Diabetes affects 1 in 18 people in Scotland, which equates to over 298,504 people 4,5,6,7,8. Type 2 diabetes accounts for 90% of those diagnosed and 10% accounts for those diagnosed Type 1 or a secondary form of diabetes6. Nutrition, lifestyle and dietary behavioural modification are the cornerstone to successful diabetes self-management. Self-management includes blood glucose monitoring, diet and exercise monitoring to achieve optimal blood glucose, blood pressure, and BMI, in addition to cholesterol levels. Patient education is fundamental to improve diabetes related outcomes19. A more person-centred approach is encouraged by The Healthcare Quality Strategy for NHS Scotland and using existing resources long term is critical in our financially aware NHS.9 Current diabetes care interventions generally are episodic, over several weeks, months or even years. A patient receives several hours a year contact with a health professional.10 However, for patients struggling with their diabetes, the potential long wait between appointments is not adequate for the improvement of diabetes self-management. Diabetes education is critical to self-management and all members of the healthcare team should use each patient visit as an education opportunity, making any clinical contact time count.11 NHS services face growing demands due to an increasing ageing population which is living longer and many services operating with limited staff resources. Diverse ways of working are required to cope with increasing demands and the use of technology to deliver personalised healthcare at a distance1,2,3 is one way of providing patients with the care they require. Telemedicine, telehealth, telehealth care and telecare can be overall defined as the use of technology to deliver personalised healthcare remotely. Data is transferred from the patient and the professional provides feedback.12
An opportunity to incorporate telehealth into my clinical practice presented itself in 2016 via the Technology Enabled Care Programme (TEC Programme). A successful funding proposal allowed the development and integration of a successful telehealth clinic structure within diabetes dietetics to support diabetes self-management and dietary behaviour change.
Telehealth on Diet and Diabetes (TODD) is now a structured embedded part of core services within diabetes dietetics and subject to ongoing audit and service evaluation. The rationale behind offering TODD appointments was to make the diabetes dietitian service more accessible to patients and review clinically agreed goals in a timelier manner. Telehealth is rapidly growing in many different interfaces and can potentially access more patients given the geography and demographics of the patients located in NHS Ayrshire and Arran. From a professional prospective, it can help enhance patient/dietitian collaboration, improve health outcomes and reduce medical costs.
The objectives of TODD were to:
- Progress patient lifestyle outcomes (agreed goal/dietetic outcome measures);
- Improve contact on a more regular basis with a diabetes specialist dietitian.
Self-management education teaches goal setting and problem solving skills and the theory is that these provide the patient with greater confidence in making life-improving changes, achieving agreed goals and yielding better clinical outcome data. The patient is able to identify any problems they are experiencing in relation to their diabetes/diet.
The TODD project was led by the diabetes dietitians at University Hospital Ayr (UHA). A standard operational procedure was developed. The methods of contact were identified, including via email, telephone, DIASEND and more recently phase 3 has started to include the use of NHS Near Me. Each agreed goal set by the patient had importance and confidence initially assessed on a 1-10 scale and confidence with each agreed goal was reviewed with each patient contact; ‘1’ being not important/not confident and ‘10’ being very important/very confident. It also linked in with the six dietetic outcome measures, 1. Glycaemic control, 2. Knowledge and Confidence, 3. Nutritional Status, 4, Supportive Advice, 5, Alleviate symptoms, 6. Nutritional Requirements.
In conclusion, all of the anticipated outcomes were achieved. These included two extra slots every clinic session: an increase of 1/3 (33%) capacity within the TODD clinic session, which is sustainable. Additionally, ‘Did Not Attend’ rates were 7% less compared with dietetic-only 1:1 appointments. Furthermore, there was an average three-point improvement in confidence across all interventions and agreed goals. Improving patient confidence in progressing agreed goals has helped patients develop self-management skills which are important in the sustainability of long-term condition health management and this project confirms it can be achieved effectively with telehealth intervention.
Finally, a considerable number of dietetic outcome statements were achieved across the six aforementioned main dietetic outcome statements. These are directly associated with agreed goals being completed, therefore providing data demonstrating the value of dietetic time within the treatment and management of diabetes. Overall, feedback was positive and patients engaged well with telehealth as an additional contact method.
Ruth Barclay-Paterson @BarclayPaterson
Diabetes Dietitian, NHS Ayrshire and Arran
Thank you to the Scottish Government Technology Enabled Care (TEC) programme board that funded this programme. Additionally I would like to thank Carolyn Oxenham, Gail Blockley and Pamela McCubbin for their contribution to the TODD project.
- McLean S, Sheikh A, Cresswell K, Nurmatov U, Mukherjee M, Hemmi A et al. The Impact of Telehealthcare on the Quality and Safety of Care: A Systematic Overview. PLoS ONE. 2013;8(8):e71238.
- Scottish Government. A national telehealth and telecare delivery plan for Scotland to 2015. Edinburgh: Scottish Government; 2012.
- The King’s Fund. Tackling the growing crisis in the NHS [Internet]. The King’s Fund. 2016 [cited 4 March 2019]. Available from: https://www.kingsfund.org.uk/publications/articles/nhs-agenda-for-action
- Diabetes UK. Diabetes Prevalence 2018 [Internet]. Diabetes UK. 2019 [cited 4 March 2019]. Available from: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics/diabetes-prevalence-2018
- Diabetes UK. More than 700 people a day diagnosed with diabetes [Internet]. Diabetes UK. 2014 [cited 4 March 2019]. Available from: https://www.diabetes.org.uk/about_us/news/more-than-700-a-day-diagnosed-with-diabetes
- Diabetes UK. Diabetes UK Facts and Stats [Internet]. Diabetes.org.uk. 2019 [cited 4 March 2019]. Available from:https://www.diabetes.org.uk/resources-s3/2019-02/1362B_Facts%20and%20stats%20Update%20Jan%202019_LOW%20RES_EXTERNAL.pdf
- NHS. Type 2 diabetes [Internet]. nhs.uk. 2019 [cited 4 March 2019]. Available from: https://www.nhs.uk/conditions/type-2-diabetes/
- NHS Scotland. Scottish Diabetes Survey 2017 [Internet]. 2017. Available from: http://www.diabetesinscotland.org.uk/Publications/SDS%202017.pdf
- NHS Scotland. The Healthcare Quality Strategy for NHSScotland [Internet]. Gov.scot. 2010 [cited 4 March 2019]. Available from: https://www.gov.scot/resource/doc/311667/0098354.pdf/
- Beck J, Greenwood D, Blanton L, Bollinger S, Butcher M, Condon J et al. 2017 National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2017;40(10):1409-1419.
- McDuffie R, Struck L, Burshell A. Empowerment for diabetes management: integrating true self-management into the medical treatment and management of diabetes mellitus. Ochsner J [Internet]. 2001 [cited 4 March 2019];3(3):147-57. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385781/
- McLean S, Protti D, Sheikh A. Telehealthcare for long term conditions. BMJ. 2011;342(feb03 2):d120-d120.
- 13. Beck J, Greenwood D, Blanton L, Bollinger S, Butcher M, Condon J et al. 2017 National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2017;40(10):1409-1419.