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
Description
Keywords
Facility-based health worker, Access to information or data, Quality of care, Demand for services, Planning and coordination, Workflow management, Pilot, Functionality, Diabetes, Non-communicable diseases, Chronic care, Hotlines and information services, Provider work planning and scheduling, Provider-to-provider communication, Disease management, SMS, Text
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