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Providing diabetes care and support to students in higher education

Gil Ramsden
, Charlotte Flatley
, Carolyn Mitchell
, Linda Clapham

Students with diabetes face many challenges when starting university. Many continue to attend a secondary care clinic in their home town, where they are known to the team, rather than being referred to a hospital clinic near the university. This can present unique challenges for a university medical practice, which is expected to provide care to a large number of young people with diabetes, most of whom have type 1 diabetes. This article describes a diabetes website, clinic and group education sessions for students with diabetes attending the Leeds Student Medical Practice. The aim was to improve and coordinate diabetes care for the students by working with their current diabetes care providers.

Providing support and care to university students with diabetes can be challenging. Arrival at university is a time of ‘firsts’ for all students: it is often the first time they have lived away from home, and the first time they have fully managed their own diet and nutrition, as well as their own finances and time. All of these add to the number of decisions that students with diabetes need to make in order to manage their diabetes successfully, which they may be doing for themselves, for the first time.

The Leeds Student Medical Practice
The Leeds Student Medical Practice is an inner-city GP practice serving particularly, but not exclusively, the needs of students attending the colleges and universities in the Leeds area. There are approximately 35500 people on the practice list; their ages range from 0 to 70 years, although the majority are under 30. Ninety-four different nationalities are represented on the list. Within the practice population, 83 have type 1 diabetes and 12 have type 2 diabetes.

In April 2005 it was agreed that a diabetes register and diabetes clinic would be set up at the practice. In addition it was recognised that there was a need to provide information on diabetes on the practice website as a resource that all] students with diabetes could access (www.leedsstudentmedicalpractice.co.uk). Several factors contributed to moving this service initiative forward:

  • The nursing manager was keen to develop the nursing roles within the practice.
  • The presence of a practice nurse and other members of the team with an interest in diabetes.
  • The publication of several Department of Health (DoH) documents: the National Service Framework for Diabetes: Standards (DoH, 2001), Agenda for Change (DoH, 2004) and Our Health, Our Care, Our Say: A new direction for community services (DoH, 2006) and – perhaps more pertinent to the timing – the introduction of the nGMS contract.

A diabetes support team was formed, and consisted of a practice nurse, a GP, a healthcare assistant (HCA) and a receptionist who provided administrative support.

A DSN and a dietitian had recently been employed by Leeds Primary Care Trust to support practices in the development of these clinics. These health professionals provided direct support by running clinics and group education sessions, and helped to develop the skills and knowledge of staff involved in the clinics, as well as the protocols and systems needed to run the clinics effectively.

The aim of the diabetes clinic, as described on the website, is to:

“…provide a service which is based on your individual needs, and have direct access to other health professionals (such as a diabetes specialist nurse, podiatrist and dietitian). We want to ensure that your care is delivered as competently, consistently and concisely as possible by working with your current diabetes care providers.”

The website
One aim of the diabetes section of the website is to advise prospective students of the service we provide. The web pages contain information on how to register with the practice, and how students can share information about their current clinical care, which can reduce repetition of tests and investigations and promotes seamless care. Forms can be downloaded and personal information completed prior to registering with us, giving details of students’ current diabetes care provider, most recent blood tests or investigations and current insulin requirements. This information can be freeposted back to the practice or brought to the initial appointment so that relevant information is promptly accessible early in the registration period.

The website also contains information developed by the team on: 

  • Hypoglycaemia and hyperglycaemia.
  • Sick day rules.
  • The implications of illicit drug taking and alcohol consumption for students with diabetes – an issue facing many students, especially when they first arrive at university.

Links were inserted to many other informative sites that provide diabetes advice. Some of which are especially relevant to the student, for example, travel advice, contraception and pre-conceptual advice. 

The website is constantly evolving and has already received favourable reports from students and other health professionals, who have accessed it and found the information clear and informative.

Plans are being made to formally audit the value of the website by asking those students who have accessed it to complete a questionnaire designed to elicit their views and opinions.

Establishing the diabetes clinic
Team meetings were held to develop a pathway of care and a patient journey, and establish individual roles and responsibilities within the clinic.

Clinics are held weekly by the practice team, with the DSN and dietitian attending one session each month.

The students with diabetes identified on the practice register were sent a letter inviting them to attend the clinic. Initially, however, the response to sending out the letter alone was very slow, so it was decided that in addition to the letter the receptionist would phone the students to encourage them to attend the clinic. This has proved very successful, especially in conjunction with sending text messages to students’ mobile phones reminding them of their clinic appointments a few days before the appointment. ‘Text messaging appointment reminders’ is a service innovation that has been praised by the Department of Health (2006). It has had the effect of reducing the high ‘Did not attend’ (DNA) rate, which students are renowned for (Centre for Innovation in Primary Care, 1999).

As the knowledge and skills of practice staff regarding the management of diabetes  increased, there were tangible benefits for students. The practice noted an overall average reduction in HbA1c of 0.76% since the new service was introduced. For example, many have now realised the benefits of changing to a more flexible insulin regimen at such an unpredictable time in their lives. Furthermore, the diabetes support team has gained the confidence to help students achieve this within the diabetes clinic, with the help of the DSN. 

Many students are extremely grateful to have someone listen to them (See Box 1, for the response of one student), and perhaps to revisit areas of their diabetes management which, until coming to university, their parents may have had most control over. The clinic has also been of value in providing the opportunity for students  to review areas of education that may not have been dealt with if they were diagnosed at a young age, such as contraception, managing alcohol, the use of illicit substances, driving and travel issues.

Annual review
It was necessary to introduce an annual review process to provide structure to the care and to ensure that all elements of the new GMS contract were addressed, in addition to meeting the gold standards of care detailed in the National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2004).

The review process is structured as follows:

  • Interview with the healthcare assistant.
  • Interview with a practice nurse.
  • Appointment with a GP.

Interview with a healthcare assistant (HCA)
First the student sees the HCA, who is responsible for recording weight and height and performing venepuncture for relevant blood tests. The HCA also sends a urine sample for microalbuminuria screening and, working within the scope of the standards for medicines management (Nursing and Midwifery Council, 2007) gives flu or pneumococcal vaccinations if required in accordance with a Patient Specific Direction (PSD). The HCA has also received training in testing visual acuity, foot screening and offering smoking cessation advice.

Interview with a practice nurse
The student then sees a practice nurse to work through the annual review computer template. This provides students with the opportunity to discuss any concerns about their diabetes management, including insulin dosage, self monitoring of blood glucose, diet, exercise, alcohol intake, and hypoglycaemic episodes and their management. 

Appointment with a GP
The student is then offered a 10-minute appointment with the GP timed for 2 weeks later to discuss the blood test results. In addition, students are given the opportunity to transfer their secondary care provider to Leeds for the duration of their studies. Students often prefer to continue attending their home-based teams; however, they can be referred just for annual retinal screening if they wish.

Group education sessions
It became apparent that dietary issues were one area that it was particularly important to address. Many students were trying to manage on a restricted budget and their knowledge of carbohydrates and insulin adjustment was also limited. They were often eating ‘fast food’ or ‘junk food’, which was often not helping them to manage their diabetes effectively. 

Carbohydrate counting and awareness sessions were organised. Up to eight students were invited to each group education session, where a DSN and dietitian gave specialist advice. Sessions are held three times a year and attendance has been variable; 50% of students have been formally invited and 25% of these have attended. The remaining 50% of students have either already attended similar sessions elsewhere or said they did not want to attend, usually because the timing of the session was inconvenient for their academic timetable. Not only did the students gain information about carbohydrates and how to adjust their insulin dose from these sessions, but they also had the opportunity to mix with and learn from other young people with diabetes.

Future plans
The diabetes support team is working on the development of a patient-held record. As previously stated, students will often attend secondary care clinics near to their home to try to avoid duplication of investigations and aid effective communication. It is hoped that a patient-held record will provide a useful record that can be shared between primary and secondary care, including agreed action plans and goals. This would also enable students to feel more closely involved in their own care – something the Nursing and Midwifery Council (2007) is trying to encourage. The possibility of giving advice to students by email is also being investigated; this has been successful in other areas within the practice, particularly the provision of travel advice.

Conclusion
Some students have achieved a clinically significant reduction in their HbA1c level as a result of insulin adjustment or other lifestyle advice received in the clinic; however, anecdotal evidence confirms that the diabetes clinic and website have improved the care of most students with diabetes registered with the practice to some degree. The clinic has also given students the opportunity to meet and learn from others with diabetes and has increased their knowledge regarding diet and insulin adjustment.

Acknowledgements
The authors would like to thank Mindy Galsinh, Community Dietitian, for her support.

REFERENCES:

Centre for Innovation in Primary Care (1999) Did Not Attends: Who are they, and what can be done about them? Available at www.innovate.org.uk/Library (accessed 07.05.08)
Department of Health (2001) National Service Framework for Diabetes: Standards. DoH, London
Department of Health (2006) Our Health, Our Care, Our Say: A new direction for community services. CM 6737. DoH, London
NICE (2004) Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in Children, Young People and Adults. Clinical Guideline 15. NICE, London
Nursing and Midwifery Council (NMC; 2007) A–Z Advice Sheet – Record Keeping. NMC, London

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