SmartLife Health Shortlisted for Diabetes Dashboard Project

SmartLife Health have been shortlisted at the General Practice Awards for our work with Long Lane PCN.

Long Lane PCN commissioned SmartLife Health to improve outcomes for patients with Type II diabetes and allow clinicians to provide treatment and support in the most effective way. LLPCN have over 3000 patients on the diabetes register and needed a better way to treat, manage and monitor the progress of the patients. SmartLife Health developed a programme which:

1. Contacted patients via text and phone follow up with a clear message to inform them about the new service for diabetes management

2. Provided a direct link for patients to register for a session with a dedicated phone line

3. Allowed clinicians to refer directly when bloods were filed

4. Allowed patients to become informed about their condition and involved in their treatment

5. Delivered an ‘easy to use’ dashboard for clinicians to monitor patients’ progress

6. Managed data agreements

The project had four KPIs:

1. To improve patient outcomes measured by nine key care processes and three treatment targets.

2. To get 7.5% of diabetic patients responding to messages and booked into sessions

3. To save clinician time by reducing the number of necessary individual appointments

4. For 40% of patients attending VGCs or GCs to receive a mental health screening SmartLife Health developed an online portal called the ‘Diabetes Dashboard’ which extracted patient data from EMIS to show the progress of patients against the KPIs. The group consultations were designed to enable a diabetes specialist to run the sessions – virtually and in person – for patients with diabetes from seven practices. Patients who feel in control of their condition and who feel supported can take action to improve their health.

Diabetes Dashboard

SmartLife Health developed an online portal called the ‘Diabetes Dashboard’ which extracted patient data from EMIS to show the progress of patients against the KPIs.

The group consultations were designed to enable a diabetes specialist to run the sessions – virtually and in person – for patients with diabetes from seven practices. Patients who feel in control of their condition and who feel supported can take action to improve their health. All patients were encouraged to make an action plan with achievable milestones and share their experiences. Patients could view their progress through the dashboard which had both a clinical and a patient view.

The project exceeded expectations, with all KPIs met and the project expanded to a new cohort of patients. Secondary outcomes, including the improvement of Quality of Life, were achieved.

The number of patients who received the nine key care processes increased from an average of 41% of patients across the PCN to 53% after three months. Of those who attended GCs, this rose to 77%.

The early number of patients who met the three treatment targets, a harder target to achieve since it requires patient behavioural change, increased from 23% to 27%.

We more than doubled our KPI of eligible patients who responded and booked into sessions by reaching 16% of those eligible – 487 of 2838 patients.

The mental health screening exceeded expectations, jumping from 14% of patients having a mental health screening prior to the programme starting, to 50% by the end of March.

For those who attended a session, a huge 78% had a mental health screening.

We ran 48 sessions with an average ten patients booked per session and six attending. On average, this means we halved the time a clinician would have spent with these patients had it been on an individual basis.