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NYC Health + Hospitals Launches Diabetes Management Program to Improve Care for More Than 60K New Yorkers

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NYC Health + Hospitals last week announced the launch of a comprehensive, primary care-centered diabetes management program, including investing in new clinical pharmacy staff, equipment, and technology to improve health outcomes and expand services through telehealth techniques for more than 60,000 New Yorkers with diabetes who receive care in the City’s public hospitals and community-based health centers. Photo Credit: Shutterstock

20 new clinical pharmacists will be integrated in primary care to help patients manage diabetes medications between primary care visits

Edited by: JV Staff

NYC Health + Hospitals last week announced the launch of a comprehensive, primary care-centered diabetes management program, including investing in new clinical pharmacy staff, equipment, and technology to improve health outcomes and expand services through telehealth techniques for more than 60,000 New Yorkers with diabetes who receive care in the City’s public hospitals and community-based health centers. Diabetes is a complex medical problem and uncontrolled diabetes can lead to health complications, including heart disease, blindness and kidney failure.

Committed to improving the care of patients with diabetes, the public health system will deploy a new cadre of clinical pharmacists to care for patients as an extension of their primary care teams, and purchase new advanced equipment to make teleretinal screening part of routine care for all patients with diabetes. NYC Health + Hospitals is also piloting a diabetes self-management app and a program that provides telephone based peer mentorship, putting an emphasis around telehealth techniques. The new services for New Yorkers with diabetes are part of the health system’s population health strategies and its broader multi-year redesign to build a competitive, sustainable organization that will continue to offer high-quality and accessible health care to the people of New York City.

“We’re investing in these new programs to make primary care more robust and effective for patients with uncontrolled diabetes, and help them adhere to their medications, take care of their vision, get counseling from someone who has experienced the same challenges, and ultimately feel empowered to take charge of their health,” said Mitchell Katz, MD, NYC Health + Hospitals President and CEO. “Our commitment to guarantee health care to all New Yorkers will be supported with smart and responsive clinical care strategies to help patients manage some of the most common chronic conditions that affect their ability to live, work, and play.”

“There isn’t a single silver bullet for treating diabetes, a disease that impacts many areas of one’s health and lifestyle, requiring a comprehensive approach to health management,” said Dave Chokshi, MD, Vice President and Chief Population Health Officer at NYC Health + Hospitals. “With this multi-pronged approach, we can help many patients who are struggling to manage their diabetes streamline their care by tracking their blood sugar levels and food intake, customizing their medication, and being more proactive around preventative screenings.”

The new NYC Health + Hospitals initiatives to help improve health outcomes for New Yorkers with diabetes include:

• Integrating Clinical Pharmacists in Primary Care – Twenty new clinical pharmacists will be added throughout the public health system by the end of 2020 to work as integrated members of primary care teams with a focus on medication management. Clinical pharmacists act as part of patients’ care teams but operate independently to help patients, in this case with uncontrolled diabetes or complicated diabetes medication regimens, to manage their medications between primary care visits. The public health system is investing approximately $3M to help hire the initial 20 clinical pharmacists as part of their first phase of implementation. They will be supported by existing patient care associates.

• Teleretinal Screening in Primary Care – Primary care sites across the City will offer advanced teleretinal screenings as part of routine primary care visit for patients with diabetes. Patients will be able to get their preventive care in a more convenient way instead of having to schedule a separate ophthalmology appointment. Annual retinal screening is an important component of comprehensive diabetes care. Those with consistently uncontrolled diabetes are at risk for developing diabetic retinopathy, the leading cause of blindness in U.S. adults aged 20-74. Diabetic retinopathy may not cause symptoms immediately; therefore, early detection through screening is the best way to prevent vision loss in patients. The program will be implemented throughout the latter half of 2019 across the system’s 11 hospitals, two Gotham Health centers in Brooklyn and Manhattan, and the system’s Correctional Health Services facility.

• Peer Mentors a Phone Call Away – Partnering with InquisitHealth, a social therapeutics company, patients with diabetes can now speak to peer mentors on the phone to help enhance their diabetes self-management. Peer mentors are patients who are successfully living with diabetes who are trained to help other patients who are struggling with their diabetes. This remote workforce of peer mentors helps address each patient’s barriers related to the social determinants of health while inspiring healthy lifestyle behavioral changes. Once a patient is referred to InquisitHealth by their primary care doctor, they are matched to a culturally appropriate mentor, scheduling regular check-in and touching base more frequently as needed. The end goal for each patient is sustained improvements in diabetes management, improved HbA1c, and a higher quality of life. The peer mentoring program is offered at NYC Health + Hospitals/Kings County and NYC Health + Hospitals/Gotham Health, Cumberland as of December of 2018.

• A Coach in Your Pocket Smartphone App – BlueStar is an app that provides real-time, individualized coaching, reminders and support, as well as diabetes educational tools that are actionable and personalized for each patient to monitor and manage their type-2 diabetes. The app helps to bridge the gap between patients and their providers outside of the clinic visit. With integrations to devices and apps, patients can connect to their pharmacies medication tracking, blood glucose meters, labs, and activity trackers. Based on the collected information, BlueStar provides patient feedback, guidance and education for better patient self-management and clinical decision support. The data analysis and feedback are evidence- and theory-based, and tailored to the individual’s clinical needs, goals, and lifestyle. The app also provides diabetes articles and videos, healthy recipes and access to the user’s own care team via the app. The app was launched in December 2018 at NYC Health + Hospitals/Metropolitan and NYC Health + Hospitals/Queens.

Nearly one million New Yorkers have diabetes, and about 19 percent are undiagnosed. Uncontrolled diabetes can cause blindness, and chronic kidney disease, which may require dialysis, and lower extremity amputations in adults. Obese New Yorkers are two times more likely as other adults to have diabetes. Black, Hispanic, and Asian New Yorkers are also at least twice as likely to have diabetes as white New Yorkers. The average medical expenditures for people with diagnosed diabetes are about $13,700 per year, with about $7,900 of this being attributed to diabetes management directly.

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