NHD Issue 145 Telehealth for diet and diabetes

COVER STORY

TELEHEALTH FOR DIET AND DIABETES

NHS services face growing demands due to an ageing population that is living longer. Diverse ways of working are required to cope with higher demands and the use of technology to deliver personalised healthcare1,2,3 is one way of providing patients with the care they require. This article reports on telehealth in NHS Ayrshire and Arran, which provides dietetic management for patients with diabetes.

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 With a limited staff resource and in an increasingly financially aware NHS,11 telehealth can help provide a fuller picture of how patients are managing diet, medication, exercise and carbohydrate counting.

It is also an opportunity to provide encouragement to achieve agreed goals by bridging the gap between clinical intervention and patient engagement.

Telehealth application can help in diabetes dietetic management by getting patients more involved in their care through educating and reinforcing selfmanagement of their condition.10 VanWormer et al (2006),13 Goode et al (2012)14 and Kohl (2013)15 are papers mentioned by PEN, The Global Resource for Nutrition Practice.17 These have demonstrated that technology-assisted interventions (eg, internet/website, email, text messaging and mobile applications) can achieve positive healthbehaviour changes in relation to diet and can promote weight loss in overweight or obese adults, compared with having no intervention or minimal care. (Minimal care refers to receiving only printed material, or having infrequent visits with a primary care provider, whilst tailored interventions and agreed goals incorporate behaviour change principles.)

Personalised patient-centred feedback via email, online discussions and phone discussions appear to be more effective than non-interactive interventions or automated responses.13,14,15,17 WHY TELEHEALTH?

In Scotland, 4 in 10 people have one or more long-term conditions8 and diabetes affects 1 in 18 people according to current statistics – that’s over 298,504 people.4,5,6,7,16 Furthermore, it is estimated that 29,850 or a further 10% of people in Scotland remain undiagnosed.18 Selfmanagement, which includes blood glucose monitoring, diet and exercise to achieve optimal blood glucose, blood pressure and cholesterol, is a key skill to managing diabetes, and improving diabetes self-management through patient education is fundamental to improving diabetes-related outcomes.19 A more patient-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.11 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.19 However, for patients struggling with their diabetes, the potential long wait between appointments is not adequate for the improvement of diabetes selfmanagement. Diabetes education is

Ruth BarclayPaterson Diabetes Dietitian, NHS Ayrshire and Arran Ruth has been a Diabetes Dietitian for five years with previous experience in community and acute.

Additionally, Ruth is currently completing a Masters in Health and Wellbeing.

She loves fitness and rugby.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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COVER STORY Table 1: Intervention category groups: confidence results and feedback Intervention category

Average improvement in confidence score

Goal examples

Patient feedback snapshot

GLP1 therapy

+3.86

• Reduce portions • Reduce snacking behaviour • Increase activity

• Portion reduction; no longer double carbohydrate at meals • Stopped snacking • Improved diabetes control • Clothes fitting better

Carbohydrate counting

+4.17

• Weigh foods/read labels • Check insulin-to-carbohydrate ratios

• Feeling more comfortable with insulin adjustment • Improved HbA1c (mmol/mol)

Structured education carbohydrate counting

+4.16

• Carbohydrate: count meal content • Establish insulin-tocarbohydrate ratio (ICR) • Treat hypoglycemia appropriately

• Improvement in HbA1c (mmol/mol) • More confident to problem solve and self-manage diabetes • Reduction on insulin/other diabetes medications

CSII

+1.5

• Regular low GI meals/snacks

• Better condition understanding • Feels more able to manage • Symptoms reduced

Reactive hypoglycaemia

+2

• Assess/calculate carbohydrate content of meals with labels and portion book • Learn carbohydrate content of foods • Keep consistent carbohydrate intake at mealtimes

• Reduced hypoglycaemia • Helped provide information and confidence to manage diabetes better

Other weight management

+2

• •

• Telehealth helped provide engagement to keep motivated to lose weight

Regular meals Carbohydrate: count meals

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.10 A Technology Enabled Care Programme (TEC Programme) was launched in 2014 to help ensure that NHS Boards, Local Authorities, Integration Authorities and their partners were utilising opportunities to include TEC within services.

An application for funding via the National TEC Programme was submitted in early 2016. The funding proposal outlined the vision to develop a structured telehealth service in NHS Ayrshire and Arran, to support diabetes self-management and dietary behaviour change. The funding request was for a 0.2 WTE Band 6 dietitian for nine months to allow a set time to develop and integrate the project.

Sustainability was considered from the offset and, once developed; it would become a structured 12

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embedded part of core services, which would include ongoing audit and service evaluation to ensure robust cost-effective service delivery.

TELEHEALTH ON DIET AND DIABETES (TODD)

The TODD project would be a structured telehealth programme designed to facilitate diabetes and dietary self-management. The rationale behind offering TODD appointments was to make the diabetes dietitian service more accessible to patients and review clinically agreed goals in a more timely 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.

COVER STORY Table 2: Dietetic outcome statements achieved Dietetic outcome statement

Achieved goal

1. Glycaemic control

60/105

2. Knowledge and confidence

66/102

3. Nutritional status

21/27

4. Supportive advice

28/32

5. Alleviated symptoms

11/11

The objectives of TODD were to: • improve patient lifestyle outcomes (agreed goal/dietetic outcome measures); • improve contact on a more regular basis with 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 following statements have been agreed as dietetic outcomes for the Dietetic Service in NHS Ayrshire and Arran: 1 To improve glycaemic control to minimise diabetic complications.

2 To improve knowledge and confidence to allow the patient/carer to self-manage.

3 To optimise/maintain/improve nutritional status using the most appropriate intervention.

4 To offer supportive advice (terminal care/ long-term conditions/palliative care).

5 To alleviate symptoms, eg, for IBS, coeliac disease, food allergy, osmotic symptoms.

6 To meet estimated nutritional requirements.

Method The TODD project was led by the diabetes dietitians at University Hospital Ayr (UHA). A standard operational procedure was developed and inclusion criteria identified. Patients had to have an initial assessment either from attendance at a 1:1 appointment, or a structured education session and be supported by secondary care for their medical/diabetes care and followed up in a TODD telehealth clinic from a dietetic perspective. This was set up in the Outlook

calendar to support scheduling of appointments.

Different methods of contact were identified, including via email, telephone, DIASEND. Outcomes anticipated • Increased patient review capacity with specialist diabetes dietitian.

• Reduced DNA rates maximising specialist clinician time. A comparison of 1:1 vs telehealth DNA. • Improved patient confidence in progressing agreed goal and, therefore, overall encouraging patient self-management skills.

Approval process • A standard operational procedure (SOP) and implementation plan were developed and approved by the diabetes Managed Clinical Network (MCN), TEC and dietetic clinical governance. This incorporated a patient pathway.

• Additionally, supporting documentation data collection forms, agreed goals sheet, patient information sheet and project evaluation questionnaires were developed and included as supplementary information in the SOP. • Each agreed goal has 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 links in with the six dietetic outcome measures.

Results • 33% increase capacity (based on a time saving of 15 minutes versus 1:1 face-to-face (based on 30 minutes for telehealth slot compared with a 45-minute face-to-face slot).

• DNA rate improvement of (7%) as 20% 1:1 face to face and 13 % TODD. • Confidence: average of three-point increase in confidence across the 46 patients with 1-3 agreed goals using a 0-10 Likert Scale.

• Dietetic outcome statements achieved are outlined in Table 2.

Six key intervention category groups were identified and each intervention category captured an improvement in patient goals (see Table 1). www.NHDmag.com June/July 2019 - Issue 145

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COVER STORY Table 3: The benefits of TODD Patient outcomes

Staff outcome

NHS

Time away from work and travel, some wouldn't have been able to get away.

Maximises clinical time and the increased capacity facilitated service delivery during maternity leave.

Car parking not required.

Reduced fuel use, CO emissions and CO footprint.

Better able to meet patients’ needs in timely manner.

Positive patient experience.

Safe alternative in adverse weather.

Patient attendance better.

Increasing patient choice.

Can increase access choice for some patients (eg, can’t get three buses here).

Optimising clinic outcomes: seeing patients right time and place.

Can have TODD running while consultant clinic running when no consultation room available for face to face.

Table 4: Limitations of TODD Patient outcomes

Staff outcome

NHS

New way of working, not all patients ready to engage.

Staff feel they already phone – unscheduled; not confident with DIASEND.

TODD is not a replacement for 1:1 appointments, but provides support.

Some patients struggled with the importance of the goal setting philosophy; they didn't get the concept.

No non-verbal cues, limited gestures.

Only really tone of voice in calls.

Email: depends how typed if replying from phone device likely.

Sticking to the TODD appointment time difficult – not being side tracked by other clinics in department, or incoming calls.

Getting a score sometimes gets in the way of the consultation flow – some scores not captured, as this was a clinician agenda, not patient.

BENEFITS AND LIMITATIONS OF TODD

Tables 3 and 4 above summarise the benefits and limitations of TODD. Evaluation feedback of TODD Eight out of 46 patients completed a questionnaire post-TODD intervention. Six questions were asked on a Likert Scale 1-7 'not helpful' to 'very helpful'. Overall, apart from one response, TODD was found to be 'helpful/very helpful'.

CONCLUSION

All of the anticipated outcomes were achieved.

These included two extra slots every clinic session: an increase of one third (33%) capacity within the TODD clinic session, which is sustainable.

Additionally, DNA 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 five main statements clinically relevant.

These are directly associated with agreed goals being accomplished, therefore showing the value of dietetic time within the treatment and management of diabetes. Overall, feedback was positive and patients engaged well with this additional contact method.

Next Steps: Phase 3 TODD is scoping the possibility of utilising Attend Anywhere (NHS Near Me), which is a new video consulting service within the TODD telehealth structure.

Acknowledgement Thank you to the Scottish Government Technology Enabled Care (TEC) programme board, that funded this programme. Additionally I would like to thank Ayrshire and Arran Diabetes MCN and dietetic colleagues for their support. I would specifically like to mention Gail Blockley for continuing this project while I was on maternity leave and Pamela McCubbin for carrying out Phase 2 at University Crosshouse Diabetes Centre.

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