Improving diabetes care in our residential homes

Older people with diabetes are more likely to have multiple pathology, macrovascular problems, and age-related problems such as dementia or Alzheimer’s disease, which will make controlling diabetes more difficult (Gregg et al, 2002). It is also recognised that older people have an increased incidence of physical disability, which may be attributable to the classic complications of diabetes such as coronary heart disease, peripheral vascular disease and visual impairment (Gregg et al, 2002).

In Bournemouth, there are 125 care homes but there is no central information available about the people with diabetes in these homes or the staff that work in them.

Aim of study
A questionnaire was devised to determine the prevalence of diabetes in the care homes and the knowledge about diabetes of the care home staff.

Method
A questionnaire was sent to 136 listed care homes in Bournemouth. The questionnaire consisted of two sections.

The first part investigated how many of the residents had diabetes, as well as the staff knowledge of and training on diabetes (Table 1). It gave an opportunity for staff to suggest what they wanted to know and the best ways that information could be delivered effectively.

The second part of the questionnaire was an individual form for each resident with diabetes. The questions included the type of diabetes, medication, HbA_1c, monitoring and the date of the last annual review (Table 2).

Results
Only 41 care homes (30%) returned questionnaires. Eleven homes (8%) had closed down.

Staff training
Twenty-two of the care homes (54% of those that responded) reported that staff had attended an annual update on diabetes, while 32 of the homes (78%) wanted, and felt they needed, more information. The information that staff requested was on understanding diabetes, diet and foot care.

When asked about how they felt the best way to deliver the information was, the staff had a variety of ideas, such as training days, leaflets, in-house training and information packs.

Residents with diabetes
In the 41 care homes that returned the questionnaires, 78 residents had diabetes, of whom 19 residents were reported as having type 1 diabetes. This was all of the residents who took insulin, which indicated a lack of understanding of diabetes – it is highly unlikely, the author felt, that every resident who took insulin had type 1 diabetes (they were much more likely, considering their age, to have type 2 diabetes).

The findings were as follows.

• Most of the residents (59 [76%]) were on tablets and dietary intervention, which was as the author expected.
• Only 15 residents (19%) had had an HbA_1c record taken in the last year that the care home staff were aware of.
• The staff reported that 35 of the residents (45%) had been seen for annual review.
• Nearly all residents (76 [97%]) had their diabetes monitored by blood or urine testing on a daily basis. 

Local service developments for the care of older people
The questionnaire was sent out to try to find out more about what was happening in the care homes in the author’s local area. While the author gained some information from the questionnaires, she realised that this information was limited by the low response rate.

However, it did give the author the incentive to talk to the care home staff about their knowledge of diabetes and what could be done to improve this and increase the awareness of diabetes care.

A quality skills measure was completed within the Bournemouth Primary Care Trust (PCT) which showed that the diabetes care available for residential homes was poor, so a working party was set up. It consisted of the service development manager, a GP, a dietitian and a diabetes specialist nurse (DSN). The author attended a local community matrons’ meeting and also linked up with the care home pharmacist.

Local conference
After the DSN expressed an interest in diabetes in the care homes, the care home pharmacist approached the DSN to attend a local conference for care home staff to discuss case studies involving diabetes care. At the conference, staff showed a great interest in learning more about diabetes and it was clear that the homes had little access to diabetes education. It was also evident that when staff had residents with diabetes, the need for understanding diabetes and access to diabetes care was greater.

A study morning was devised for the care home staff to give them basic diabetes information. The care home pharmacist was a very useful link, as she was visiting the homes on a regular basis and she could advertise the study morning and encourage the staff to attend.

The study morning was organised for the care home staff at a local venue which was easily accessible for the staff, and this was attended by 60 care home staff and evaluated positively. This addressed the problem of giving general diabetes information, but it was still difficult for staff to access information when they were having problems with their residents with diabetes, and some immediate information was required.

Although the study morning was successful, only a small proportion of staff had been able to attend, it was realised another method had to be devised as a way to reach more staff, at a time when they needed information.

Resource pack
The author attended a national meeting for DSNs; during discussion with individuals who had an interest in diabetes care in  residential homes, a suggestion was made about a resource pack which a district nurse had produced.

At a meeting with the local care home matrons, the suggestion of a resource pack for each care home was proposed. The matrons were keen to help develop this for the author’s local area.

It has been suggested that the pack should contain a checklist for annual review as well as information on:

• what diabetes is
• healthy eating
• weight management
• foot care
• management of hyperglycaemia (through tablets and insulin, for example)
• management of hypoglycaemic episodes
• how to contact the local diabetes department.

This pack is now being developed so that it can be made available to the care homes. The plan is to audit the resource pack in ten of the care homes that showed an interest at the local matrons meeting, to check how often it is used, before distributing it across all 125 homes.

Conclusion
The residential care home is not a glamorous area of health care (Benbow et al, 1997; Kerr, 2003). It is often difficult to monitor standards as the care homes are privately run and the staff can have difficulty in accessing training because of financial constraints.

It has been clearly stated that older people with diabetes are more vulnerable (Gregg et al, 2002), and if they receive improved diabetes care then the cost of health care for the local PCT could be decreased.

Bournemouth PCT has a responsibility to ensure that all people with diabetes in local care homes have access to good health care (Tattersall and Page, 1998). This should be achieved by setting up good communication links through a process that ensures staff are able to access the specialists when advice is needed.

It is a challenge to try to improve care for older people with diabetes in a residential setting. The problem cannot be solved by one simple method. If training can be delivered in a variety of ways and is accessible to all staff, the level of diabetes care can improve (Deakin and Littley, 2001), decreasing the risks to this vulnerable population.