Diabetes prehab service using population health tech reports benefits, including drops in blood sugar levels, BMI and weight.

One Wirral CIC has reported that its data-led diabetes prehabilitation service is already resulting in significant patient benefits.

The community based and patient-centred service was launched in April 2023 to reduce surgery postponements, tackle waiting lists, and improve postoperative outcomes for patients - utilising a personalised prehabilitation approach as opposed to a traditional clinical model.

It uses Graphnet Health’s population health platform and analysis of hospital waiting lists at Wirral’s Arrowe Park Hospital to identify and support diabetes patients that are most at risk of having surgery postponed.

Since the programme was launched, the following benefits have been recorded: 

-              178 patient referrals.

-              Average HbA1c drop from 73.4mmols to 63.25mmols over course of 12 weeks.

-              Average BMI drop from 34.2 to 32.99 over course of 12 weeks.

-              Average weight drop from 98.41kg to 95.45kg over course of 12 weeks.

Fifty-eight people have been reviewed by a diabetes specialist nurse, 37 have had medication added, following a review (such as SGLT2i, metformin or gliclazide), 19 patients have received support with their insulin, and 6 patients have commenced on Libre sensors (a sensor-based glucose monitoring system).

Initially, the service supported two Primary Care Networks - Moreton and Meols PCN and North Coast Alliance PCN, funded by the North West Coast Clinical Networks. However, the service has now been extended across Wirral to all Primary Care Networks. The goal is for the approach to be adopted nationally. 

The early identification of patients at risk of having their surgery postponed removes the need for GP surgeries to make referrals. The service also receives referrals directly from secondary care, for people that have had their surgery postponed, and have diabetic risk factors. 

Lucy Holmes, Wellbeing Lead at One Wirral CIC explained: 

Once identified, patients are contacted within 48 hours and booked in for an appointment with a diabetes prehabilitation health coach, in a local community setting, such as a library. If a person’s HbA1c is over 69, they are automatically booked in for an appointment with a diabetes specialist nurse, who will look at medicines management and optimisation.

Once they have seen the health coach and nurse, they commence a personalised prehabilitation lifestyle plan, which they follow up until surgery, whether that is a matter of weeks or months.

The population health and data-driven approach means we are able to contact the right people at the right time and give them the best intervention before their procedure. We look at their lifestyle and they’re encouraged to participate in activities, including the free diabetes exercise sessions that are held in the community each week. Their medications are also assessed. It means we’re looking at a person from a holistic point of view, not just clinically and not just non-clinically. It’s a true community-based, multi-disciplinary team approach.

Engagement and feedback have been overwhelmingly positive with patients attending appointments and exercise sessions with confidence and enthusiasm.

That includes local resident, Paul, who was originally refused surgery due to a high HbA1c. Initially, he could only do five minutes of activity. With the help of the prehabilitation team, he has now completed the service and continues to make positive lifestyle changes on his own.

I have been able to get a grip on my blood sugars, largely due to the fact that I can now use the Libre 2 Freestyle to help me monitor my blood sugars on a much more regular schedule, and understand the impact of certain foods.

I am happy to see that my blood sugars have been a lot lower and there have been a few occasions where I have experienced a hypo (when blood sugar levels are lower than the standard range), which I have not done for years. This has led me to being able to reduce my insulin.

I never understood the people who said that they enjoyed exercise, and who said they felt in a better mood after exercise. Well, I can say that this service has made me do a 180 on my views.

To hear more about the benefits of the diabetes prehabilitation service, please click the video link: