A population health improvement project developed by a participant on the CARE programme focused on providing high risk diabetic patients with a total of 2 hours of telephone based diet and life style support over 3-6 months. Calls were aimed at improving trust through a motivational interview based technique. 50% of patients were from BAME communities previously considered hard to engage. Results saw over 30 point reduction in glucose levels, a 12% reduction in BP readings and increased patient activation. ROI of 0.83 in year one and 1.7 in year 2 based on 120 minute nursing time saving 100 minutes of GP time, which doesn’t account for increased patient benefits or reduced demands on other services.
