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How implementing digital solutions in primary care improved diabetes patient management

Overview

A GP practice in North London illustrates the practicalities of implementing digital health solutions, with digital inclusion in mind, to help patients with diabetes to have the access, skills, and confidence they need to benefit from them.

Cost and workforce pressures, as well as the growing demand for services, are driving the need for digital technologies in primary care.

Challenges that led to the practice adopting digital solutions

The practice implemented the mySugr® app and RocheDiabetes Care Platform to help overcome a variety of challenges, including:

  • To help combat workforce pressures
  • To provide patients with easier access to care
  • To provide more dynamic monitoring of patients
  • To help increase patient self-management of diabetes
  • To help overcome population-based challenges such as language barriers, cultural challenges and digital literacy
"We have fewer people managing a growing number of relatively high-risk patients. Once you add in the complexity of barriers to patient self-management, such as language barriers and communication, you have a perfect storm of diabetes management challenges, which we hope digital technology can help with.”

GP Partner

Results: After introducing the mySugr app and the RocheDiabetes Care Platform

Nurse with patient and tablet

Improved access to accurate real-time blood glucose data

With improved access to accurate real-time blood glucose data, healthcare professionals at the practice felt they had more confidence in making clinical decisions. Using the mySugr app and RocheDiabetes Care Platform enabled healthcare professionals to have increased knowledge of individual patient circumstances, enabling them to deliver more personalised care.

Hypo safety concerns were able to be identified, and patients could also be risk stratified, which helped improve capacity at the practice.

Patients also reported feeling more engaged with their diabetes self-management.

How digital solutions were implemented at the practice

What

  • Type 2 diabetes patients, without moderate or severe frailty, were placed on the Accu-Chek Instant blood glucose meter with the mySugr app and connected to the RocheDiabetes Care Platform

Who

  • GP Partner ran searches and decided which patients to focus on
  • Senior Clinical Pharmacist with an interest in diabetes managed the platform on a day-to-day basis
  • Practice reception manager coordinated patient activities

How

  • As the patient cohort included patients with language barriers, a structured face-to-face clinic for connecting the RocheDiabetes Care Platform and mySugr app was delivered
  • Letters were sent to patients advising them what to bring to the appointment and what to do before coming into the clinic
  • When required, follow-up telephone support was provided

Data

The team focused on the following patient data:

  • Safety thresholds e.g. hypo events
  • How many times the patients had checked their blood glucose levels based on the advice the GP had given them
  • Measurements in range
Patient example 1

Visibility of data gives confidence that the patient is under control

Profile: Aged 65, has LADA, under the care of a hospital diabetes clinic

Prior to digital solutions

The patient’s HbA1c was stable, their self-reported blood glucose readings were 7-8 mmol/L

Results following onboarding to digital solutions
  • Using technology, the patient’s measurements in range increases from 62% to 81%, alongside increased blood glucose monitoring
  • The patient reports that they think the mySugr app is ‘great’ and reports feeling far more engaged now than ever before
  • The patient finds the colours in the app help them understand their readings and their relationship with food
  • With visibility of this data, their GP has confidence that the patient’s diabetes is well managed
  • As this patient requires limited intervention from the GP, the practice can focus on interventions with other patients
“His HbA1c has been only a little out of range but having a clear idea of when his spikes were was the most useful bit to me from a clinical perspective.”

GP Partner

Patient example 2

Hypo risk now highlighted with RocheDiabetes Care Platform

Profile: Aged 52, type 2 diabetes, on insulin, English isn't first language

Prior to digital solutions

The patient was self-reporting their blood glucose readings with no reported hypos

Results following onboarding to digital solutions
  • The GP found significant number of hypos, at one point patient’s blood glucose was low 100% of the time, of these 56% of blood glucose measurement were very low (less than 3.0mmol/L)
  • The patient was then called in by the GP for a full face-to- face review and medication adjusted
  • Following this appointment, the patient’s blood glucose readings improved, with their measurements in range 64% of the time, with only 35% of these measurements being low
  • Technology has allowed the GP to change how they monitor this patient and has given them awareness of hypos
“The patient didn’t come to us reporting hypos, we spotted these because we had this technology in our hands. These hypos wouldn’t have been apparent to us without this technology.” 

GP Partner

Key recommendations for implementing digital solutions

From a primary care practice in North London

 

1. Consider who in your practice is involved

Involving at least three people is helpful - one to have oversight, one to run the technology and one to coordinate patient logistics.

 

2. Consider the patient cohort you select

There is a window of opportunity for patient engagement, introducing digital at this time can help to shape their diabetes self management.

For engaged patients this technology could reduce the amount of times they visit the practice.

Disengaged patients, at a higher risk of developing complications, may require significant time investment, but the impact of digital for those patients could be huge.

 

3. Consider the patients with access to compatible tech

Don’t make assumptions based on a patient’s digital literacy, age, ethnicity etc.

 

4. Consider how you communicate to patients

The practice saw an 86% attendance rate to their RocheDiabetes Care Platform clinic, in their cohort of largely disengaged patients.

Make the benefits of the digital solutions clear to the patient to help increase engagement.

By sending a letter detailing key points to patients, and making a pre-appointment telephone call, patients were clear on why they were attending the clinic.

 

5. Consider a protocol for using the system

By determining how frequently you will review the data and what action you will take you can manage expectations within the clinical team and with the patient.

Consider regular meetings to assess the platform and data - the practice reviewed data monthly, identifying patient trends and making assessments of whether to bring the patient in earlier, shortening the gap from review to review in patients who need an intervention.

"Not only does your confidence in making clinical interventions improve but you have the opportunity, should you wish, to share the management plan with the patient to titrate their insulin independently.”

GP Partner

Download the full case study
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Learn more about the RocheDiabetes Care Platform

If you would like to learn more about the Accu-Chek Instant blood glucose meter, mySugr app or RocheDiabetes Care Platform and how these could support your healthcare setting, please fill in the form below to request a demo.

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The lifestyle images included in this article are stock photos used for illustrative purposes only.

Quotations sourced from recorded interviews as part of a consultancy agreement with Roche Diabetes Care in 2023.

The mySugr Bolus Calculator is licensed for people with diabetes over the age of 18 years. The mySugr logbook is licensed for people with diabetes over the age of 16 years.