Chronic Care Management Services for Complex Diabetes Management: a Practical Overview

Valle, Kayla L. Del; McDonnell, Marie E.

doi:10.1007/s11892-018-1118-x

Cited by 19 publications

(15 citation statements)

References 26 publications

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“…(Hill et al, 2013) Questions regarding possible mediators of the relationship between financial hardship and health, such as stress, should also be considered. In addition, these results highlight the importance of interdisciplinary care teams that include clinicians and social workers trained in addressing financial challenges (Ambrose-Miller & Ashcroft, 2016; Del Valle & McDonnell, 2018; McGill et al, 2017).…”

Section: Discussionmentioning

confidence: 94%

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes

et al. 2020

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Aim: To examine the relationship between multiple measures of financial hardship and glycemic control in older adults with diabetes. Methods: Using data from Health and Retirement Study (HRS), we investigated four measures of financial hardship: difficulty paying bills, ongoing financial strain, decreasing food intake due to money, and taking less medication due to cost. Using linear regression models, we investigated the relationship between each measure, and a cumulative score of hardships per person, on glycemic control (HbA1c). Results: After adjustment, a significant relationship existed with each increasing number of hardships associated with increasing HbA1c (0.09, [95%CI 0.04, 0.14]). Difficulty paying bills (0.25, [95%CI 0.14, 0.35]) and decreased medication usage due to cost (0.17, [95%CI 0.03, 0.31]) remained significantly associated with HbA1c. Conclusion: In older adults, difficulty paying bills and cost-related medication nonadherence is associated with glycemic control, and every additional financial hardship was associated with an increased HbA1c by nearly 0.1%.

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Section: Discussionmentioning

confidence: 94%

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes

et al. 2020

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“…As technology advances, there is an increasing opportunity for a comprehensive, affordable, and personalized solution that can leverage existing technology to provide care to patients post discharge in real-world settings [31,43]. Recently, CMS approved reimbursement codes for remote monitoring and nonface-to-face chronic care disease management [44]. Diseases with increasing cost and health burdens such as HF could particularly benefit from such solutions.…”

Section: Discussionmentioning

confidence: 99%

Impact on Readmission Reduction Among Heart Failure Patients Using Digital Health Monitoring: Feasibility and Adoptability Study

Park¹,

Otobo²,

Ullman³

et al. 2019

JMIR Med Inform

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BackgroundHeart failure (HF) is a condition that affects approximately 6.2 million people in the United States and has a 5-year mortality rate of approximately 42%. With the prevalence expected to exceed 8 million cases by 2030, projections estimate that total annual HF costs will increase to nearly US $70 billion. Recently, the advent of remote monitoring technology has significantly broadened the scope of the physician’s reach in chronic disease management.ObjectiveThe goal of our program, named the Heart Health Program, was to examine the feasibility of using digital health monitoring in real-world home settings, ascertain patient adoption, and evaluate impact on 30-day readmission rate.MethodsA digital medicine software platform developed at Mount Sinai Health System, called RxUniverse, was used to prescribe a digital care pathway including the HealthPROMISE digital therapeutic and iHealth mobile apps to patients’ personal smartphones. Vital sign data, including blood pressure (BP) and weight, were collected through an ambulatory remote monitoring system that comprised a mobile app and complementary consumer-grade Bluetooth-connected smart devices (BP cuff and digital scale) that send data to the provider care teams. Care teams were alerted via a Web-based dashboard of abnormal patient BP and weight change readings, and further action was taken at the clinicians’ discretion. We used statistical analyses to determine risk factors associated with 30-day all-cause readmission.ResultsOverall, the Heart Health Program included 58 patients admitted to the Mount Sinai Hospital for HF. The 30-day hospital readmission rate was 10% (6/58), compared with the national readmission rates of approximately 25% and the Mount Sinai Hospital’s average of approximately 23%. Single marital status (P=.06) and history of percutaneous coronary intervention (P=.08) were associated with readmission. Readmitted patients were also less likely to have been previously prescribed angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (P=.02). Notably, readmitted patients utilized the BP and weight monitors less than nonreadmitted patients, and patients aged younger than 70 years used the monitors more frequently on average than those aged over 70 years, though these trends did not reach statistical significance. The percentage of the 58 patients using the monitors at least once dropped from 83% (42/58) in the first week after discharge to 46% (23/58) in the fourth week.ConclusionsGiven the increasing burden of HF, there is a need for an effective and sustainable remote monitoring system for HF patients following hospital discharge. We identified clinical and social factors as well as remote monitoring usage trends that identify targetable patient populations that could benefit most from integration of daily remote monitoring. In addition, we demonstrated that interventions driven by real-time vital sign data may greatly aid in reducing hospital readmissions and costs while improving patient outcomes.

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“…Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients' self-management (13)(14)(15). There are references to guide the implementation of the CCM into diabetes care delivery, including opportunities and challenges (16).…”

Section: Chronic Care Modelmentioning

confidence: 99%

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2021

Association¹

2020

Diabetes Care

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The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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Chronic Care Management Services for Complex Diabetes Management: a Practical Overview

Cited by 19 publications

References 26 publications

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes

Relationship Between Multiple Measures of Financial Hardship and Glycemic Control in Older Adults With Diabetes

Impact on Readmission Reduction Among Heart Failure Patients Using Digital Health Monitoring: Feasibility and Adoptability Study

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2021

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