Neighborhood Healthcare combined team-based care and virtual technology to pilot a new model for caring for patients with chronic disease.
With the onset of COVID-19, many of the quality metrics at the health center declined, particularly those related to diabetes and hypertension. This brought new urgency to quality improvement work. However, telehealth and remote patient monitoring brought new opportunities as well.
The center launched a new virtual care team in early 2021 to target the needs of patients with diabetes and hypertension. The team received special training to provide care for new-onset diabetes, hypertension, and nicotine cessation.
The team sees patients two days a week. Most patient visits are virtual. In-person appointments occur when needed for labs, retinal screening, foot exam or patient education. Visit duration is 15-30 minutes.
Compared with the center’s usual care, the virtual team offers improved patient communication and care coordination, longer appointments for time-intensive services, standardized care with greater adherence to best practice guidelines, and improved access to affordable medication.
After one year, the team had completed 2,200 patient visits, enrolled 631 patients, and “graduated” 193 patients who no longer needed intensive services. Among hypertension graduates, 84% remain controlled. Among diabetes graduates, 89% have their most recent A1c level at less than 8%.
The health center also reports that among its graduates, staff see a reduction or elimination of disparities in outcome by race and ethnicity.
In coming months, the center plans to expand the size and scope of the team to allow more patients to benefit from this new model of care delivery.
Neighborhood Healthcare serves San Diego and Riverside counties. It has 20 sites, and serves about 78,000 patients per year.