Grant enables Boston-area center to mobilize data in diabetes treatment

An award from a recent grant program will enable Dimock Center to scale up information technology tools to better treat patients with diabetes.

An award from a recent grant program will enable Dimock Center to scale up information technology tools to better treat patients with diabetes.

The Roxbury, Mass.-based community health center plans to expand use of population health data to identify the community’s most at-risk patients with diabetes. The grant money also will support comprehensive medication reviews and point-of-care testing with a pharmacist and endocrinlolgist, with patients receiving personalized medication plans and follow-ups weekly to reduce their A1C levels.

“We are in an underserved area of Boston offering primary care, building a team and getting some help,” says Holly Oh, MD, chief medical officer.

The team-based program will enable Dimock to give patients medication management checks, assistance from a nutritionist and visits with their endocrinologists with the goal of enhancing patient engagement. Based on collected population health data, the team also can access social determinants that are affecting patients.

Also See: How telehealth can help improve medication management and patient safety

New population health modules from software vendor Azara will offer centralized data reporting and analytics for community health centers and enable the organization to pull registry reports to recruit patients who should be placed in a new treatment program that includes scheduling that will show a patient’s A1C level is out of the accepted range. A medical assistant can then use to the data to engage the patient in a conversation, take some tests and get the patient on a new management plan upon approval from a physician.

“The modules let us create quality dashboards and conduct pre-visit planning,” Oh explains. “This is how the data is available to the patient and doctor during the visit.”

Medical assistants will come in the treatment room before the physician arrives and use the registry information and glucose results to engage patients and give them printouts from the EHR on their progress. The printouts can be encouraging or sober; either way, they will further enhance the conversation with the doctor.

“We hope to do continuous glucose monitoring by sending patients home with a glucose monitor, link to a computer and have them report blood sugars every two weeks, then update the information into the electronic health record,” Oh says.

Dimock also will develop self-management curriculum for patients and screen them more regularly for social determinants of health, such as having access to food, transportation, utilities and housing.

Dimock was among five community health centers each were recently awarded $200,000 grants to help vulnerable patients better manage their medications. The winners were selected from a field of 50 community centers that applied for the funds, with the awards coming from Becton, Dickinson, Direct Relief and the National Association of Community Health Centers.

Other healthcare organizations that received the $200,000 grants include Consejo de Salud dePuerto in Puerto Rico; Baldwin (Mich.) Family Health Centers; Queens Care Health Centers in Los Angeles; and Santa Rosa (Calif.) Community Health.

More for you

Loading data for hdm_tax_topic #better-outcomes...