Digital connection, coaching offers more support for people with diabetes
Key Takeaways:
- OSF OnCall, the digital health arm of OSF HealthCare, is supporting people with diabetes through unique medium and high-touch digital support
- The 24/7 digital connection is a wraparound service after some individuals have been hospitalized while another program is for those with rising risks from their diabetes
- People with diabetes can qualify for either program if they have Medicaid. The high touch, acute care program is also covered by Humana Medicare Part C
John Thurman, 73, says there were times during his health struggles that he almost gave up on trying to get better. The Peoria resident has Type 2 diabetes, high blood pressure, atrial fibrillation and Stage 3 kidney disease.
But, after he suffered seizures and a stroke that put him in the hospital a little more than a year ago, Thurman and his wife, Starr, have been on a journey that has led to better management of his diabetes and other health conditions. During his stay at OSF HealthCare Saint Francis Medical Center in Peoria, Thurman was introduced to OSF OnCall Advanced Care, a program offered by the digital health arm of OSF.
The program uses a multidisciplinary team dedicated to providing in-home treatment or digital support for patients with complex conditions such as diabetes, hypertension, heart failure and COPD. The OSF OnCall Advanced Care team treats patients who have been hospitalized and have two or more chronic conditions. The 24/7 digital care team includes nurses, digital health navigators, clinical counselors, dietitians, an e-pharmacist and providers.
Beth Wharton, manager of Virtual Care Operations for OSF OnCall, says the team treats all issues impacting someone’s health.
“It is more of a holistic approach. It's not just a nurse or a physician looking at numbers. They're really treating the patient for all of their needs.”
People with diabetes are two to three times more likely to have depression than people without diabetes. It can be stressful. Wharton explains that’s why it’s important to have a therapist available as part of the advanced care at home program.
“A lot of patients with chronic complex diseases have some form of behavioral health need, they have anxiety, or they have depression. And so, as you know, coming home from the hospital, sometimes that can be even more amplified. You're now at home and you're trying to manage your care after you've been admitted. So having that resource available is very important. as well.”
Thurman hasn’t used the counselors, but he has talked through strategies for managing temptations. For example, Thurman says riding a motorcycle and trips with friends regularly include stops for pie or ice cream. Before his hospital stint and enrollment in the OSF OnCall Advanced Care program, Thurman says he would have indulged in the sweets.
Now, he still goes for the rides but orders water and simply enjoys the camaraderie.
Program keeps him accountable
Thurman says the care team keeps him on track.
“It keeps me accountable, yeah. If I was left on my own, I probably wouldn’t do it,” Thurman admits. As he recalled his old habits he shares, “If my blood sugar went low, I’d just go grab something to eat real fast and be done with it or if it got too high, I would ignore it,” he says with a chuckle of embarrassment.
Wharton says an important aspect of the program is working with individuals who have diabetes to set goals based on what is important to them.
“We really try to identify with patients what is important with this disease diagnosis, what means the most to you – Do you want to stop smoking? Do you want to reduce your smoking? Do you want to lose weight? How much weight do you want to lose? What do you think is an achievable goal? And then how can we help you get there?”
For Thurman, the team had him focus on concrete, achievable goals – eating more fiber, drinking 64 ounces of water a day and finding ways to exercise. Thurman gets winded and light-headed easily, but he does what he can to join Star while she exercises to short fitness programs that she finds on TV.
Using a tablet provided by the OSF OnCall Advanced Care program, Thurman reports his blood glucose readings three times a day, and he uses Bluetooth devices that transmit his weight, pulse, temperature and blood pressure into his electronic medical record. If his glucose reading is too low, the phone rings almost immediately.
“And if it’s too high, I’ll get a call and I’m glad there’s someone watching out all the time. That’s really nice, a nice feeling.”
The biggest goal for Thurman was reducing his hemoglobin A1C, an important marker that measures a person's average blood sugar levels over the past two to three months. Specifically, the A1C test measures how much sugar is in your red blood cells, which transport oxygen throughout your body. The higher your A1C is, the higher your risk of developing complications.
Getting off of insulin
For people with diabetes, the goal is usually to keep their A1C levels below 7%. Before entering the program, Thurman’s A1C was at 8.3%. Through support of the Advanced Care wraparound services, Thurman has been able to get that number down significantly – to 6.9%. He is no longer taking insulin but is on Ozempic and lost 50 pounds.
Even though he was reluctant to enroll in the OSF OnCall Advanced Care program at first, Thurman is thrilled he did. And for anyone worried they won’t be able to work the technology, he says it requires a touch-screen tablet that is so easy to use.
“All you need to do is just turn it on and scroll to whatever feature you want to go to, whether it’s blood sugar, your blood pressure or your temperature or whatever, just scroll to it, touch it and it’ll tell you what to do. It’s really simple … simple to use.”
OSF OnCall also has a lower-touch approach for people who want to better manage their diabetes on their own, before it becomes a significant health threat. OSF OnCall Connect Remote Patient Monitoring for Chronic Conditions offers 24/7 digital support with education, self-reporting and monitoring. Currently there are 1,384 people enrolled in the Medicaid Innovation Collaborative remote patient monitoring program – part of a national effort to transform health care and meet related social needs for the millions of Americans who rely on Medicaid.
Since the remote patient monitoring program was launched in June of 2022, individuals enrolled have lowered their collective A1C on average by 1.5% for those with a starting A1C of greater than 9%.
With a need for more proactive management of chronic conditions, OSF OnCall is showing that through programs such as OSF OnCall Advanced Care and Remote Patient Monitoring for Chronic Conditions, there are better ways to engage people with diabetes, like John Thurman, to create a new roadmap for improving health outcomes and defining a more sustainable model of care.