Written by: Center for Care Innovations

Idea: Use a cellular glucometer to increase patient compliance with recommended diabetes care and improve patient health outcomes.

Target: Diabetes patients with high HbA1c levels.

Project Highlights: Using a cell-enabled blood glucose meter, the patient is taught to check blood sugar 3 times per day. The meter works like other glucose meters, except that the results from each test are downloaded to a database. The panel manager views the patient’s test results and confers with the clinician on any adjustments in medication or other intervention. The initial pilot with 5 patients showed positive results with a drop in HbA1c across all patients (with an average decrease of 31% across 3 patients for whom HbA1c was verified).

The Pitch: “The most obvious benefit will be closer monitoring of patient blood glucose; especially important for the critical diabetics identified for this project. This paves the way for outcomes that need additional clinical support. The in-depth orientation and teaching that occurs at the beginning of the test period clarifies expectations and goals between the clinician and the patient, and the weekly ‘touch base’ strengthens the relationship between the panel manager and the patient. Keep in mind that the patients selected for this project have critically high HbA1c levels and, as such, the potential of sudden changes in blood sugar caused by new interventions may need to be mitigated by adjustments in medication. Therefore, it is imperative that the clinician is alert to these possible sudden changes; hence, the need for frequent monitoring of the results from the patient’s self-administered tests. There is also the benefit of knowledge gained in this innovation. As the clinic struggles with how to manage large volume patient populations, the innovation provides a rapid way to gather data on resources required to carry out a high intensity intervention.

“The introduction of a tangible item with enhanced functioning, i.e. the cell glucometer, signals a new beginning for patients who may feel a little hopeless in getting their health under control. In some ways, the patients may see the gadget as a representation of their clinician’s renewed willingness to invest in them. The orientation, teaching, and focused time the panel manager spends with the patient may help the patient understand that this is a partnership; one in which they play a significant role.

“Neighborhood Healthcare’s self-imposed Care Transformation initiative, a key concept in the organization’s current strategic plan, is premised on one target; what do we need in place to protect and optimize the Patient-Care Team relationship? Because, that relationship is key if the goal is a healthier patient. This innovation is impacting in that regard because it requires close and frequent contact between the partners, it empowers the patient and allows him/her to ‘own’ their care, and it brings the patient in as part of the Care Team. This project also makes a strong statement in the area of how we can provide patients with powerful tools that support self-care. One of the strongest benefits is that it encourages proactive behavior on the part of the patient (a rigid testing schedule and adherence to concepts learned) as well as the clinic (frequent monitoring of results data and adjusting interventions appropriately). Much of the ‘care’ is delivered over the telephone or via the data lookup, with potential to fold in other means of communication such as the patient portal. This alleviates the need for certain appointments with the exception of ones that are necessary. In a large sense, because unnecessary visits are potentially being curbed, this also creates access within the clinic schedule while decreasing cost for the patient and, if applicable, the health plan.”

Evidence of Cultural Change from the Innovation Process:

• The organization is more willing and eager to conduct more rapid tests of change.

• “The process was helpful in causing us to consider more of the 360o view around a problem. We see the value in taking time to consider all ideas as possible and then letting the probable rise to the top. Also key is the pause to interview and consider different, sometimes opposing, viewpoints and using the input to direct the project rather than merely to say that part of the process was fulfilled.”


Consent Form

Diabetes Nutritional Health Teaching Program—Pre and Post Test

TelCare Data Hub Screenshot

TelCare Follow Up Form