DIABETES STRUCTURED EDUCATION IN WORCESTERSHIRE Information for Healthcare Professionals May 2011 What is Structured Education? Diabetes Structured Education is referred to in the Diabetes NSF standards 3 and 4. The new NICE Quality Standard for Adults with Diabetes states that people with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education. Key criteria that a structured education programme should meet to fulfil the NICE requirements* Evidence Based Structured Curriculum Trained Educators Quality Assured Audited Support Self Management * The Department of Health and Diabetes UK (2005) Structured Patient Education in Diabetes: Report from the Patient Education Working Group. London. What Programmes are available in Worcestershire? X-PERT DIABETES - For people with type 2 diabetes, newly diagnosed or on tablets X-PERT INSULIN - For people with type 1 or type 2 diabetes treated with insulin DAFNE (Dose Adjustment for Normal Eating) An intensive approach for people with type 1 diabetes on multiple daily injections (basal bolus regimen). Specific referral forms are available for each programme. X-PERT DIABETES 6 x 2.5 hour sessions over 6 weeks At 14 months Trial Group Control HbA1c (%) -0.6% +0.1% Cholesterol (mmol/l) -0.3-0.2 Weight (kg) -0.5 +1.1 BMI (kg/m2) -0.2 +0.4 Waist circumference (cm) Women -4-1 Men -2 0 Diabetes Medication Trial Group Control Reduced (%) 16 1 Same (%) 63 53 Increased (%) 21 46 At 14 months HbA1c, weight, BMI and diabetes medication were all reduced. 1
There were significant increases in; Physical activity Diabetes foot care Intake of fruit and vegetables Knowledge of diabetes Satisfaction with diabetes treatment Self-empowerment Readiness to change Self management skills- setting & achieving goals Deakin, T. A., Cade, J.E., Williams, R & Greenwood, D.C. 2006. Glycaemic Control: The X-PERT Programme makes a Difference. Diabetic Medicine: 23; 944-954 Type 2 diabetes- newly diagnosed* or on tablets Suitable for group education Motivated and able to attend 6 half day sessions *Where courses are oversubscribed priority will be given to the newly diagnosed as required by NICE guidance. The X-PERT Programme is based upon the theories of patient empowerment, discovery learning and patient-centred care. Its main aim is to develop the knowledge, skills and confidence in participants to enable them to make informed decisions regarding lifestyle and diabetes management. Week 1: What is diabetes? Digestion and blood glucose, Exploring medications and how they work, Health results what do they mean? Week 2: Eating with diabetes, Physical activity, Weight management, How to assess your diet Week 3: What are carbohydrate (starchy and sugary) foods and their effect on blood glucose? What carbohydrates are you having? Week 4: Shopping for foods, Reading and understanding food labels, Understanding the traffic light system, guideline daily amounts and nutritional labels, Dispelling the myths Week 5: Low and high blood glucose levels, Prevention of the complications of diabetes, Special considerations when living with diabetes Week 6: Are you an X-PERT? game questions and answers, Making plans and setting goals for change Some surgeries offer X-PERT Diabetes in house. Where this is not available please refer to your local diabetes specialist nurse team using the X-PERT DIABETES referral form. X-PERT Diabetes is held at many different venues across the county and is available in mornings and afternoons with some evening provision where required. Patients will be invited to the next available group in their locality. Group sizes are between 10 and 18 patients. Partners/ carers are welcome www.xperthealth.org.uk or contact your local Diabetes Specialist Nurse 2
X-PERT INSULIN 6 x 2.5 hour sessions over 6 weeks X-PERT Insulin Programme pilot results February/March 2008 OUTCOME BASELINE SIX MONTHS DIFFERENCE Weight (kg) 90.7 85.7-5.0 kg BMI (kg/m 2 ) 32.6 30.8-1.8 kg/m 2 HbA1c (%) 8.6 7.4-1.1 % Systolic BP (mmhg) 137.7 132.2-5.5 Total cholesterol (mmol/l) 4.3 4.0-0.3 Diabetes empowerment 2.3 4.2 +82.6% score Participant Evaluation Satisfaction Score 97.5% Over 17 years old Suitable for group education Able and willing to perform regular home blood glucose monitoring Motivated and able to attend 6 half day sessions Type 2 diabetes. Any patients treated with insulin (any regimen ie. OD. BD. TDS. Basal plus, Basal bolus) Type 1 diabetes. Patients on any insulin regimen from diagnosis onwards EXCLUDING- patients on insulin pumps EXCLUDING- Patients on basal bolus regimen who want the flexibility and intensity of the DAFNE approach and are able and willing to attend DAFNE. Patients will learn about the up-to-date treatments and management of diabetes in an interactive, informative group environment. Week 1: Diabetes, insulin and healthy living What is diabetes, the role of insulin and the diabetes health profile, Healthy living: eatwell plate and physical activity, What I am eating Week 2: All about insulin Insulin-specific challenges with self-managing diabetes, Hypoglycaemia / hyperglycaemia Ketoacidosis (DKA) & HONK, Exploring insulin onset, peak and duration, regimens and devices, My insulin injection technique Week 3: Know your carbs Identification of carbohydrate foods and drinks, Carbohydrate counting estimation, calculation and reading food labels, Self-monitoring blood glucose, meters, frequency of testing technique and safe sharps Disposal, My what should I do? scenarios Week 4: Inspiration for insulin Troubleshooting: strategies to take control, Inspiration : a game for insulin X-PERTs covering everyday scenarios, What troubleshooters may work for me? MATCH IT challenges Week 5: MATCH IT taking control MATCH IT: My diary, my diabetes A day in the life of, A chance to learn and share, Apply troubleshooters to MATCH IT challenges 3
Week 6: Are you an insulin X-PERT? Game: MATCH IT 24/7 to challenge real living with diabetes on insulin situations, What did I learn from troubleshooting the MATCH IT challenges, The way forward X-PERT INSULIN is currently being piloted at different venues across the county. Please refer to your local diabetes specialist nurse team using the X-PERT INSULIN referral form. Patients will be invited to the next available group in their locality. Group size is 10-12 patients. Partners/carers are welcome. www.xperthealth.org.uk or contact your local Diabetes Specialist Nurse DAFNE Dose Adjustment For Normal Eating Type 1 Diabetes: Less guesswork, More freedom, Better health 5 day course (Monday to Friday 9.15-4.30) 169 patients ½ DAFNE immediately, ½ after 6 months Biomedical and quality of life outcomes measured at 0,6 and 12 months At 6 months those attended dropped HbA1c by 1% compared to delayed DAFNE group. Improved quality of life and freedom to eat No increase in severe hypoglycaemia Significant psychological improvements which outweigh improvements in glycaemic control. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: DAFNE RCT. BMJ 2002; 325:746 Worcestershire GP Type 1 DM for at least 6 months Over 17 years old HbA1c < 12% Motivated Need for flexibility Willing to inject and test > 4 times daily Absence of end stage complications eg. Renal disease Availability to attend 5 day course Basal bolus insulin regimen Numeracy skills 5 day intensive structured education programme for type 1 diabetes Adult Learning principles in a group setting learning from and sharing experience through group work. Gaining autonomy Gaining confidence to adjust insulin with dietary freedom in safe setting. Learning about carbohydrate counting and applying the principles in daily life 4
Also covered o Pathophysiology o Complications o Hypos o Physical Activity o Pregnancy o Alcohol o Social issues o Illness o Annual review o Doctors Q & A session o Goal setting and action planning Current venues o Kidderminster Diabetes Centre o South Worcestershire Diabetes Centre o Upton Warren outdoor education centre, near Bromsgrove A recruitment evening will be held biannually for patients to have the opportunity to find out about the course, meet the team and sign up to a date/ venue of their convenience. Group size 6-8 patients. Partners/Carers are invited to specific sessions only eg. Hypos and illness. Please refer to the DAFNE team using the DAFNE referral form and demonstrating that the referral criteria have been met. Note- Patients will not hear from us until the next recruitment evening. Currently there is a waiting list but we plan to train more educators and increase the number of courses available from 6 to 12 per year. www.dafne.uk.com or contact the DAFNE team Rosanne Dunkley- Community Diabetes Specialist Dietitian (DAFNE Educator) 01527 488679 rosanne.dunkley@worcspct.nhs.uk Sue Rogers- DSN (DAFNE Educator) 01905 760775. susan.rogers@worcsacute.nhs.uk What is the difference between DAFNE and X-PERT Insulin? DAFNE is an intensive approach where people with type 1 diabetes on multiple daily injections learn to adjust their quick acting insulin according to the amount of carbohydrate consumed using their insulin to carbohydrate ratio. Over the week patients learn how to adjust their insulin using a stepwise approach whilst modifying background insulin doses and quick acting insulin to carbohydrate ratios according to the DAFNE principles and scientific guidelines. Following attendance DAFNE graduates are encouraged to carbohydrate count and to monitor blood glucose before each meal and at bedtime to allow quick acting insulin doses to be calculated. On attending X-PERT Insulin, patients with type 1 or type 2 diabetes on all insulin regimens learn about managing their diabetes by matching their carbohydrate intake and activity levels to their insulin regimen and doses. Patients are taught to be aware of the carbohydrate content of different meals but they do not need to count carbohydrates daily. The X-PERT insulin course and the method of ongoing diabetes management taught is less intensive than DAFNE so is appropriate for people with type 1 diabetes on a basal bolus insulin regimen who do not wish to adjust each mealtime insulin or would struggle with the numeracy skills or motivation to benefit fully from the DAFNE approach. 5