Using mobile health to support the chronic care model: developing an institutional initiative

Abstract

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a "human face" to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

Figure 1

Conceptual representation of the text message-based chronic care program. ¹Health plan care managers enroll eligible member with type 1 or type 2 diabetes over the phone. ²Patient receives self-management support via automated text messages and respond to queries via text message. ³Patient's responses help to dynamically tailor content. ⁴The CareSmarts system collects patient data from the text message responses and ⁵alerts the care manager when exceptions require attention. ⁶Using protocols, the care manager provides telephone-based support to the patient and ⁷coordinates care with the provider. ⁸The provider follows up with the patient for any necessary care.