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Case Study 1: Telehealth Enhances Diabetes Team Care in Hawaii

Joe Humphry, M.D.

Setting

Ms. LK is a 54-year-old Hawaiian female living on the Hamakua Coast on the Island of Hawaii with her husband and daughter. She has had type 2 diabetes for 10 years and associated hypertension and hyperlipidemia. She is under the care of a primary care physician at the rural community health center, which is about 10 miles from her home.

Team members

Team members include the patient and her family, primary care physician, eye specialist, chronic care nurse, community health worker, librarian, endocrinologist, and pharmacist.

Services provided at the Community Health Center

Ms. LK received her annual retinal screening using the teleophthalmology non-mydriatic camera at the health center. She previously had limited access to eye care. The retinal images were read by the Hawaii Telephthalmology Imaging Center, and the report was electronically sent to her primary care physician.

Ms. LK received education about insulin use and administration, and hypoglycemia management from the chronic care nurse when insulin therapy became necessary.

Services provided by the Native Hawaiian Health System

To help manage her diabetes, Ms. LK enrolled in the Native Hawaiian Health System remote monitoring program. As part of the program, a community health worker visited Ms. LK at home and delivered a blue tooth­­­-enabled blood glucose (BG) meter and blood pressure (BP) cuff for BG and BP monitoring, demonstrated how to transmit the BG and BP readings after each reading, and uploaded the BG readings to the web-based Chronic Disease Management Program. Shortly after the upload, Ms. LK received a text message from her health care team thanking her for enrolling in the monitoring program. The community health worker referred Ms. LK and her daughter to the local public library for training to access her online portal and view her personal health record. The program donated a computer to the library in exchange for the librarian training of patients and patients’ use of the computer.

Other aspects of the Chronic Disease Management Program include an educational library, patient alerts, email consultation, nutritional survey and assessment, behavioral health risk survey, electronic health record interface with the community health center, remote home monitoring, and a complete care plan. The program also conducts medication reconciliation to ensure that the patient is taking only currently prescribed medications and dosages.

Communication

The secure web-based Chronic Disease Management Program enabled the patient and the community health worker to communicate with the community health center physician and chronic care nurse. Ms. LK uploaded BG and BP readings for their review and received their instructions for adjusting her medication doses.

The community health worker recorded the findings of her patient visits for the community health center physician and chronic care nurse to review and to convey further instructions as necessary. The patient and other team members also conducted secure email consultations with an endocrinologist located on the Island of Oahu. The community pharmacist who refilled Ms. LK’s medications was able to help her understand why she needed insulin.

Insurance coverage

In the current traditional payment system, the e-health activities and the outreach worker’s time are not covered. The Community Health Center and the Native Hawaiian Healthcare System are compensated for “enabling services,” making the e-health system a covered service. In the future, coverage will be through the management fee for the Medical Home Model or covered through an Accountable Care Organization Model* with a single payment to a larger organization that has an integrated delivery system. Kaiser Permanente currently uses many of the components of this system to reduce cost and improve access.

Outcomes

Ms. LK’s insulin was effectively adjusted, and she took her BP medication daily. Her improved BG and BP values were recognized by the web application, and she received supportive text messages recognizing her improved diabetes management. The community health worker visited her every two weeks. Ms. LK visited the community health center physician and chronic care nurse every three months. Between visits, they were in touch via email. As a result of the telehealth support, face-to-face visit time focused on reviewing and setting self-management goals and discussing the support she needed to achieve her goals. Ms. LK took more responsibility for her diabetes self-management. Her self-monitored BG, A1C, and BP values improved.

*The Accountable Care Organization Model encourages physicians and hospitals to integrate care by holding them jointly responsible for Medicare quality and costs.

February 2013

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