Identifying High-risk Cohorts through Reconnect to RetinaScreen Initiative to Prevent Sight Loss

NEC Care Ireland along with the National Screening Service (NSS) piloted an initiative ‘Reconnect to RetinaScreen’ to identify a cohort of patients who have never attended a diabetic retinopathy screening appointment. The initiative improved screening uptake and early disease detection in high-risk patients.

Overview

Diabetic eye disease can progress silently to irreversible vision loss without early detection. Hence, to improve wider public health, Diabetic RetinaScreen (DRS) is delivered through the National Screening Programme.

The Challenge

Diabetic retinopathy is a preventable disease. If diagnosed early, slight loss can be minimised and prevented. However, there are many people who have never attended retinopathy screening appointment despite being registered with the Diabetic RetinaScreen Programme. This group represents significant public health and patient safety risks.

The screening team recognised the need to identify such cohorts, understand their problems, and provide them with targeted support through the Reconnect to RetinaScreen initiative.

Objectives

The ‘Reconnect to RetinaScreen’ initiative was developed with clear, measurable objectives aligned to public health impact, prevention and service sustainability.

• Improve patient safety and prevention by supporting early detection and intervention.
• Increase engagement among high‑risk cohorts
• Deliver measurable population impact with clear metrics for contact rates, attendance and confirmed future engagement.
• Enhance equity of access through personalised contact and flexible appointment options.
• Support long‑term health management
• Improve service efficiency and sustainability
• Success was defined not only by attendance, but by demonstrable engagement outcomes, improved data integrity and the creation of a repeatable model that can be applied to future cohorts within national screening services.

The Solution

NEC Care Ireland implemented the ‘Reconnect to RetinaScreen’ initiative in 2025-2026. The strategy was unique and involved identifying cohort, data-driven targeting with compassionate, user-centered outreach to support patients back into screening or to guide them to alternative care options.

The Impact

Reconnect to RetinaScreen was designed as a scalable model with standardised coding and clear evaluation criteria. Of the 80 patients screened –

• 61 returned to annual recall
• 19 required further intervention, including 7 ophthalmology referrals (4 for Diabetic Retinopathy, and 3 for other eye pathology) and 2 urgent sight-saving referrals.
• an additional 5 patients were placed on a one-month DS recall.

Without outreach, the 9 patients needing specialist care may have remained undiagnosed and at risk of preventable vision loss.

Conclusion

The Reconnect to RetinaScreen initiative demonstrates that non-attendance is not disengagement—it is a solvable access issue.

By combining data, persistence and patient-centered care, the initiative, reengaged high-risk patients, improved early detection, reduced inequity in access, and strengthened patient safety.

Through this model, Diabetic RetinaScreen has evolved from a traditional screening service into a proactive, equitable, and patient-first healthcare system. By combining data, empathy, and innovation, we have proven that engagement—not just access—drives outcomes, delivering measurable improvements in capacity, inclusion, and patient experience at a national scale.