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.

Implementation science approaches for integrating eHealth research into practice and policy

“…The Expanded CCM supports the intrinsic role that social determinants of health have on individual, community, and population health behaviors and strengthens opportunities for community action, building health public policy and creating supportive environments [32]. An example of effectively using IS methods to integrate mobile health technology using existing health system resources to support the CCM is the diabetes self-management program being implemented in the University of Chicago Health Plan [37].…”

A Taxonomic Integrative Review of Short Message Service (SMS) Methodology

“…3 To acquire self-management skills that affect clinical outcomes, collaboration and communication with one's health care team is essential, yet many health care systems are not designed adequately to be responsive to a patient's efforts to self-manage. 4 The Health Information Technology for Economic and Clinical Health Act of 2009 includes financial provisions for the development and implementation of electronic health record (EHR) provider incentive programs, administered by the Center for Medicare and Medicaid Services, known as "meaningful use." 5 This incentive program requires-for reimbursement-that health care systems integrate technology such as EHR, decision support guidelines, and patient portals, which allow for EHRconnected, secure short message service (SMS) communication between health care teams and patients.…”

Primary healthcare reform in the United Nations Relief and Works Agency for Palestine Refugees in the Near East

“…support adherence to protocols and facilitate patients' follow-up (51)(52)(53)(54). Community strengthening is especially relevant given the upcoming mental health policy of UNRWA.…”