventionhasreduced,andMrSmithsinsulinregimeremainsunchanged.

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Priortothetraining,attendeeswereaskedtocompleteaselfassessmentbasedonthecompetenciesthatwouldbecoveredduringthetraining(Module1andModule2).ThesecompetencieswerebasedontheTRENDcompetencyframeworkforUnregisteredPractitioners.Keyareas(hypolgycaemia,sickdayrulesandfootcare)ofimprovementarenotedinthetablebelow:CompetencyArea PreCourse–

CompetentPostCourse-Competent

Understandtheroleofbloodglucosemonitoringandwhotoshareresultswith

42%

100%

Beabletodefinehypoglycaemia 29% 88%

Beabletodiscussthesymptomsofhypoglycaemia

16%

100%Knowthetreatmentforhypoglycaemia

29%

92%Understandadditionalrisksforhypoglycaemiainthecarehomesettingandpreventionofhypoglyceamia

13%

96%

UnderstandtheriskofDiabeticfootdisease 30% 96%

Beabletodiscusspreventionofthediabeticfootanddailycare 17% 96%

Beabletoimplement‘sickday’rulesandprinciples 4% 100%

Thesecompetencyimprovementsweresupportedbycommentsmadebyattendees:

• Feelmoreconfidentininsulinadministrationanduseofpens• EnjoyedCheckinjectionsites• Bemoreawareandobserveindividualfor“changes”• Nowhaveabetterunderstandingofdiabetes• Interestedtolearnmoreandbemorecompetent• Nowhavegoodgeneralknowledgeandmoreconfident

AllstaffwhoattendedModule2tookthecompetencytest–withapassmarkof90%.OneattendeedidnotpassthetestandwasthereforenotcompetenttoadministerinsulinatthistimebutwouldbeinvitedtofuturetrainingaswellasbeinggivensupporttheCommunityMatron.

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6. LessonsLearnedThesuccessofthemodelreliesheavilyonstakeholderinvolvement–GP’s,CCG’s,CommunityNursingTeams,PracticeNurses,ResidentialandCareHomeStaff,Pharmacist–tonamebutafew.Allofthesestaffareinvolvedinthecareofpatientsatsomepointandintegratedworkingtoimprovethestandardofcare,aswellasinsulindelegationtounregisteredpractitioners,iskeytosuccess.Atthefirstsession,theCommunityNursingteamwereinvitedbutdidnotregarditasnecessarytostayforthewholetraining–thiswashighlightedbythetrainerandfuturetraininginvolvedalloftheteams,aswellasthepharmacytechnicianinvolvedinsupportingstaff.CommunityNursingstaffareoverwhelmedbythevolumeofpatientsontheircaseloads-manyfeelthatcarehomefacilitieschargetheirpatients/residentslargeamountsofmoneytocareforthemyetarenotadequatelytrainedtolookafterthemandthatthisistheresponsibilityoftheNHS.Theyfeelpatientsarenotadequatelyinformedabouttheircondition,arenotempoweredondiagnosisandareundertheimpressionthattheNHSjustdealswiththeirhealthandthattheyhavenoresponsibilityforit(QuotefromLeadNurse,LongTermConditionsaftermeetingwithCommunityNursingTeam)Todevelopthemodel,moreformalcaseloadreviewsarerequired–althoughthiscanbetimeconsumingitidentifiespatientswhocouldpotentiallybemanagedbyothers,orselfmanagementencouraged.CommunityNurseswerenotfullypreparedforthepotentialimpactthetrainingmayhave,andforfuturereviewsthefollowingquestionsbeingasked(from‘HowtoManageinsulinadministrationintheCommunity–DiabetesUK2016)

• Howmanypeopleareonthecommunitydiabetescaseload?• Howmanypeoplecurrentlyrequireinsulinandhowmanyneedsupportwiththeirinjections?• Whatisthecurrentratioofstaff(registeredandnon-registered)topeoplewithdiabetesinthe

community?• Havestaffadministeringinsulinreceivedrelevantandup-to-datetraining?• Howmanyreportedinsulinerrorshavetherebeeninthelastyear?Whydidtheyhappenandhow

couldtheyhavebeenprevented?• Howmanydiabetes-relatedambulancecalloutsorhospitaladmissionshavetherebeen?What

werethereasons?• Howmuchtimeisspentondiabetescareinthecommunity?Atimelogmighthelpyouassessthis.• Howdonursingstafffeelabouttheircaseload?• Whatisthejobroleandbandingofthoseadministeringinsulin?Thiscanhelptoclarifythe

appropriatenessoftasksandwherecostscouldbesaved.• Arethereanyotherquestionsthatneedtobeansweredtohelpmeetyouraimsandobjectives?

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Thetrainingmodeldemonstratesanevidencebased,practicaltrainingwhichgivesaanoverviewofbasicdiabetescaretomeetCQCexpectationandguidelinesrecommendedbyDiabetesUK,aswellasawrittenquestionnaireforthosecompletingModule2andaretobeadministeringinsulin.ThismodelisnowsupportedbytheDiabetesUK‘HowtoManageinsulinadministrationintheCommunity’whichwaspublishedinMarch2016andsomekeyfeaturesofthisdocumentwillbeincorporatedintothesecondversionofthemodel.Thisguidegivesacomprehensiveguidetoinsulindelegation,andstaffwhohaveattendedshouldbeencouragedtoformallyadoptthechecklistinthedocument.

7. Recommendationsforfuturetraining

§ Thetrainingneedstobesustainableo Considerationofstaffinvolvedinimplementingtheproject,venuesandassessing

competencieso Considerationofchangingworkforces–bothinthoseworkingincarehomesettingsand

thosedeliveringtheeducation§ Formaliseduseofevidencebasedguidancealreadyincirculation

o UseofdocumentssuchastheDiabetesUK‘HowtoGuides’,TRENDcompetenciesandRCNpublicatoins

§ EnsuringthatCommunityNursingteamsareawarethattheresponsibilityforthepatientremainso CareHomestaffaregenerallynottrainednursessocannotberesponsibleforchanging

treatmentregimesorcareplans–patientsremainunderthecareoftheGPandCommunityNursingteams.Registerednursesshouldonlydelegatetasksanddutiesthatarewithinthecarersscopeofcompetence,andareabletoprovidesafecare.

§ Importanceofcareplanningo Careplansshouldbereviewedatleastevery6-12months–bytheGP,CommunityNursing

teamorHCPresponsibleforthediabetesmanagement.Careplansshouldbewrittenwiththepatientorapatientadvocatepresent

§ Importanceofcaseloadreviewo Lookatthediabetescaseloadasawhole,reviewcareonanindividualleveltounderstand

thequalityandappropriatenessofcare,includingthetimeandresourcesrequiredforthatperson(DiabetesUK,2016)

§ QualityAssuranceandContinuingProfessionalDevelopment(CPD)o ForHealthCareProfessionalstakingontraininganddevelopmentinthisarea(whoarenot

experiencedDiabetesSpecialistNurses)considerQualityAssuranceofthetrainingprovided,andCPDpoints.