Enhancing care in residents with type 1 diabetes

The original National Advisory Panel for Care Home Diabetes (NAPCHD) project developed a series of documents underpinning a national Strategic Document of Diabetes Care for Care Homes. This proved to be an effective and welcome opportunity to provide guidance on delivering quality diabetes care in the UK. Further work by the NAPCHD has led to the recent publication of a position statement on the practical management of type 1 diabetes in care homes, following the identification of this area as being clinically important and topical in diabetes care. 

In this very brief review, I draw on the position statement to provide some key perspectives on type 1 diabetes care in care homes. In particular, I discuss minimum standards of diabetes care, insulin regimens, the use of continuous glucose monitoring and coordinated management in care homes.

Background

There are currently limited data on the prevalence and clinical outcomes associated with type 1 diabetes in care homes, and management policies have been non-existent in the UK. Residents are often highly comorbid, with reduced functional status, and at least two thirds could be described as having frailty of varying degrees.

Communication among all key stakeholders involved in the direct care of residents with type 1 diabetes is generally fragmented and lacks coordination. This is compounded by a slowly growing utilisation of diabetes technology and the absence of a standard/agreed community-based model of interdisciplinary collaboration.

The situation in Europe is not fundamentally better but, in the US and Canada, care processes are often more comprehensive, with a lower threshold for introducing technology, and care staff are often exposed to better training and education. The NAPCHD was motivated to produce its position statement for three principal reasons:

1. There was little published work on type 1 diabetes in community-dwelling older adults and even less on care home residents with type 1 diabetes. 
2. There was insufficient description of the key features of type 1 diabetes in care homes. 
3. There was a need to develop minimum standards of diabetes care for managing type 1 diabetes in care homes.

The full guidance can be accessed at https://bit.ly/4j2UWrq. It includes an appendix on assessment procedures that provides details on how to access key assessment tools on nutritional status, the detection of frailty, sick-day rules and foot risk stratification.

Summary of three key recommendations for commissioners

These could be considered to be generic, but are written in the context of residents with type 1 diabetes: 

• Access to specialist services is available to everyone with type 1 diabetes throughout their lifetime, as needed. This should encompass a personalised diabetes review schedule, based on individual needs, including blood tests as necessary, and appropriate health assessments. 
• A regular diabetes review, with a frequency based on individual’s needs, including health assessments. 
• Provision of local arrangements for a structured programme aimed at promptly initiating education and insulin therapy upon diagnosis. This will include managing insulin or insulin pump therapy, and training healthcare professionals and carers/patients.

Minimum standards of type 1 diabetes care in care homes

We emphasise that minimum standards of care ensure a consistent framework for managing residents with diabetes and form the basis of quality care provision and audit work. A degree of responsibility is required to ensure that each standard is met. Responsibility for each standard lies either: with the care home management and its staff; the care home management and its staff jointly with the individual resident; or, where standards of competency in diabetes care apply, with individual care staff. 

We defined 15 standards that range from every resident having a personalised care and nutritional plan, an annual diabetes review, regular reviews of self-care capabilities and a care passport, to the presence of a well-stocked and up-to-date “hypo” box, the regular half-day release of care staff for education and training in type 1 diabetes, and regular auditing to collect data.

Insulin regimens in care homes

We emphasise that insulin treatment strategies should be individualised according to health status and presence and severity of frailty and life expectancy. If the resident with type 1 diabetes still has preserved self-care skills, a basal–bolus (or multiple daily injections) regimen with a long-acting insulin (e.g. detemir or glargine) once/twice daily and a rapid-acting analogue with meals (according to their individualised treatment plan) is often the gold standard approach to treatment.

It is recognised that if the dexterity of the care home resident with type 1 diabetes is impaired (e.g. visual loss, tremor or neuropathy), the insulin can be given under supervision by trained care staff or, alternatively, by registered nursing staff (if available) or district nurses from the community. Details of different regimens can be found in the full guidance.

Continuous glucose monitoring in care homes

There is no accepted or published guidance for glucose “metrics” in older people. A consensus published a few years ago, recommended for older individuals with type 1 diabetes a time in range of >50% and time below range of <1%. These targets do not, however, take into consideration the presence of frailty, health status or duration of diabetes. The full guidance discusses the currently available continuous glucose monitoring (CGM) metrics, use of pump therapy and other automated insulin delivery systems.

Coordinated management of type 1 diabetes in care homes

The responsibility for high-quality care for residents with type 1 diabetes must be shared between the care home management, primary care (including the GP), community nursing care and the diabetes specialist teams operating in the hospital and the community. Evidence for type 1 diabetes pathways for older people is, unfortunately, minimal. Figure 1 provides a number of key elements.

Summary

It must be emphasised that to implement this guidance, local authorities and the NHS need to work more collaboratively with the care sector and share their training provision. For example, if community nurses are receiving management of diabetes training, extend the invitation to the local nursing homes. Community nurses could also work with the local nursing and care homes to provide training and assess and confirm registered nurses’ competence in the administration of insulin and the use of insulin pumps and CGM.

Key messages

• An England-wide, multidisciplinary collaboration by the NAPCHD on the management of type 1 diabetes is now available.
• The Position Statement provides the first comprehensive guidance on the implementation of insulin regimens, use of glucose and HbA_1c targets, and monitoring frequency for residents with type 1 diabetes, and the avoidance of acute complications for optimum safety.
• 15 minimum standards of care for type 1 diabetes in care homes are shown in the published article in Diabetic Medicine.
• We have listed the key elements of a community scheme for the management of type 1 diabetes in care homes.