Developing an Integrated Text Message-Based Care Management Program for Diabetes

Mobile phones are increasingly recognized as a viable

platform for improving chronic care delivery in low-

resource settings.

• Improving care for vulnerable populations:

Address patient-level barriers to medical care within the

resource constraints of current health systems

• Availability of mobile phones and text messaging:

High rates of mobile phone ownership and texting usage

among racial and ethnic minorities

How to integrate into real-world systems?

Three key challenges:

• Maintaining level of patient engagement

• Integrating with team-based care

• Identifying sustainable funding

Background

To develop a text message-based diabetes program for

University of Chicago Medicine (UCM) that could be both

sustainable and scalable.

Purpose of the Study

An iterative process of program design built upon a pilot

study and engaged multiple institutional stakeholders.

Our pilot study demonstrated high patient engagement and

satisfaction.

• 30-day intervention (n=18): automated self-management

reminders and weekly phone calls from administrator

• High engagement (80% response rate), high satisfaction,

improved confidence in self-management (p<0.002)

• Regular interaction with the text administrator important to

patient engagement.

We engaged institutional stakeholders to translate these

findings into a funded initiative.

• Primary care physicians, endocrinologists, diabetes

educators, and administrators of University-affiliated

health plan, physician's group, and medical center

• Widely recognized need to integrate with primary care

team, but concerns about demands on clinician time

• Needed protocols for clinical oversight and patient privacy

Methods

Primary Care Group

Nurse-administrators at 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.

• Providing self-management support:

Automated messages personalized to patient diabetes

care plan, self-management behaviors, and preferences.

• Supporting care management:

Members connect directly to nurse-care managers.

System facilitates exception-based care coordination.

• Front line health plan staff are key enablers:

Despite increased workload, frontline staff enthusiastic

about increased patient contact.

Discussion

We have developed an innovative diabetes program that

uses text messaging to provide self-management

support and augmented care management services.

• Care managers directly engage larger patient population

Automates time-consuming tasks, e.g. weekly outbound

calls or identifying members who require additional

support

• Provides the critical 'human element‘

Facilitates sustained patient engagement, while

minimizing the impact on clinic workflows.

Results

Topic Message Type Example Text Message

Medication

Prompt Reminder: Time for your medicine!

Assessment In the last 7 days how many days did you take all of your diabetes medications?

Glucose Monitoring

Education A good blood sugar within two hours after eating is less than 180 mg/dl. A good fasting (before breakfast) blood sugar is 80 to 125 mg/dl

Encouragement Monitoring blood sugars is not just so your doctor knows how you are doing. Glucose monitoring is a tool for YOU to know how you are doing.

Feedback 7 for 7, perfect job!

Nutrition

Education Corn and potatoes may be vegetables, but they are also starches that can increase your blood sugar. Stick to non-starchy vegetables like spinach and carrots.

Tip If it's not in your kitchen, you probably won't eat it. Avoid temptation by not keeping desserts or unhealthy snacks in the house.

Encouragement Developing a tasty but healthy food plan with diabetes can be hard. Diabetes educators can help. Do you want to meet with one? (yes/no)

Table 1. Sample text messages

Figure 1. Conceptual representation of the program

Shantanu Nundy MD1, Jonathan J. Dick MD2, Anna P. Goddu MSc1, Patrick Hogan BA1, Emily Lu BA3, Marla C. Solomon RD CDE4, Arnell Bussie RN MPH5, Marshall H. Chin MD MPH1, Monica E. Peek MD MPH1 1 Section of General Internal Medicine, Department of Medicine, University of Chicago. 2 College of Physicians and Surgeons, Columbia University. 3 Pritzker School of Medicine, University of Chicago. 4 Section of Pediatric Endocrinology, University of Illinois at Chicago. 5 University of Chicago Health Plan.

Acknowledgments: Dr. Nundy is supported by the Agency for Healthcare Research and Quality Health Services Research Training Program (T32 HS00084). Dr Peek was supported by the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development program and the Mentored Patient-Oriented Career Development

Award of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (K23 DK075006). Dr. Chin is supported by a Midcareer Investigator Award in Patient-Oriented Research from the NIDDK (K24 DK071933). This research was also supported by the NIDDK Diabetes Research and Training Center (P60 DK20595) and the

Chicago Center for Diabetes Translation Research (P30 DK092949).