WNY Beacon worked with home health and visiting nurse organizations to deploy telemonitoring devices that allow patients at home to remotely submit their glucose, blood pressure, and weight readings. The focus was on high-risk diabetic patients with a goal of reducing preventative emergency room visits and hospital re-admissions. Where appropriate, the data was also made available to primary care providers via HEALTHeLINK, giving physicians the ability to adjust their patients’ treatment quickly and proactively.
Diabetic patients participated: 144
Enrolled for a two-year timeframe: 105
- Patients have reported a better understanding of their condition, lower blood pressure, lower glucose, and weight loss. Many of those patients who had a baseline HbA1C>9 are now below 9.
- The seven practices and 32 primary care doctors who participated found the intervention to be useful, particularly in improving their care programs and workflows. Nutritional programs were developed, and one of the participating home health agencies received a $1 million federal grant to expand the telemonitoring intervention into rural communities.
“I see all of this as one big puzzle and without all of the pieces it falls apart. I have maintained better blood sugar control, blood pressure control, and weight loss since beginning on telemonitoring.”
Medication therapy management
To improve transitions of care for diabetic patients, WNY Beacon launched a medication history pilot featuring a real-time alert system.
Often, high-risk diabetic patients require changes to their medications after visits to emergency rooms or other facilities. This program ensured that upon discharge, a comprehensive medication review would be performed and primary care providers would be notified of any and all recommended changes to a patient’s medication regimen.
- Six practices and one hospital system participated in the initial pilot.
- In addition to improving patient care, this pilot increased the amount of medication history data available within HEALTHeLINK through the addition of hospital discharge and long-term care pharmacy medication information.
A patient portal enables physicians to forward data directly to a personal health record that providers and patients control. Working in conjunction with its clinical transformation partner, Catholic Medical Partners, WNY Beacon focused on assisting practices in setting up their patient portals through their EHR systems.
- WNY Beacon assisted 57 practices in implementing a patient portal, giving over 700 diabetic patients access to their prescription refills, appointment requests, and lab results.
- In 2010, only 12% of the participating Beacon practices were using a patient portal. By the end of the program, that figure had grown to 55%.
- WNY Beacon’s work with patient portals served as an important foundation for HEALTHeLINK’S ongoing efforts to develop a communitywide patient portal network.
“It’s a nice way to reach out to the patients through a different medium to improve the one-on-one connection that we have where they can ask us questions and we can send them helpful information that may be good tools for the patient.”
Dr. Chad Szymanski
Wheatfield Family Medicine
To help patients take a more active role in their health care, a kit that kept their health information and medication together was developed. Patients were asked to bring this HEALTHeHISTORY kit, which included a tote bag and folder to store visit summaries and lab results, to each doctor visit and any trip to the hospital.
- 5,000 kits were distributed to diabetic patients as part of WNY Beacon.
Each tote = 100 kits