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Health Center Launches Digital Diabetes Management Program Through Remote Patient Monitoring

South Central Family Health Center (SCFHC) has been delivering high quality primary care and preventive health services, including dental, vision, and behavioral health, to residents of marginalized communities across South and Southeast Los Angeles County since 1981. Diabetes is a major chronic health condition within the largely low-income, Latino population SCFHC serves, with diabetes rates in their service area surpassing that of Los Angeles County. In March, HRSA awarded SCFHC an Optimizing Virtual Care (OVC) grant to implement the evidence-based Continuous Glucose Monitoring (CGM) Intervention Program, aimed at providing real-time biofeedback for diabetes care and management, digital health literacy, and behavior change through remote patient monitoring (RPM). The program provides participants with a CGM device, allowing them to continuously measure their blood glucose levels without needing to poke their fingers for a blood sample. Providers at SCFHC are then able to monitor participants remotely through the data gathered from the devices and relayed via a cloud-based patient portal. 

In addition to following up with their provider regularly, participants work closely in-person and virtually with Juan Ramos, the Patient Coordinator for the program and a CGM device user himself. Juan onboards each participant, trains them on how to use the device and what to do if their sugar is too low or too high, and provides education on healthy behavior changes. He also speaks with participants about his own experience and success with using the device to help educate and guide participants through digital diabetes management. 

The program kicked off June 1 and has already helped patients improve their health. SCFHC providers are able to see from the remote data relayed from the CGM devices that participants are increasingly maintaining their blood glucose levels in a safe range. Participants are also sharing positive feedback and excitement about the program during their regular check-in appointments. One woman, for instance, started the program with blurry vision and an A1C level of 12.2. After a month in the program, her vision improved, she lost weight, and her A1C dropped to 6.8, a 44% difference. A man who started the program in the same month also reduced his A1C level from 9.8 to 6.2, a 36% difference. William Diaz, Data and Support Analyst at SCFHC, explained, “It is not that our patients refuse to take care of themselves, they just lack the means or assistance to do it. This program offers patients an opportunity to look for patterns, to see when their blood sugar rises, and it gives them a chance to catch those hidden sugar rises.” 

SCFHC is also analyzing the costs of the program to understand the overall potential cost savings of using CGM devices and RPM as a long-term, sustainable treatment model to manage diabetes. Any cost savings seen from the program will support SCFHC’s goal of increasing access to diabetes management through RPM to even more patients in their community and across the Health Center Program community at large. Today’s RPM technology affords SCFHC the ability to not only monitor the health of their patients with chronic conditions in real time and create positive patient-provider relationships to improve health outcomes but also to create an innovative model of care to be adopted and scaled across the Health Center Program community.